A 64-Year-Old Woman with Imaging Features Consistent with a Posterior Intrapericardial Lipoma and 5-Year Imaging Follow-Up.

BACKGROUND Primary cardiac and pericardial neoplasms are rare and may be found incidentally on echocardiography. We present a case of a 5-year imaging follow-up in a patient with a large posterior pericardial lipoma diagnosed by magnetic resonance imaging of the mediastinum. CASE REPORT A 64-year-old woman was admitted to the Department of Cardiology for detailed assessment due to an intrapericardial mass revealed on transthoracic echocardiography in an outpatient setting. Computed tomography revealed a capsulated posterior intrapericardial homogenous mass of fat density. There was no enhancement of the lesion with contrast agent administration. Ultimately, magnetic resonance imaging confirmed the benign nature of the tumor, leading to the intrapericardial mass being classified as a lipoma. Due to the clinical features of the lesion - the preserved intracardiac flow and the asymptomatic course of the disease - conservative treatment was appropriate for this patient. A 5-year imaging follow-up was uneventful, the patient remained asymptomatic, a mild tumor growth was identified by computed tomography, and there was still no recommendation for surgery. CONCLUSIONS This case has shown that although echocardiography and computed tomography imaging can identify posterior intrapericardial tumors, magnetic resonance imaging can identify diagnostic features and support the benign nature of a tumor that may not be amenable to surgical removal.

Pisa syndrome: Pathophysiology, physical rehabilitation and falls risk.

BACKGROUND: Pisa syndrome (PS) is a postural disorder characterised by lateral flexion of the spine (> 10°), predisposing the affected individuals to falls, and contributing to increased mortality in neurodegenerative diseases. OBJECTIVE: An overview of currently applied therapeutic management options, primarily focused on specifically structured rehabilitation exercises, in conjunction with falls-risk assessment in the individuals affected by PS. METHODS: A narrative literature review, augmented with the authors' own experience in physical rehabilitation management. RESULTS: As individuals affected by PS are evidenced to be intrinsically exposed to higher falls-risk through acquired postural deformities, they often fall victims of traumatic accidents, occasionally also facing relocation into 24-hour nursing facilities due to the injuries sustained/resultant disability, consequently having overall quality of their life appreciably reduced. CONCLUSIONS: sA comprehensive approach is postulated in designing optimal therapeutic management, comprised of the exercises controlling postural stability, whilst reducing lower back pain, and the ones also promoting specific skills essential for coping unassisted after an accidental fall effectively. Rehabilitation of individuals affected by PS should be a fully integrated service, eliminating all identified risk factors for falls. As clinical PS symptoms tend to recur after completion of a full course of therapeutic management, all PS patients should continue the pursuit of therapeutic exercises on an individual basis, to effectively retard their recurrence. In view of overall scarcity of clinical studies completed on the large population samples of PS patients, further in-depth research is still required to ensure higher credence to overall efficacy of the presently proposed therapeutic solutions.

Giant Left Atrial Thrombus Despite Anticoagulation with Apixaban in a Patient with Mitral Stenosis and Atrial Fibrillation.

BACKGROUND In patients with atrial fibrillation (AF), the presence of a left atrial thrombus correlates with the highest risk of stroke. Mitral stenosis (MS) is an acquired disease that leads to atrial pressure overload and subsequent significant anatomical and electrical remodeling of the left atrium. This promotes the occurrence of AF and atrial thrombus formation. Proper anticoagulation decreases the stroke risk in AF patients. Unfortunately, there is insufficient data on the effectiveness of non-vitamin K antagonist oral anticoagulants (NOAC) in patients with AF and MS. CASE REPORT We present a case of 64-year-old woman referred for electrical cardioversion (CV) due to symptomatic AF. She was administered an apixaban for stroke prevention, but she missed the scheduled echocardiography prior to referral. Imaging performed on-site revealed a giant left atrial thrombus and moderate MS. High mobility of the intracardiac mass together with moderate AS and MS were assessed as significant predictors of distal embolization. The patient underwent mitral valve replacement with the thrombus removal. Her further recovery was uneventful. CONCLUSIONS Mitral stenosis significantly affects the anticoagulant selection in patients with atrial fibrillation. Thus, echocardiography is mandatory if the first diagnosis is atrial fibrillation to exclude contraindications for NOAC therapy.

Functional capacity and dual-task cost in the institutionalized older adults, both affected and unaffected by mild cognitive impairment.

