Goran Tasic

Neuroendocrine dysfunction in patients recovering from subarachnoid hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage (SAH) is a recently identified risk factor for hypopituitarism, particularly growth hormone (GH) and corticotrophins deficiencies. The aim of our study was to identify possible predictor(s) for neuroendocrine dysfunction in SAH survivors. DESIGN: Pituitary function was evaluated in 93 patients (30 males, 63 females), aged 48.0±1.1 years (mean±SE), and with a Glasgow Outcome Scale score of 4.6±0.6 (mean±SE) more than one year following SAH. In the acute phase, SAH was complicated by vasospasm (VS) in 18 and by hydrocephalus (HDC) in 9 patients. Baseline serum values of Insulin Growth Factor 1 (IGF-I), cortisol, Thyroxine (T4), Thyroid Stimulating Hormone (TSH), Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), testosterone (in males), estradiol (in females) and prolactin were determined. RESULTS: According to the results of baseline hormonal evaluation, 47 patients (50.5%) had no hormonal abnormalities. Seven patients (7.5%) had multiple pituitary hormone deficiencies: Four patients (4.3%) had two (GH and cortisol), one patient had three (gonadal, adrenal and GH) and two patients had deficiency of all pituitary axes. Thirty-nine patients (42%) had one abnormal axis (13 adrenal, 2 thyroid, 4 gonadal and 20 GH). None of the subjects was treated with desmopressin or exhibited symptomatic polyuria. The VS and HDC during the acute phase of SAH were related to abnormal pituitary status (VS with low IGF-I levels and HDC with low cortisol levels). CONCLUSION: Through a screening procedure, neuroendocrine dysfunction was identified in a substantial number of asymptomatic patients with previous SAH. Cerebral VS and HDC at the time of SAH emerged as risk factors possibly predicting development of pituitary dysfunction. Low basal levels of IGF 1 and cortisol may help in selecting patients requiring further evaluation of pituitary function.

The role of surgical decompression of Cauda equina in lumbar disc herniation in recovery of bladder function

INTRODUCTION Cauda equina syvndrome from lumbar disc herniation accounts for up to 2-3% of all disc herniations. The aim of this study was to investigate whether recovery of bladder function after surgery depends on preoperative duration of desease. PATIENTS AND METHODS This retrospective study included 47 patients who underwent surgery for cauda equina syndrome due to a herniated disc in the period between 1997 and 2002. Eleven patients were female and 36 male, with a mean age of 43 years (range 23-67). All presented with sciatica and saddle hypoesthesia, whereas 13 presented with motor weakness of legs. All patients had been catheterized at the time of admission to the Neurosurgical unit. Levels of herniation were L4-L5 in 27 (57%), L5-S1 in 14 (30%), and L3-L4 in 6 (13%) patients. In 7 (15%) patients, surgery was performed within 48 hours of the cauda equina syndrome onset. None underwent surgery within 24 hours. 13 (28%) patients were operated between the 2nd and 7th day and 27 (57%) after 7th day of the cauda equina onset. The role of preoperative duration of symtoms in recovery of bladder function was examined (chi 2 analysis). RESULTS The follow-up ranged from 15 to 74 months (mean 24.2 months). In 33 patients (70%) excellent result were achieved, in 9 (19%) patients good results and 5 (11%) patients presented with poor results. There was no statistically significant difference concerning the time between the onset of symptoms and surgical decompression and subsequent recovery of bladder function (p>0.05). CONCLUSION After accurate diagnosis and adequate operative treatment, postoperative results of cauda equina syndrome due to lumbar disc herniation appear satisfactory regardless of the timing of surgery.

Asymptomatic perforation of large bowel and urinary bladder as a complication of ventriculoperitoneal shunt: Report of two cases

