"Stent-within-a-Stent" technique for the endovascular treatment of giant aneurysm of basilar artery bifurcation: A case report.

Stents have become very important devices in the treatment of intracranial aneurysms. Flow diverters as high metal coverage stents are developed for hemodynamic treatment of challenging intracranial aneurysms. High level of metal coverage can also be achieved by implementing regular stents telescopically one in another. We present the case of a patient successfully treated for giant aneurysm of basilar artery bifurcation by a "Stent-within-a-Stent" technique. After stent implantation, coil embolization was performed using multiple-sized platinum helical coils. Control angiography performed at the end of the procedure revealed aneurysm occlusion. After 3 years, the patient is fully neurologically recovered, without pyramidal deficit, independently active and able to work.

Simultaneous bone remodeling and surgical decompression of large Sylvian arachnoid cyst.

The most common location for intracranial arachnoid cysts is the region of the Sylvian fissure, where they can be found in 49% of cases. Management of these cysts is still quite controversial. We present our surgical technique for the treatment of large Sylvian fissure arachnoid cysts which involves cyst decompression and simultaneous calvarial remodeling. After decreasing cyst size, remodeling of the frontal, temporal, and parietal bones follows. The cyst itself is treated with a cystoperitoneal shunt. In immediate postoperative period, correction of the deformity is observed. The cyst volume is reduced immediately after surgery, and adequate adaptation of the bone is achieved. Our surgical procedure for simultaneous bone remodeling and cyst decompression is a fast, simple, and effective treatment option for patients with large Sylvian fissure arachnoid cysts associated with significant cranial disfigurement. We consider cranial remodeling in case of large arachnoid cyst important not just because of the cosmetic result but also for reducing remaining intracranial space filled with cerebrospinal fluid. It may be an important factor to reduce the risk of intracystic and subdural hemorrhage. It is a widely applicable procedure that does not require special tools and expensive equipment, and yet it can help avoid multiple surgeries and complications tied to them.

Outcome after brachial plexus injury surgery and impact on quality of life.

BACKGROUND: The aim of this study was to investigate outcomes after surgery for brachial plexus injury (BPI), not only motor outcomes but also the quality of life of the patients. METHODS: We operated on 128 consecutive patients with BPI from 1992 to 2012. We documented the information on the injured nerve, level of injury, type of treatment used, timing of surgery, patient age, and preoperative and postoperative motor deficits. In 69 patients who agreed to participate in a quality of life study, additional assessments included functionality, pain, quality of life, patient satisfaction, and psychosocial health. RESULTS: Of patients who underwent only exploration and neurolysis, 35.3% showed a good quality of recovery. Patients who underwent nerve reconstruction using nerve grafting showed a better rate of good quality recovery (56.7%), and the results following nerve transfer depended on the type of transfer used. After surgery, 82.6% of patients showed significant improvement, 82.6% were satisfied, and 81.2% responded positively when asked if they would undergo surgery again if they knew the current result beforehand. Overall, 69.6% patients continued working after surgery. The mean DASH disability score was high (58.7) in the study group. Patients who had early surgery showed a consistently higher DASH score. About 76% of patients reported having pain regularly, and 18.8% reported depression or anxiety. CONCLUSIONS: We consider that it is important to report not only muscle recovery, but also other aspects of recovery.

Iatrogenic Peripheral Nerve Injuries-Surgical Treatment and Outcome: 10 Years' Experience.

BACKGROUND: Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician. METHODS: We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment. RESULTS: The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients. CONCLUSIONS: Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery.

Ancient Olfactory Schwannoma - Case Report and Literature Review.

Intracranial schwannomas are benign tumors that arise from Schwann cells. Since it is well known that optic and olfactory nerves do not have a Schwann cell sheath, schwannoma should not develop from these nerves. We report a very unusual case of a 73-year-old female who presented with generalized seizures and had radiological features of an intracranial aneurysm. Additional imaging showed an extracerebral mass 2.5 x 2.0 cm in size, which most likely corresponded to a meningioma. It was resected in total. Subsequent histological analysis revealed that the tumor was in fact ancient schwannoma WHO grade I. Only about 41 case of olfactory schwannoma have been reported in the literature. Olfactory groove schwannomas are extremely rare tumors, occurring less frequently than any other intracranial nerve schwannoma. As in this case, the schwannoma should be included in the differential diagnosis of the anterior cranial fossa tumor. Further research on the pathogenesis and the origin of olfactory groove schwannoma is needed.

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome.

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.

Triple square extended osteotomies for treatment of scaphocephaly (Renier's "H" technique modification).

Scaphocephaly is the most common single suture craniosynostosis. Surgical technique has evolved from simple strip craniectomy over π-procedures and vertex craniectomies to extensive cranial remodeling which is preferred procedure nowadays. The purpose of this paper is to present our modification of Renier's standard "H" technique and its preliminary results in detail. Eleven patients with scaphocephaly were surgically treated from January 2011 until January 2014. Only children with isolated sagittal synostosis were included in the study. Our modified Renier's technique reduces the possibility of lesion of superior sagittal sinus, dividing parietal bone in three bone fragments, thus achieving shortening of the scull in AP diameter without detaching the bone from the superior sagittal sinus. The possibility for potential secondary stenosis is minimized using extended V-shaped osteotomies with rounding of the bone edges, as well as making wide neocoronal and neolambdoid sutures. Cosmetic results were estimated as very pleasing immediately after surgery by both the parents and the surgeons in all cases. The majority of patients presented in our study were categorized as Sloan Class 1. Improvement or normalization of the cranial index was accomplished in all patients. No revision surgeries were required during the follow-up. Triple square extended osteotomies technique is a fast, simple, and efficient surgical option for children with sagittal synostosis and can be safely applied in the first months of life in children even under weight of 6 kilos. Preliminary results are encouraging and deserve a longer follow-up and comparative surgical analysis to verify its usefulness in the future.

