[Development of new intracranial saccular aneurysms].

Newly formed aneurysms developing from a cerebral vessel which had appeared to be normal in a previous angiographic study are very rare. Four cases of angiographically documented newly developed saccular aneurysms are described in this report. In all four patients, the new aneurysms were symptomatic, causing subarachnoid hemorrhage (SAH). Repeat angiography, performed after the second SAH, revealed new aneurysms that were not demonstrated on initial angiograms after the first SAH. They were clipped with good postoperative course. Our observations and literature data suggest that some patients with SAH need further neuroradiological followup. The presence of the risk factors and age of the patient should be taken into consideration.

[Space reconstruction of the aneurysms of the vertebrobasilary confluence based on conventional angiography--our experience].

Besides current development of the new diagnostic procedures conventional angiography still represents the golden standard in the diagnosing of intracranial aneurysms. Since it gives a two-dimensional image if the presentation of the third dimension is wanted it is necessary to apply appropriate algorithm structures and computers. In this study we show our experience in the application of space reconstruction of blood vessels and aneurysms of the vertebrobasilary confluence in 6 patients operated at the Institute for Neurosurgery, Clinical Center of Serbia. Intraoperative finding in all patients matched the finding that we got by space reconstruction of the blood vessels, which was possible to observe from different angles. Postoperative course in all patients was satisfying. Upon discharge the patients were without rough lateralization of the pyramidal system. Our initial results and their practical agreement with the interoperative finding give us right to recommend this method as the standard for the preoperative diagnostic protocol.

[Natural course of the arteriovenous malformations of the brain].

Arteriovenous cerebral malformations represent congenital malformations. Considering the anatomical characteristics of the cerebral angiomas and their localization, in a great number of cases they demand a combined therapeutic approach--surgery, embolization and radiotherapy. Besides the constant progress of technology, 5% of all cerebral angiomas can not be completely excluded from the circulation. Therefore, the need to understand their natural course became a necessity. Our results point to the fact that they are vascular malformations of a considerably more benign clinical course than the aneurysms. Our clinical model points to an annual risk of hemorrhage which is 3.3% with total mortality of 5.3%, especially if the size of the angioma is 2.5-5 cm, localized in the motor zone of the brain, with combined type of vein drainage and arterial supply from the vertebrobasilary confluence. Epilepsy caused by the cerebral angioma is in 26.7% refractory to medicamentous therapy and in 25% (every 4th patient) will have hemorrhage with an annual risk of 0.14%.

[Treatment of patients with spontaneous intracranial hematomas].

Spontaneus intracerebral haemorrhage is a common cause of stroke especially in the young. The term "spontaneuos intracerebral haemorrhage" refers to bleeding without coincident trauma. About 80% of this haemorrhage occur supratentorial in the basal nuclei and they are associated with hypertension. Etiological factors range from congenital vascular malformations (aneurysmas, AVM, cavernomas) to acquired and degenerative vascular and brain conditions. In primary intracerebral hemorrhage arterial hypertension and consequent vascular changes are the major etiological factors. In secondary- nonhypertensive hemorrhage cause may be associated with aneurysms, AVM, tumors, coagulation disorders. Contemporary diagnosis imaging (CT, MRI) and neurological evaluation, allow early diagnosis and effective medical and/or surgical therapy in a majority patients. Without treatment, the risk of mortality and morbidity is high. Medical management involves normalization of blood pressure, reduction of intracranial pressure, control of brain edema and prevention of seizures. In design for operative treatment must be include age of the patient, hematoma size and location, clinical condition, the level of consciousness and patient outcome. The role of surgery remains contraversial.

[Neurosurgical treatment of spontaneous and traumatic intracerebral hematomas].

