[Show abstract][Hide abstract] ABSTRACT: Therapeutic protoclol for intracranial aneurysm treatment is very complex. In depand od patient status and anviografic founding we determinate modality and time of treatment. Analysis included 137 patients who were treated in Neurosurgical clinic CCS because sponatenus subarachnoid haemorrhage rigine from aneurysm belading. We performed direct surgery (microsurgery) in 109 patients. In early termine we operated 28 patients (25.69%), in first 24 hours 5 of them. In interemdiate period we performed surgery in 9, and other 72 patient we operated in postpone period. Embolisation was performed in 22 patinet. GOS form embolised patient was 4.636 +/- 0.581 and in operated 4.113 +/- 1.106 (p < 0.05). Cumulative experient of Neurisurgical Clinic CCS and summation of international experience impose as the best treatment is the treatment which is best known for the physician.
[Show abstract][Hide abstract] ABSTRACT: AVM because of outstanding tendency toward bleeding, even though 20 times more rare then aneurysm on the blood vessels of the brain and her own specific anatomical structure even today represents big neurosurgical challenge. MATERIAL and
Series which is shown here consists of 39 patients which were hospitalized in the institute for neurosurgery of the Clinical Center of Serbia in the period between 1995 and 2004. This group was exposed to symptomatic therapy or it was estimated that surgery, embolization and radio surgery.
Combined type of venous drainage brings a high risk (p < 0.001) from repeated bleeding. Combined artery bringing from different flows (p < 0.05) contributes to genesis of 'steal phenomenon', in combination with deep venous drainage it presents predisposing anatomical characteristics for repeated bleeding (p < 0.001) according to our results should present AVM with dimensions 2.5 to 5 cm localized in eloquent zone of big brain with combined type of venous drainage and cobined artery bringing from vertebro-basilar flow and carotid flow.
Perception of natural course of AVM point to certainly more benign pathology in regard to other vascular malformations. Specific anatomical structure requires planning of treatment from case to case, most often combination of embolization, radio surgery and surgical treatment.
[Show abstract][Hide abstract] ABSTRACT: Specific microanatomical characteristics of the trigeminal nerve root (TNR) blood supply and close neurovascular relationships with surrounding vessels as well as their possible clinical significance were the main reasons for this study.
The vasculature of 25 adult and four fetal TNRs were microdissected and examined under the stereoscopic microscope, after injecting their arteries with India ink.
The trigeminal vessels, which varied between two and five in number, arose from two or three of the following arteries: the superolateral pontine (92%), anterior inferior cerebellar (AICA) (88%), inferolateral pontine (72%), and superior cerebellar (SCA) (12%). The trigeminal vascular twigs had a mean diameter of 0.215 mm. A single vessel may supply either the motor portion of the nerve root or the sensory portion or both. The trigeminal vasculature formed the proximal and distal rings. The proximal ring was located at the trigeminal root entry zone. Its central branches extended along the TNR to the principal sensory and motor trigeminal nuclei while its peripheral longitudinal twigs followed the TNR fascicles. The incomplete distal arterial ring embraced the middle portion of the TNR before the level of its entrance into the arachnoid sleeve. The most frequent contact of the TNR was noticed with the SCA (20%), the petrosal or Dandy's vein (24%), and the AICA (12%).
The observed characteristics of the TNR vasculature could be the anatomical basis for decompressive neurovascular surgery.
[Show abstract][Hide abstract] ABSTRACT: Different clinical and surgical factors can influence the occurrence of anesthesiologic complications in pediatric neurosurgery. Preoperative knowledge of these factors is of great importance in the application of safe anesthetics and a favorable surgical outcome. The objective was to establish the importance of clinical and surgical risk factors on the frequency of anesthesia complications in pediatric neurosurgery.
The research, from 1996 to 2000, involved 705 children, aged from <1 year to 15 years, who underwent surgery for elective neurosurgical pathology and severe head injuries. We analysed the influence that: age, the preoperative neurologic diagnosis, the urgency of the operation, additional disorders, the surgical position, and the duration of anesthesia had on the frequency of anesthesia complications. To test the statistical relevance and to confirm the hypothesis, the Pearson's chi-square test, Mann-Whitney U-test, and univariate and multivariate logistic regressions were used.
Anesthesia complications (cardiovascular, respiratory, air embolism, allergic reactions) were present in 68/705 (9.6%) patients. Their frequency was statistically greater in children for whom the surgery was >240 min, who were in the sitting position and when comorbidity was evident. Neither age nor the urgency of the operation or reoperation had any significant influence on the occurrence of anesthetic complications.
The duration of anesthesia, the sitting position of the patient, and the presence of comorbidities significantly increase the risk of anesthesia complications in pediatric neurosurgery.