A rare case of peripheral nerve hemangioblastoma­case report and literature review.

Hemangioblastoma is a rare benign tumor that consists of neoplastic vacuolated stromal cells and highly developed capillary blood vessels. These tumors are almost exclusively found in the central nervous system, but in extremely rare cases, it can arise in peripheral nerves. In the majority of cases, it occurs sporadically (60 to 75%), but in about 25% of cases, it is associated with von Hippel-Lindau disease. We present the first case of ulnar nerve hemangioblastoma in a 70-year-old male. The patient presented with a slow-growing palpable mass on the front side of the right upper arm. Macroscopically, the tumor was round shaped, encapsulated, reddish-orange in color, very well vascularized, and about 3 cm in diameter; one nerve fascicle was entering the tumor tissue, so it was resected with the tumor. The rest of the nerve fascicles were intact. Postoperative course was uneventful. Histopathological analysis with immunohistochemical analysis confirmed that the tumor was a peripheral nerve hemangioblastoma WHO grade I. Physical treatment was conducted, and there was no motor neurological deficit on follow-up after 3 months, only hypoesthesia of the fourth and fifth finger. These lesions are so rarely found arising from peripheral nerves that only four published cases exist in literature today. There is very little data about these tumors in world literature, so we consider our paper a valuable contribution to global knowledge on these tumors.

Collateral branches of the brachial plexus as donors in nerve transfers.

BACKGROUND/AIM: Nerve transfers in cases of directly irreparable, or high level extensive brachial plexus traction injuries are performed using a variety of donor nerves with various success but an ideal method has not been established. The purpose of this study was to analyze the results of nerve transfers in patients with traction injuries to the brachial plexus using the thoracodorsal and medial pectoral nerves as donors. METHODS: This study included 40 patients with 25 procedures using the thoracodorsal nerve and 33 procedures using the medial pectoral nerve as donors for reinnervation of the musculocutaneous or axillary nerve. The results were analyzed according to the donor nerve, the age of the patient and the timing of surgery. RESULTS: The total rate of recovery for elbow flexion was 94.1%, for shoulder abduction 89.3%, and for shoulder external rotation 64.3%. The corresponding rates of recovery using the thoracodorsal nerve were 100%, 93.7% and 68.7%, respectively. The rates of recovery with medial pectoral nerve transfers were 90.5%, 83.3% and 58.3%, respectively. Despite the obvious differences in the rates of recovery, statistical significance was found only between the rates and quality of recovery for the musculocutaneous and axillary nerve using the thoracodorsal nerve as donor. CONCLUSION: According to our findings, nerve transfers using collateral branches of the brachial plexus in cases with upper palsy offer several advantages and yield high rate and good quality of recovery.

[Primitive trigeminal artery associated (corrected) with arteriovenous malformation of cerebellum].

INTRODUCTION: Persistence of fetal cerebral carotid basilar anastomoses is rare. When it occurs, it is often associated with other vascular malformations, and other pathological conditions. Trigeminal primitive artery persistence is the most often among them. Coincidence of primitive trigeminal artery with cerebellar arteriovenous malformation is extremely rare. CASE REPORT: We reported a case of a 31-year-old woman with subarachnoid hemorrhage and cerebellar hematoma admitted in serious condition. Angiography demonstrated cerebellar arteriovenous malformation, primitive trigeminal artery and other malformation of Willis circle. After a complete surgical removal of arteriovenous malformation the patient was discharged without neurological or any other deficit. CONCLUSION: We reported an extremely rare condition, which had been reported very few times in the literature. The importance of primitive artery persistence is in changed anatomical and physiological condition of cerebral circulation, that is especially important in surgical procedures.

Transvenous embolization of dural carotid cavernous fistula through the facial and ophthalmic vein.

INTRODUCTION: Dural carotid cavernous fistula is acquired, relatively rare, condition comprising of numerous small-caliber meningeal arterial branches, draining directly into cavernous sinus. Endovascular therapy is the treatment of choice, preferably by a transvenous approach. In the case of inaccessible inferior petrosal sinus, other alternative routes are considered. We presented a case of dural carotid cavernous fistula completely occluded with Guglielmi detachable coils, using a transvenous approach through facial and superior ophthalmic vein. CASE REPORT: A 62-year-old man was referred with a gradual worsening proptosis, red eye, and decreased visual acuity, on the right side. Digital subtraction an giography revealed the presence of a right dural carotid cavernous fistula, predominantly supplied from dural branches of the right internal carotid artery siphon, with minimal contribution from the right middle meningeal artery and contra lateral dural branches of the left internal carotid artery siphon. The fistula was drainaged through the dilated superior ophthalmic vein, and via the facial to the internal jugular vein. There was neither pacification of pterygoid and petrous sinuses, nor cortical venous reflux. Endovascular treatment was performed by a transvenous approach. A guiding catheter was placed in the right facial vein. A microcatheter was advanced through the dilated angular and superior ophthalmic vein, and its tip positioned into the right cavernous sinus. Coils were deployed, until a complete angiographic occlusion of the fistula had been achieved. The patient experienced rapid improvement in the symptoms, with complete normalization of his condition one month after the treatment. CONCLUSION: Coil embolization of dural carotid cavernous fistula by transvenous catheterization, through the facial and superior ophthalmic vein, can be considered as safe and effective treatment option in the presence of marked anterior drainage.