Multiple Aspergillus brain abscesses in immuno-competent patient with severe cranio-facial trauma.

Aspergillosis of the central nervous system (CNS) is a rare, but well described disease in immuno-competent patients. We present a 65-year-old patient who developed neuro-aspergillosis 10 months after severe cranio-facial trauma (Le Fort III). He was treated successfully with surgery including stereotactic drainage and, with Amphotericin B, Liposomal Amphotericin B, and Itraconazol.

Extranodal sinus histiocytosis (Rosai-Dorfman disease) of the brain parenchyma.

Rosai-Dorfman Disease (RDD) is an idiopathic histiocytic proliferation affecting lymph nodes. Although extranodal involvement has been reported in diverse sites, manifestation in the central nervous system (CNS) is extremely rare, particularly in the brain parenchyma. A 39-year-old male presented with an isolated well-circumscribed brain mass in the right temporal lobe, preoperatively thought to be a meningioma. Histology and immunohistochemistry confirmed that the lesion was RDD. The intraparenchymal brain location of RDD appears to have a benign course. Although the adjuvant therapy is a treatment of choice, surgical resection seems to be the appropriate treatment modality. From the clinical point of view RDD might be an important intracerebral entity because it may mimic other lesions, particularly other histiocytic disorders.

Minimally invasive treatment of cavernous angioma of the optic chiasm: case report.

Cavernous angioma of the optic chiasm or optic nerve is extremely rare. We report the case of a 58-year-old woman with cavernous angioma of the optic chiasm. The lesion was totally removed through the eyebrow keyhole approach, which allowed appropriate intraoperative exploration of the optic chiasm and related structures. The present case confirms that a cavernous angioma located in the optic chiasm can be totally resected without further impairment of visual function.

Endoscopic third ventriculostomy with ultrasonic contact microprobe.

The authors describe their first clinical experiences in endoscopic third ventriculostomy (ETV) with the original ultrasonic contact microprobe (UCM) designed at the Department of Neurosurgery in Zagreb. The analysis includes the clinical course of disease in eight patients submitted to surgery from May to September 1999 (3 men and 5 women, from 14 to 61 years of age). Surgery was performed in patients with neurological symptoms of elevated intracranial pressure and neuroradiological evidence of non-communicating hydrocephalus caused by mesencephalic aqueduct stenosis. The perforation in the base of the third brain ventricle made by the ultrasonic contact microprobe was widened by a balloon catheter. The authors have come to conclusion that the ETV when performed by contact ultrasonic microprobe is a small risk procedure in case of non-communicating hydrocephalus. For its small diameter (1.6 mm) and simple handling the newly designed contact ultrasonic microprobe is very suitable for use in neuroendoscopy as it enables fenestration of the third brain ventricle with minimal thermal and ultrastructural damage to the adjacent neurovascular structures. Further research will be focused on defining indications for the use of the device in other neuroendoscopic procedures as well.

The difference between ultrasound-guided and stereotactic-guided neurosurgical procedures.

We evaluate two different methods, ultrasound (US) guidance and stereotactic guidance, routinely used in our Department for navigation in various neurosurgical procedures. We have performed 53 US-guided and 101 stereotactic-guided procedures. These procedures were intracranial lesion biopsies, intracranial cysts and abscesses puncture and evacuations, ventricular punctures for hydrocephalus shunt operations, stereotactic-guided microneurosurgical resections, and stereotactic-guided endoscopic operations. Advantages of the US-guided operations are the shortness of the procedure, simplicity (no need for moving patient for additional CT scanning), no irradiation and the possibility of real-time imaging. The disadvantages of the US-guided procedures are worse resolution of the images in deep-seated and small lesions as well as the need for a bigger trepanation because of the transducer's dimensions. Stereotactic procedures are time-consuming but more precise and usually done in local anaesthesia because only a small trepanation is required. Main disadvantage of the stereotactic-guided procedures when compared with the US-guided procedures is a lack of real-time intraoperative control. According to our experience, both methods are complementary and safe and they do not cause any additional complications when used as a navigation tool in microneurosurgical operations. Both methods are highly reliable when used in properly selected patients.

Ultrasonic contact microprobe: experimental results.