[Show abstract][Hide abstract] ABSTRACT: The use of computer models for the 3-dimensional reconstruction could be a reliable method to overcome technical imperfections of diagnostic procedures for the microsurgical operation of giant intracranial aneurysms.
We presented a case of successfully operated 52-year-old woman with giant intracranial aneurysm, in which the computer 3-dimensional reconstruction of blood vessels and the aneurysmal neck had been decisive for making the diagnosis. The model for 3-dimensional reconstruction of blood vessels was based on the two 2-dimensional projections of the conventional angiography. Standard neuroradiologic diagnostic procedures showed a giant aneurysm on the left middle cerebral artery, but the conventional subtraction and CT angiography did not reveal enough information. By the use of a personal computer, we performed a 3-dimensional spatial reconstruction of the left carotid artery to visualize the neck of aneurysm and its supplying blood vessels.
The 3-dimensional spatial reconstruction of the cerebral vessels of a giant aneurysm based on the conventional angiography could be useful for planning the surgical procedure.
[Show abstract][Hide abstract] ABSTRACT: Haemorrhage is most important sequelae of brain cavernoma, so the surgical treatment is very important for treatment that complication. There are two types of bleeding chronic subclinical microhaemorrhage and acute real haemorrhage. Pathophysiological factors wich are responsible for bleeding are not still understanding. The reason for this study is understanding of clinical curse of cavernomas and identification of factors of influence. This is retrospective and prospective study. We analised 36 patients with simpthomatic brain cavernoma, surgicaly treated in Institute of neurosurgery KCS in 10 years period (1987-1997). Female were dominant but without statistical significance (p > 0.05). Male patients were older (32,1:29,8), but without statistical significance (p > 0.05). Almost 75% lesions were supratentorial, 25% infratentorial (p < 0.05). Focal neurological deficite (FND) was dominant clinical presentation in 52.8%. FND was dominant in 52.6% female, but without statistical singnificans (p > 0.05). Clinical presentation according the age was not statisticaly significant (p > 0.05). Clinical presentation was very diferent according the size of lesion (p < 0.001). FND as a sign of bleeding was in 57.9% supratentorial cavernomas and in 42.1% infratentorial (p < 0.005). More than 1/3 patients have recurent bleeding with 21 atack of haemorrhage or almost 2 atack per patient. We find that dominant predictive factors for recurent haemorrhages are localisation and size of lesion.
[Show abstract][Hide abstract] ABSTRACT: To provide updated outcome data (10 years) of a Phase II study of combined surgery, postoperative radiotherapy, and adjuvant chemotherapy in patients with anaplastic oligodendroglioma and oligoastrocytoma.
In 23 adult patients, surgery, postoperative radiotherapy (60 Gy in 30 daily fractions within 6 weeks), and adjuvant modified chemotherapy (procarbazine 60 mg/m(2) on Days 1-14, lomustine 100 mg/m(2) on Day 1, and vincristine 1.4 mg/m(2) [maximum 2 mg] on Days 1 and 8) were administered every 6 weeks for up to six cycles or until progression occurred.
The median follow-up was 116 months for all patients. The median survival time was 118 months, and the 5-year and 10-year survival rate was 57% and 47%, respectively. The median time to tumor progression was 78 months, with a 5-year and 10-year progression-free survival rate of 52% and 39%, respectively. Gender, age, Karnofsky performance status, location, and histologic type did not influence survival. Patients with tumors <or=4 cm did better than those with tumors >4 cm (p = 0.0470), as did those with total tumor resection compared with those with subtotal tumor resection or biopsy only (p = 0.0024). Gender, Karnofsky performance status, location, and histologic type did not influence progression-free survival, but younger age (p = 0.0389), smaller tumor size (p = 0.0357), and more radical surgery (p = 0.0033) correlated positively with it. Acute high-grade (Grade 3 or worse) chemotherapy-related toxicity was mainly hematologic, with 3 patients (13%) experiencing acute Grade 4 toxicity.
The results of this 10-year update confirmed that the trimodality approach is effective in patients with anaplastic oligodendroglioma and oligoastrocytoma.
International Journal of Radiation OncologyBiologyPhysics 07/2004; 59(2):509-14. · 4.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To provide a 10-year update of hyperfractionated radiation therapy (Hfx RT) in adults with incompletely resected supratentorial low-grade glioma.
A total of 37 patients were treated with 55 Gy in 50 fractions in 25 treatment days in 5 weeks to tumor plus 2 cm, and additional 17.6 Gy given in 16 fractions in 8 treatment days in 1.5 weeks to tumor plus 1 cm, (1.1 Gy twice daily). Total dose was 72.6 Gy in 66 fractions in 33 treatment days in 6.5 weeks.