BACKGROUND: Mild cognitive impairment (MCI) affects 10-20% of the individuals over the age of 65; this proportion being higher in the institutional care facilities than within a general population. AIM: To assess whether dual-task cost in the individuals affected by MCI depends exclusively on gait, or possibly some other functional capacity components might also come into play, as compared to the healthy controls also remaining in the institutional care. METHODS: The study was conducted in five nursing facilities, involving 88 subjects in total, i.e. 44 subjects affected by MCI (mean age of 83.8 years; 34 women (77.3%) and 10 men (22.7%), and 44 healthy controls (mean age 81.67 years; 38 women (84.4%) and 7 men (15.6%). Cognitive functions were assessed through Mini-Mental State Examination (MMSE), while gait by Timed Up and Go Test (TUGT). Gait speed was calculated by the 10 Meter Walk Test, and the fear of falling with the Falls Efficacy Scale International. Dual tasks were assessed by TUGTMAN (Timed Up and Go Test Manual) and TUGCOG (Timed Up and Go Test Cognitive). Dual Task Cost (DTC) of TUGTMAN and TUGTCOG was established. Statistical analyses were completed with STATISTICA Package v. 10. RESULTS: Individuals affected by MCI differed significantly from the unaffected ones with regard to their gait test results, when assigned a single-task activity, and dual-task activities, as well as in the gait speed. Dual Task Cost Manual (DTCMAN) in the MCI group was significantly higher, as compared to the subjects unaffected by MCI. Around 25% of the variance of DTCMAN result regarding the MCI group was accounted for by gait performance in the single-task conditions (TUGT). In the case of Dual Task Cost Cognitive (DTCCOG), this value equalled to approx. 10%. A 1% change in DTCMAN corresponded to approx. 0.5 s change in TUGT, whereas a 1% change in DTCCOG entailed approx. 0.35 s change in TUGT walking time. CONCLUSION: Individual functional capacity affected the dual-task performance, especially the motor-motor tasks. Dual-task cost in the subjects affected by MCI was significantly reduced, being more dependent on the gait speed in the motor-motor tasks, which entailed visual memory, than in the motor-cognitive tasks.

Neuroregenerative effects of polyethylene glycol and FK-506 in a rat model of sciatic nerve injury.

The recently introduced polyethylene glycol (PEG) treatment restores axonal continuity after nerve injury, leading to rapid recovery of nerve function. The impact of PEG therapy on neuroregeneration has not yet been compared with any intervention with an established proneuroregenerative potential. FK-506 is an immunosuppressive agent with documented proneuroregenerative potential in nerve injury models. The aim of this study was to compare the effects of PEG therapy and preinjury FK-506 administration in rats with sciatic nerve transection injury. Four groups of male Sprague Dawley rats (seven per group) underwent sciatic nerve transection with primary repair. Group A received placebo injections, group B placebo injections and PEG treatment, group C FK-506 injections, and group D both FK-506 injections and PEG treatment. Clinical outcomes were assessed by the skin prick test and Sciatic Functional Index (SFI). Regenerated nerves underwent histomorphometric analysis. The histomorphometric analysis demonstrated that compared with the controls, nerve specimens from all treated groups showed signs of enhanced neuroregeneration (higher mean axonal area) (p < 0.001). The histomorphometric parameters for group D (PEG + FK-506), mean axonal area (p < 0.001) and axonal count (p > 0.05), were significantly better than those in the other study groups. The Form factor was closest to its optimal values in group B (p < 0.0001). At the end of the study, mean skin prick test scores in all treated groups were significantly higher than those in controls (p > 0.05). During the first postoperative week, PEG-treated rats (groups B and D) presented with higher values of the SFI than animals from groups A and C, but the difference was not statistically significant. Combined therapy with PEG and FK-506 seems to produce better neuroregeneration outcomes than a simple suture-based repair complemented with either PEG or FK-506 treatment.

Novel Model of Somatosensory Nerve Transfer in the Rat.