INTRODUCTION Insertion of a ventriculoperitoneal (VP) shunt, the method of choice in the treatment of hydrocephalus, is often followed by various mechanical and/or infective complications. We present two children with asymptomatic perforation of the large bowel and urinary bladder, relatively rare and potentially severe complications of this surgical procedure. OUTLINE OF CASES In both patients a VP shunt was implanted in the first month after birth; in a boy due to congenital hydrocephalus and in a girl due to the consequences of intracranial haemorrhage. Immediately after surgery, as well as during the further course, in both children growth and development were optimal and without any signs of infection or VP shunt malfunction. In the boy at age 6 months and in the girl at age 4 years, without any signs of complications, mothers noted the prominence of the VP shunt tip from the anus in the first case and from the urethral orifice in the second one. The VP shunts were immediately changed, so that both complications were resolved without any consequences. CONCLUSION Insertion of a VP shunt represents the most frequent method of choice of the surgical treatment of hydrocephalus, but also potentially a highly risky procedure followed by various complications about which parents should be informed when patients are children. Owing to adequate approach in the follow-up of children with implanted VP shunt, large bowel and urinary bladder perforation, examples of severe and potentially fatal complications of this surgical intervention, could be disclosed on time and adequately resolved.

A tissue-implant reaction associated with subcutan implantation of alpha-tricalcium phosphate, dental ceramic and hydroxyapatite bioceramics in rats

Calcium phosphate ceramics are among the more commonly used and biocompatible ceramics. Recently, we have synthesized a new calcium phosphate ceramic, alpha tricalcium phosphate (aTCP). The aim of this study was to assess the biocompatibility of this original, in our laboratory modified, newly synthesized aTCP ceramic, by carefully evaluating the inflammatory reaction of soft tissue in response to its subcutaneous implantation, and by comparing this result with the results of already widely used virtually non-toxic, non-immunogenic, and almost chemically inert dental (DC) and hydroxy apatite (HAP) ceramics. Implants (diameter 5x2 mm) of aTCP, DC and HAP were implanted into 12 adult male rats subcutaneously. At 2 weeks and 12 weeks post-implantation, the animals were euthanized and the tissueimplant reactions were analyzed histologically. Evaluation of routine stained sections (5 _m, hematoxylin & eosin) of the cutis and subcutis surrounding the aTCP, DC and HAP ceramics revealed the following: 1) all the ceramic devices had fibrous connective tissue capsules; 2) there were significant differences in the tissue - implant reactions based on the estimated time, while there were no differences in the tissue-implant reaction based on the type of ceramic material; 3) two weeks after implantation hyperemia and cellular proliferation were the most expressive results, while twelve weeks after implantation extensive angiogenesis and collagen fibers production were the prominent findings for all types of implanted calcium phosphate ceramics.

The value of multidetector computed tomography of orbits in globe protrusion in comparison to hertel exophthalmometry

The use of multidetector computed tomography (MDCT) is an integral part of contemporary diagnostics of Graves‘ orbitopathy. The aim of this study was to assess proptosis measurement by MDCT and to compare it to the current standard, Hertel exophthalmometry. A cross-sectional study was conducted at the Clinical Centre of Serbia and included 91 patients (19 male and 72 female) with verified Graves‘ orbitopathy. Globe protrusion measured by MDCT (globe protrusion, GPR) was correlated to Hertel measured protrusion (HR). There was no constant or any systematic bias between the two methods. GPR significantly correlated with the best-corrected visual acuity, while HR did not. Age, body mass index and duration of the disease did not influence proptosis measurement by either method. Proptosis was significantly larger in males. According to our results, GPR compared to HR provides better assessment of the protrusion in Graves‘ disease. GPR measurement is simple and should always be part of the radiological assessment of orbits in Graves‘ disease.

Assessing the quality of angiographic display of brain blood vessels aneurysms compared to intraoperative state.

BACKGROUND/AIM Aneurysms in brain blood vessels are expanding bags composed of a neck, body and fundus. Clear visibility of the neck, the position of the aneurysm and surrounding structures are necessary for a proper choice of methods for excluding the aneurysm from the circulation. The aim of this study was to evaluate the reliability of spatial reconstruction of blood vessels of the brain based on the original software for 3D reconstruction of the equipment manufacturer and a personal computer model developed earlier in the Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, compared to intraoperative identification of these aneurysms. METHODS This study included 137 patients of both sexes. The presence of an aneurysm was verified by angiographic methods [computed tomographic angiography (CTA), multislice computed tomography angiography (MSCTA), magnetic resonance imaging angiography (MRA), or digital subtraction angiography (DSA)]. RESULTS The quality score (0 to 5) for CTA was 3.180 +/- 0.961, MSCTA 4.062 +/- 0.928, and for DSA 4.588 +/- 0.758 (p < 0.01). The results of this study favorite conventional angiography as the gold standard for diagnostic of intracranial aneurysms. CONCLUSION The results of this study are consistent with current publications review and clearly recognize the advantages and disadvantages of diagnostic neuroradiological procedures, with DSA of brain blood vessels as a binding preoperative diagnostic procedure in cases in who it is not possible to clearly visualize the supporting blood vessel and neck of the aneurysm by using the findings of CTA, MRA and MSCTA.