At the Department of Neurosurgery, School of Medicine, University of Zagreb, the original ultrasonic contact microprobe (UCM) was designed. The efficacy of the instrument was tested on 120 brains of Wistar strain rats. The authors have been investigating the possibility of transferring high-energy ultrasound through the titanium wire probe of the device and the efficacy of UCM in controlled punctiform destruction of brain tissue. Light and electron microscope assessed the lesions made in the brains of experimental rats. Histological findings in the preparations showed the zone of thermal injuries from 100 to 200 microm and the zone of ultrastructural changes from 200 to 300 microm, indicating the sparing effect of the microprobe with regard to the adjacent neurovascular structures. The small dimensions of the ultrasonic contact microprobe (1.6 mm) enable its introduction through the operating canal of a ventriculoscope. Further research is expected to show the efficacy of the ultrasonic contact microprobe in endoscopic neurosurgery.

[Endoscopic ventriculocisternostomy of the third cerebral ventricle]. / Endoskopska ventrikulocisternostomija trece mozgovne klijetke.

Endoscopic third ventriculocisternostomy (ETV) is a minimally invasive technique that establishes a communication between third ventricle and interpeduncular cistern. We analyzed clinical files of eleven patients (7 males and 4 females) operated on between September 1996 and February 1998. Patients' age ranged from 3 to 61 years. ETV was performed in hydrocephalic patients with neurological signs of increased intracranial pressure (ICP) and CT or MRI diagnosed noncommunicating hydrocephalus (aqueductal stenosis). The fenestration instrument was a monopolar coagulation wire and dilation instrument was a balloon catheter. Post-operative decrease in the third ventricle diameter is the most reliable neuroradiological sign of successful operation. All patients, but one, were able to remain independent of the shunt system after the ETV. ETV is a low-risk neurosurgical technique that should be considered as the initial treatment of noncommunicating hydrocephalus. Features that increase ETV probability of success include age over 1-year, relatively recent obstruction, no meningitis or subarachnoid haemorrhage history and normal ventricular anatomy. ETV excludes mechanical complications and lowers the risk of biological complications which are characteristic for CSF drainage operations. Economic aspect is also very important because drainage devices are very expensive.

Neuroendoscopic fenestration of arachnoid cysts.

The authors report 6 patients with arachnoid cysts treated endoscopically. The series includes 6 patients with temporobasal arachnoid cysts. The age of the patients at the time of diagnosis ranged from 5 to 71 years. The patients' symptoms included headache, seizures, vomiting, nausea, dizziness, and problems with balance. The authors performed cystocisternostomies via burr holes with the aid of a universal neuroendoscopic system. In 4 cases the endoscopic fenestration was a unique treatment which enabled the avoidance of a definitive cystoperitoneal shunt. In the two cases treated subsequently, cystoperitoneal shunts were performed. The surgical endoscopic technique and the postoperative radiological findings which indirectly confirm the patency of the fenestration are discussed. The authors conclude that endoscopic fenestration of intracranial fluid cysts represents the treatment of preference. In cases where the endoscopic procedure fails a microneurosurgical procedure or cystoperitoneal shunting is recommended to avoid exposing the patient to additional risk.

Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations.

We reviewed our experience with shunt implantation during two time periods. From June 1985 to December 1990, 201 children with hydrocephalus underwent 382 operations. Among these children 36 (18%) developed a proven shunt infection, with an incidence rate per procedure of 9.4%. As a result of this study, a new effective protocol for shunt procedures involving modifications to the perioperative (antibiotic prophylaxis) and intraoperative management (meticulous surgical technique, complete shunt revision) of children undergoing initial shunt implantation or revision was initiated. With this new protocol 75 children underwent a total of 112 procedures between January 1991 and December 1995. The incidence of shunt infection decreased, with a per patient rate of 8% and a per procedure rate of 5.3%. The majority of infections in our study were caused by Staphylococcus epidermidis, which was found in 22 (52.3%) patients.

Drug trials on healthy volunteers in Yugoslavia.

Ninety-seven healthy volunteers who participated in different clinical trials (phases III and IV) in a clinical pharmacology unit were interviewed over the period December 1988-February 1990 using questionnaire method. The aim of the investigation was to analyze the examinees' occupational distribution, the degree of insight in the trials they participated in, their opinion about the remuneration they get and their estimate of the importance or inconveniences of numerous trial elements. Only 39 volunteers (40.2%) were members of medical staff: 17 (17.5%) physicians, 17 (17.5%) medical students and 5 (5.2%) nurses. The volunteers assessed the importance of different elements related to the trial marking them from 1-5. They were more afraid of possible adverse drug reactions (ADR) occurring during the trial (median 3.87) than of those that might occur afterwards (2.94). Significant was their concern about the kind of investigated drug (3.49). "Potential contribution of the trial to the medicine and society" (3.30) and "length of time spent in the laboratory" (3.17) followed. The conduct of clinical trials on healthy volunteers in Yugoslavia and legal regulations are discussed at the end of the paper.