Nerve transfer (neurotization) is a reconstructive procedure in which the distal denervated nerve is joined with a proximal healthy nerve of a less significant function. Neurotization models described to date are limited to avulsed roots or pure motor nerve transfers, neglecting the clinically significant mixed nerve transfer. Our aim was to determine whether femoral-to-sciatic nerve transfer could be a feasible model of mixed nerve transfer. Three Sprague Dawley rats were subjected to unilateral femoral-to-sciatic nerve transfer. After 50 days, functional recovery was evaluated with a prick test. At the same time, axonal tracers were injected into each sciatic nerve distally to the lesion site, to determine nerve fibers' regeneration. In the prick test, the rats retracted their hind limbs after stimulation, although the reaction was moderately weaker on the operated side. Seven days after injection of axonal tracers, dyes were visualized by confocal microscopy in the spinal cord. Innervation of the recipient nerve originated from higher segments of the spinal cord than that on the untreated side. The results imply that the femoral nerve axons, ingrown into the damaged sciatic nerve, reinnervate distal targets with a functional outcome.

Electrospun nanofiber mat as a protector against the consequences of brain injury.

Traumatic/surgical brain injury can initiate a cascade of pathological changes that result, in the long run, in severe damage of brain parenchyma and encephalopathy. Excessive scarring can also interfere with brain function and the glial scar formed may hamper the restoration of damaged brain neural pathways. In this preliminary study we aimed to investigate the effect of dressing with an L-lactide-caprolactone copolymer nanofiber net on brain wound healing and the fate of the formed glial scar. Our rat model of surgical brain injury (SBI) of the fronto-temporal region of the sensorimotor cortex imitates well the respective human neurosurgery situation. Brains derived from SBI rats with net-undressed wound showed massive neurodegeneration, entry of systemic inflammatory cells into the brain parenchyma and the astrogliosis due to massive glial scar formation. Dressing of the wound with the nanofiber net delayed and reduced the destructive phenomena. We observed also a reduction in the scar thickness. The observed modification of local inflammation and cicatrization suggest that nanofiber nets could be useful in human neurosurgery.

Morphological evidence of the beneficial role of immune system cells in a rat model of surgical brain injury.

The blood-brain barrier prevents infiltration of peripheral immunocompetent cells into the CNS under physiological conditions. Following brain trauma there is reported a rapid and massive immunological response. Our earlier data indicated that surgical brain injury causes breaking of brain parenchyma integrity and results in cell changes and death, astrogliosis and disruption of blood vessels. The aim of the present studies was to investigate and characterize immunocompetent cells entering brain damaged parenchyma in the early period following the injury in a rat model of surgical damage. In the investigations we used light and electron microscopy techniques. Four days following the lesion many monocytes and macrophages were detected in the injured parenchyma. We also found many activated microglial cells with phagosomes within the cytoplasm. The phagocytes digest the cellular debris and clean up the parenchyma. The data suggest the beneficial role of immunocompetent cells following surgical injury.

Nanofiber nets in prevention of cicatrization in spinal procedures. Experimental study.

Excessive cicatrisation or epidural fibrosis in the operative field is an inappropriate event occasionally occurring after neurosurgical procedures (i.e., spine procedures and craniotomies). This excessive process may disturb the postoperative course and render reoperations more difficult and risky. The literature describes this phenomenon as accompanying up to 20% of neurosurgical procedures. The scar tissue that forms postoperatively adheres to the dura mater, penetrates into the spinal canal and can cause narrowing symptoms, neurological deficits and pain. The incidence and spread of this excessive scar or epidural fibrosis can be prevented through the modification of the surgical technique by incorporating endoscopic or microscopic access to minimize the operative field and the use of isolating substances (autogenous or heterogeneous) administered intraoperatively. The aim of this experimental study was to morphologically assess the cicatrization process, adhesion and to prevent excessive scar formation with the local use of membranes manufactured by an electrospinning process (nanotechnology). We also investigated whether the biodegradable nanofibrous net triggers or modifies the immunological response or the local inflammatory process. Micro-nanofibrous membranes were produced by the electrospinning process. A biodegradable, medically certified copolymer poly(L-lactide-co-caprolactone) (PLCL) was used as the electrospun material. An experimental rat model was used in this study. Experimental and control groups were formed with specified follow-up times of 4, 14 and 30 days. During the operation, a two-level laminectomy in the thoracic segment was performed. The operative field was divided into two regions. Isolating material was used on the dura mater and surface of the spinal cord in the area where the laminectomy was performed. The material was analysed with the use of light and electron microscopy. Local cicatrisation can be modified using nanomaterials. Scar formation and epidural fibrosis can be limited and modified locally. No local inflammation process was observed. Initial observations indicate the potential for the effective use of materials obtained in the electrospinning process to prevent cicatrization.