True Aneurysm of Temporal Superficial Artery Arise Spontaneously. Case Report

Abstract Aneurysms of the temporal superficial artery (TSA) are very rare clinical entity. From 1861 to the present day, is described less than 200 cases. The most common cause of these aneurysms is so called blunt head trauma but there are described many cases of iatrogenic aneurysms, very rarely, aneurysms arise spontaneously. We report a case of 17-yearold patient with spontaneously formatting aneurysm of TSA. Three months prior to admission, he noticed the existence of tumefaction localized frontotemporal on the right side. MSCT angiography of blood vessels of the scalp showed an aneurysm on the frontal branch of TSA diameter of 15 mm. The aneurysm was resected with uneventful postoperative course. PH findings pointed to a true aneurysm. Treatment protocol for the aneurysms of the TSA include clinical monitoring, compression of the aneurysm, the injection of thrombin, endovascular treatment and surgical resection. Surgical resection has proven to be a safe and effective treatment modality and still is the method of choice.

Intracerebral hemorrhage as a first sign of pheochromocytoma: case report and review of the literature

Pheochromocytomas and sympathetic paragangliomas are rare catecholamine-secreting tumors and represent very rare causes of intracerebral hemorrhage in young, with only few cases reported. A 32-year-old man presented to our emergency department because of sudden onset of severe headache. He had a six months history of paroxysmal headache, palpitations and sweating. During examination he became somnolent and developed left-sided hemiplegia. A computed tomographic (CT) scan of the brain showed a right temporoparietal hematoma. He was admitted to the Clinic for Neurosurgery and hematoma was evacuated. The patient was comatous, on assisted respiration, with frequent hypertensive crises. An examination for possible secondary causes of hypertension was undertaken. Plasma metanephrine value was elevated (414 pg/ml, reference values < 90pg/ml). Abdominal CT scans revealed a large mass (6cm) in the right adrenal gland. After adequate control of the hypertension was achieved with an nonselective α and β adrenergic blockers, the tumor was excised. The histopathologic findings confirmed the diagnosis of pheochromocytoma. The genetic analysis demonstrated a duplication in exon 1 of VHL gene. We reported a rare, potentially fatal complication of pheochromocytoma, an intracerebral hemorrhage. This case and review of the similar rare cases in the literature illustrate the importance of early recognition of the characteristic symptoms of catecholamine excess in young patients with hypertension.

Determination of Predictive Anatomic Parameters for Bleeding of Brain Arteriovenous Malformations by Multidetector CT Angiography

Patients with brain arteriovenous malformation (AVM) have a certain risk to bleed, and the goal of this study was to examine the effect of radiological and clinical predictive characteristics of AVM hemorrhage using multidetector computed tomographic (MDCT) angiography. The study included a series of 57 patients, mean age 35.46 years, who were diagnosed during their hospitalization at Clinical Department of Neurosurgery, Clinical Center of Serbia, in the period from January 2008 to March 2016. In all patients, the diagnosis was made using MDCT angiography. Two groups of patients were observed. The first group included patients who did not initially present with hemorrhage, while the second group initially presented with hemorrhage. Both groups were treated with medical therapy or a combination of medical therapy with embolization/surgery/radiotherapy. Deep venous drainage (p<0.05), combined arterial supply from different basins (p<0.05) with a length <60 mm, venous dilatation present in the drainage vein (p<0.01), and the angle of casting sup-ply arteries in the nidus (p<0.01) carry a risk of repeated bleeding. In the group of patients who had initial hemorrhage, the mean value of the casting angle size was 130°, while in the group that did not have initial bleeding the mean value of the measured angle size was 103.81° with standard deviation of 17.21° (p<0.01). In conclusion, AVMs with deep venous drainage from the carotid and vertebrobasilar basin, the length of the feeding arteries <60 mm, the angle of the casting feeding arteries in the nidus ≥130° and dilatation and/or venous aneurysm of drainage vessel are predictive for clinical presenting by hemorrhage.