In the period from 01.01.2000 until 31.12.2002 34 patients with spontaneous intracerebral hematoma (ICH) and with deeply disturbed state of consciousness were operated in the Department of neurosurgery of the Urgent Center, Clinical Center of Serbia. In all operated patients the indication for surgery was given on the basis of CT scan of the brain, state of consciousness, defined Glasgow coma score (GCS) and neurological status, but due to existing or threatening incarceration not even one patient was submitted to angiography of the blood vessels at the cerebral base, thus preoperatively we did not know the cause of the hemorrhage. Of 34 operated patients 22 or 64.7% died, and 12 or 35.3% survived. 14 patients were in the deepest phase of coma, where the preoperative GCS is from 3 to 5 points, and in the postoperative course only one survived, aged 25. The other survivors had somewhat less disturbed state of consciousness, they also were younger, CT scan of the brain was without blood in the chamber system. In the same period, in the Department of Neurosurgery of the Urgent Center, Clinical Center of Serbia 43 patients with traumatic intracerebral hematoma (TIH) were operated; 9 patients survived, 34 died. Only 4 patients had acute TIH. All of them were in the terminal stage of incarceration, and despite being immediately submitted to surgery all of them died. The remaining 39 patients had, the so called delayed TIH where the secondary CT scan of the brain showed development of the traumatic intracerebral haematoma that was not verified on the incipient scanner. Indication for a repeated CT scan was given in 19 patients due to focal or general neurological deterioration. However in 20 patients subsequent neurological disturbances were not registered. Those that survived were younger patients, and they were not in the deepest stage of coma, most often they had a temporal localization of hematoma.

[Neurosurgical treatment of patients with supratentorial cavernoma].

The aim of this study is to present the principal clinical manifestations and neurosurgical results of the treatment of patients with supratentorial cavernoma and epilepsy. The retrospective study included 14 patients with supratentorial lesion on MRI and CT scan of the brain that manifested with epileptic seizures. All patients were surgically treated and pathophysiologic evaluation in all patients confirmed that cavernoma was in question. Results were analyzed and compared with data from the literature. Epileptic seizures are the most frequent clinical manifestation found in supratentorial cavernoma and neurosurgical treatment gives excellent result as regards the control of epilepsy, with a very low incidence of morbidity and mortality. A complete resection of all cavernomas in this study was confirmed by postoperative neurosurgical diagnosing. 12 patients did not have any more epi seizures in the postoperative period, and in 2 patients we found decrease in the occurrence of epilepsy seizures.

[Results of surgical treatment of patient with supratentorial cavernoma and epilepsy].

In past, cavernoma was frequently cause of symptomatic epilepsy without pathological supstrat. We present the group of the patient (32) who illness were presented by epilepsy, and who were treated in Institut for Neurosurgery from 1998 to 2003. There is the good correlation between presentation of epilepsy and largness of the cavernoma (Phi 0.683). In 22 patinets the epilepsy was controlated by medicaments, and in other the seayurs were uncontrolled. Cavernoma initially presented with seayures had no inclination for massive intralesional or parenhimal bleeding. After surgical extirpation of leasion, there was good outcome during the following period of 3 years

[Neurovascular compression (conflict)]].

Since Dandy first reported vascular compression of the trigeminal nerve, the concept of neurovascular compression syndrome for trigeminal neuralgia and hemifacial spasm (HFS) has been accepted, and neurovascular decompression has been performed for this condition. The further investigations indicated that some other clinical syndromes such as glossopharyngeal neuralgia, disabling positional vertigo, tinnitus, geniculate neuarlgia, spasmodic torticolis, essential hypertension, cyclic oculomotor spasm with paresis and superior oblique myokymia also may be initiated by vascular compression of the glossopharyngeal, cochleovestibular, intermediate, accessory, oculomotor and trochlear nerves or the ventrolateral medulla oblongata. In this study several hypotheses regarding the development of cranial nerves vascular compression syndromes are presented. It is alsoemphasized the value of high-resolution magnetic resonance tomographic angiography for visualization of vascular compression. The most frequent clinical syndromes caused by vascular compressionof the cranial nerves are discussed regarding the pathogenesis, symptomes and therapy. We present our series of 124 patients with preoperative evidently positive finding of vascular compression to the trigeminal nerve (MRI). Microvascular decompression (MVD) was performed in all of them. Initial postoperative result was excellent in 110/124 (89%) patients,while in 11/124 (9%) patients the pain relief was satisfactory. In the remaining three patients MVD failed. Recurrence of pain after two years reached 19%. Complications were related to diplopia associated with transient fourth nerve dysfunction in 5 (4%) patients, facial motor dysfunction in 4 (3%) patients, transient facial hypesthesia in 27 (22%) patients and partially hearing loss in 4 (3%) patients. Cerebellar hemorrhagic infarction occurred in 1 (0.8%) patient and cerebrospinal fluid leaks appeared in two (1.6%) cases. There was no lethal outcome.