[Schwannoma of the common peroneal nerve. A differential diagnosis versus rare popliteal cyst]. / Nerwiak oslonkowy nerwu strzalkowego wspólnego w obrebie dolu podkolanowego. Róznicowanie z torbielami zwyrodnieniowymi.

The presented case concerns a patient with neuralgia of the common peroneal nerve and progressive neurological deficit caused by interfascicular growth of schwannoma. The ultrasound diagnostics identified the lesion as a popliteal cyst. Magnetic resonance imaging revealed features of atypical cyst location. Due to the clinical course, it was decided to decompress the nerve trunk. An interfascicular tumor was identified intraoperatively. Particular nerve bundles were separated microsurgically and the tumor of schwannoma morphology was removed. The postoperative course brought resolution of neuralgia and improvement of peroneal nerve function. In the case in question attention was focused on the differential diagnostics of processes located in the popliteal fossa. Imaging examination indicated an atypical cyst location rather than a morphologically solid tumor. The clinical course is essential for determining the nature of the lesion. Decompressing the common peroneal nerve in microsurgical technique allows the prevention of further neurological symptoms in the postoperative course.

[Occipito-cervical fixation in plasmocytoma. Method modification. Technical report]. / Stabilizacja potyliczno-szyjna u chorego w przebiegu szpiczaka. Modyfikacja metody operacyjnej. Nota techniczna.

Intraoperative modification of use and stabilization of the Axon system (Synthes) for occipito-cervical fusion in a patient treated oncologically due to plasmocytoma is presented. Pathological fracture, range of the process and damage of anterior cervical fusion necessitated the use of occipito-cervical stabilization. Different anatomical conditions within the occipital bone in the form of its thinning was observed. Fixing with screws was impossible due to the bone structure. In consequence, modification of stabilization with an ad hoc elaborated technique (burr holes in the occipital bone and stabilization with titanium wire) was implemented. Modifications and specific indications related to the clinical course of plasmocytoma are discussed.

Empyema in spinal canal in thoracic region, abscesses in paravertebral space, spondylitis: in clinical course of zoonosis Erysipelothrix rhusiopathiae.

OBJECTIVES: Erysipelas is an animal disease caused by Gram-positive bacteria Erysipelothrix rhusiopathiae. Among the domestic animals, domestic pig (Sus scrofa f. domestica) suffers most frequently from the disease in human environment. This is a typical animal-borne disease observed mainly in occupational groups employed in agriculture, farming (of animals and birds), fishing and manufacturing industry. METHODS: We are presenting the clinical course of infection (E. rhusiopathiae) and discuss clinical forms. E. rhusiopathiae in humans may have the following clinical course: mild form of skin infection diagnosed as local erythema (erysipeloid), disseminated form of skin infection and the most serious form of infection of systemic course (endocarditis and sepsis). Mild skin infection and local erythema are the most common forms. Very rare case of animal-borne infection course has been presented in which after initial phase the disease was generalised to the abscesses formation in paravertebral space, spondylitis and empyema formation in spinal canal. In the presented clinical case, the patient was suffering from diabetes. It was probably an additional risk factor of the disease generalisation. Patient underwent drainage of empyema in spinal canal, after which his neurological status gradually improved. Antibiotic therapy was implemented and continued for 8 weeks. Such course of erysipelas was not previously described in the literature. RESULTS: After therapy neurological status was improved. In follow MRI control exam empyema and spondylitis was successfully eliminated. CONCLUSIONS: Various complications of the disease, such as endocarditis and heart valves disturbances, are well known and are the most severe complications of the generalised infection. Proper targeted and long-term antibiotic therapy is crucial.

Granulomatous inflammation of dura mater--a rare side effect after application of hemostatic and insulation materials in case of two-stage operation of huge meningioma.

Haemostatic and isolating materials may cause local reactions as a foreign body. The case presented here of intracranial granulomatous lesion pertains to a patient operated in two stages due to a huge meningioma. During the first operation the tumour was partially removed. Because of persistent intraoperative haemorrhage haemostatic flakes of Oxycel and Spongostan were applied locally. In order to cover the lack of the dura, an insulation material--Tachosil was used. Histological examination of the tumour specimens confirmed the preoperative diagnosis of benign meningioma, mainly of the angiomatous subtype. The second stage of operation was performed after 3 months and the meningioma was completely removed, as well as dura mater and meningioma attachment with its oncological margin. The resected dura mater was thickened and histologically showed intensive granulomatous infiltrations and foreign body reactions most likely to Oxycel. Clinically no local and general infection and improper healing was observed after the first and the second treatment stage, but an allergic skin lesions and increased eosinophils in peripheral blood smear were noted. It was stated that systemic allergic reaction and granulomatous inflammation of dura mater were an uncommon response to the applied haemostatics and/or insulation material used during the first operation. This report show that haemostatic and isolating agents, generally used in neurosurgical procedure, may rarely cause local granulomatous processes considered as delayed hypersensitivity and the foreign body reactions. Therefore, they may hinder morphological assessment of the tissues during re-exploration and must be differentiate with the other infectious and non-infectious granulomatous processes.

Ultrastructural and immunochemical studies of glial scar formation in diabetic rats.

We explored the rebuilding of the brain parenchyma after surgical injury due to reactive astrogliosis. In the present study, we investigated the initial stages of rebuilding in the perilesional cortex of streptozotocin-induced diabetic rats. Our methods utilized ultrastructural and immunohistochemical studies as well as Western blot analysis of glial fibrillary acidic protein (GFAP) and vimentin. Data was collected at 2 days, 7 days and 2 months following a unilateral sensorimotor cortex lesion. Electron-microscopic studies revealed not only formation of glial scar tissue but also ultrastructural features of death in the elements of neurovascular unit. Immunohistochemical studies, confirmed by Western blot analysis, demonstrated the enhancement of vimentin and GFAP immunoreactivity (IR) in astrocytes located in the perilesion cortical area of the diabetic rats that were operated upon. We suggest that the process of rebuilding brain parenchyma following surgical injury may be disturbed by the induction of astrocytes and the degeneration of astrocytes, as well as by morphological changes within capillaries that are accompanied by the presence of macrophages.

Occipital neuralgia: possible failure of surgical treatment - case report.

Surgical intervention in severe cases of occipital neuralgia should be considered if pharmacological and local nerve blocking treatment fail. The literature suggests two types of interventions: surgical decompression of the greater occipital nerve (GON) from the entrapment site, as a less invasive approach, and neurotomy of the nerve trunk, which results in ipsilateral sensation deficits in the GON innervated area of the skull. Due to anatomical variations in the division of the GON trunk, typical neurotomy above the line of the trapezius muscle aponeurosis (TMA) may not result in full recovery. The present study discusses a case of a female treated with GON decompression as a result of occipital neuralgia unresponsive to pharmacotherapy, who thereafter was qualified for two consecutive neurotomies due to severe relapse of pain.

Ten years observation and treatment of multifocal pilocytic astrocytoma.

Pilocytic astrocytoma (PA) usually occurs in younger patients. It is a benign, generally well-delineated, WHO grade I tumour with favorable prognosis, which makes it different from diffuse astrocytomas, classified as higher grades of malignancy. A case study of PA was presented in a young female patient, observed and treated at the Neurosurgical Department for the period of 10 years, during which time she had frequent surgical procedures due to recurrence and dissemination of the tumour. The initial symptom of the disease was epileptic seizure at the age of 16. Neuroradiological study revealed cerebral tumour in the right temporal lobe, then the first temporal lobe surgery followed by re-operation and radiotherapy was performed. The patient developed hydrocephalus, treated with the ventriculo-peritoneal shunt. After 5 years local recurrence of the tumour appeared in the right temporal region. The patient was operated and the tumour was totally removed. Initially, the histopathological diagnosis of ganglioglioma was suggested for primary tumour, finally the diagnosis of pilocytic astrocytoma for both recurrent and primary tumour was established. During the next years of observation increasing neurological symptoms in lower limbs developed. Subsequently, the patient reported pain syndrome in lumbosacral and perineal area. Consecutive MRI studies revealed a spinal canal tumours localized at the thoracic level and next at sacral level. The spinal tumour was surgically treated in both locations; the last operation was done 10 years after surgery of the primary temporal lobe tumour. Histopathological examinations of the excised foci from spinal canal revealed neoplasm consistent with WHO grade I pilocytic astrocytoma. The presented case indicates that despite the spread of the neoplastic process, a histopathologically benign tumour (WHO I grade) allows for long-term survival and observation period. Unfortunately, multifocal tumour involving midline structures causes major neurological symptoms and deficits. In the presented case we dealt now with the ascending spread process and the occurrence of the new foci in both subtentorial and parameningeal spaces inside the cranial cavity. It is a rare clinical manifestation of a disease ever described in the literature.

The immature endothelial cell in human glioma. Ultrastructural features of blood capillary vessels.

New vessel formation is a prerequisite for the growth of a tumour mass. Growing evidence suggests that endothelial progenitor cells circulate in the blood and participate in that process. The purpose of the present study was ultrastructural and electron microscopic immunocytochemical examination of capillary blood vessels in human glioma. The results showed striking morphological changes in these vessels. Our observations indicate that tumours build vessels by cooption of pre-existing vasculature and de novo recruitment of endothelial progenitor cells. Immature endothelial cells characterized by fibrils in the cytoplasm and Flk-1 positive immunoreactivity were observed as small clusters or luminally localized individual endothelial progenitor cells that participate in intussusceptive vessel growth. This observation indicates that the tumour microenvironment determines biological and functional attributes of endothelial progenitor cells.

Involvement of immature endothelial cells in vascular alterations in Alzheimer's disease.

The aim of the present study was to investigate ultrastructural features of cerebral capillaries and the pattern of new vessel formation in a patient with Alzheimer's disease (AD). Recent neuropathological studies have demonstrated that patients with AD have cerebrovascular pathology. Using electron microscopy, we showed that alterations of the capillaries are a common finding both in vascular disease and in AD, suggesting that vascular factors may also play a role in the pathogenesis of AD. We also found regionally increased capillary density, and in many sections immature endothelial cells lying on the preexisting endothelium were present in the lumen of capillaries. These cells might thus contribute to the pathological pattern of capillaries. The cytoplasm of immature endothelial cells in the patient with AD was characterized by accumulation of amyloid fibrils. We suggest that immature endothelial cells may be an important source of circulation-derived amyloid in the brain.

Hemosiderin pigmentation of tumour cells in cerebellar pilocytic astrocytoma associated with post-traumatic hemorrhage in adults.

The pilocytic astrocytoma is only rarely associated with gross intratumoral hemorrhage despite rich vasculature and blood vessel changes, accompanied often by perivascular depots of hemosiderin. We report an unusual case of pigmented cerebellar pilocytic astrocytoma presenting with posttraumatic hemorrhage in a 38-year-old man with no history related to the tumor. CT and MRI examination after head injury demonstrated unexpectedly the cystic lesion of 2 cm in diameter in the region of the right cerebellar hemisphere and vermis. The lesion was associated with hematoma and it was surgically removed 3 weeks after trauma. Histopathological examination revealed pilocytic astrocytoma tissue with broad hemorrhagic changes and with an unusual pattern of massive pigmentation of the cytoplasm of pilocytic astrocytes, consistent with hemosiderosis. Positive stains for iron and ferritin and ultrastructural study confirmed deposition of hemosiderin granules in the tumour cells. There was no evidence of melanin or melanosomes. This finding of hemosiderin accumulation in the cytoplasm of neoplastic astroglia seems to be analogous to post-hemorrhagic pigmentation of the normal Bergmann glia and subpial astrocytes. In the literature, the examples of neuroepithelial tumors with hemosiderin pigmentation of tumor cells have been rarely documented. To our knowledge, this is the first reported case of pigmented pilocytic astrocytoma exhibiting extensive intracellular hemosiderin deposition.

[Difficulties in microsurgical treatment of aneurysms after coiling]. / Trudnosci w mikrochirurgicznym leczeniu tetniaków tetnic mózgowych uprzednio zaopatrzonych spiralami (MDS).

BACKGROUND AND PURPOSE: The paper presents our own experience with microsurgical clipping of the cerebral aneurysms previously treated using endovascular techniques. MATERIAL AND METHODS: The presented clinical material consists of 3 patients treated in such a way. A group of 60 patients was embolized. An initial satisfactory effect of endovascular treatment was verified within 12 months of observation. Control radiological examinations--plane skull x-ray and cerebral angiography (DSA)--revealed coil displacement and recanalization of the aneurysm. In each case a surgical clipping of the aneurysms was performed. RESULTS: Proper clipping of previously coiled aneurysms sometimes presents a serious problem. Certain difficulties included rebuilding of the aneurysmal wall with a change of anatomical configuration in vessel ramifications. CONCLUSIONS: Qualification for endovascular treatment and the existing risk of introduction of additional coils into the aneurysm sac was discussed in connection with our observations. Problems concerning surgical treatment of initially embolized cerebral aneurysms were discussed and illustrated. Radiological monitoring of patients after endovascular treatment was proposed.