After a median follow-up time of 121 months for all patients, the median survival time (MST) for all 37 patients was 145 months, whereas 10-year survival rate was 67%. Median time to tumor progression (MTP) has not yet been attained, but 10-year progression-free survival (PFS) rate was 62%. There was no difference in survival or PFS regarding gender, age, location, site, size, CT enhancement, and histology; whereas lower KPS, higher neurologic status, and lesser extent of surgery had an adverse influence. Infield progression occurred in 15 (88%), whereas in only 2 (12%) patients, tumor progression was described as marginal. Brain necrosis has not been observed so far. Autopsy findings confirmed recurrent glioma and excluded post-RT necrosis in 14 (38%) patients. Of those, 7 (50%) patients had either Grade 3 (n = 4) or Grade 4 (n = 3) glioma.
High-dose HFX RT is effective with mild to moderate toxicity. Further studies are warranted with more patients before testing it against standard fractionation RT in this patient population.
International Journal of Radiation OncologyBiologyPhysics 11/2003; 57(2):465-71. · 4.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The importance of the extent of surgery as a prognostic factor in multiform glioblastoma has been investigated for years. Some studies could not establish its influence on survival of patients treated with surgery, postoperative radiotherapy, with or without chemotherapy. On the other hand, there are data suggesting benefit for patients treated with more aggressive surgical approach. The aim of this study was to investigate the influence of the extent of surgery on survival/progression-free survival of patients with multiform glioblastoma treated with two consecutive protocols of a combined approach.
Of 86 patients that entered this study, thirty-seven were treated with surgery, postoperative hyperfractionated radiotherapy using 1.2 Gy b.i.d. to a total tumour dose of 72 Gy in 60 fractions in 30 treatment days and adjuvant chemotherapy consisting of BCNU, vincristine, procarbazine and cisplatin for up to 6 cycles or until tumour progression. Forty-nine patients were treated with surgery and postoperative accelerated hyperfractionated radiotherapy using 1.5 Gy b.i.d. fractions to a total tumour dose of 66 Gy in 44 fractions during 22 treatment days. BCNU and hydroxyurea were given once weekly during the irradiation period. Surgery consisted of biopsy in 25 patients and subtotal or gross total tumour resection in 61 patients. Patients treated with a more radical surgery had longer median survival time and higher 1- and 2-year survival rates than those treated with biopsy (56 v.s. 29 weeks, respectively; 62% and 23% v.s. 16% and 0%, respectively; long rank, p = 0.0000) (Figure 1). They also had longer median time to tumour progression and higher 1-year progression-free survival rate than those treated with biopsy only (33 v.s. 21 weeks, respectively; 20% v.s. 0%, respectively; log rank, p = 0.00000) (Figure 2). Multivariate analyses using both survival and progression-free survival as endpoints confirmed that the extent of surgery was an independent prognostic factor, together with the age, tumour location, and interfraction interval (Tables 3 and 4).
The benefit of a more radical surgery remains controversial in patients with multiform glioblastoma, although maximal tumour reduction should be supported from the cytokinetic point of view. Findings of various authors support this view. Results of this study add further evidence that the aggressive surgical approach carries significant benefit for patients with multiform glioblastoma regarding the survival and progression-free survival. These observations are confirmed with multivariate analyses that showed independent influence of this prognostic factor.
Srpski arhiv za celokupno lekarstvo 01/1997; 125(3-4):93-8. · 0.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sixty-four adult patients with malignant glioma entered into a Phase II study on the use of accelerated hyperfractionated radiation therapy. Histology included anaplastic astrocytoma (AA) in 15 patients and glioblastoma multiforme (GBM) in 49 patients. Treatment consisted of radiation therapy doses of 66 Gy in 44 fractions in 22 treatment days in 4.5 weeks, fractions of 1.5 Gy, b.i.d. 1,3-bis(2-chlorethyl)-1-nitrosourea (BCNU) 80 mg/m2 and hydroxyurea 800 mg/m2 were both given on treatment days 1, 6, 11, 16, and 21 during the irradiation course. Median survival time for all 64 patients is 61 weeks (range; 12-163 weeks) from the date of starting irradiation. Median time to tumor progression (MTP) for GBM patients is 31 weeks, and 1-year and 3-year progression-free survival (PFS) are 16% and 0%, respectively, while MTP for AA patients is not attained yet, and 1-year and 3-year PFS are 100% and 73%, respectively. On univariate analysis of prognostic factors for GBM patients, younger age, total or subtotal tumor removal, and frontal tumor location are associated with a better prognosis. A multivariate analysis confirmed the importance of the extent of surgery and tumor site and revealed the interfraction interval (4.5-5.0 hours vs 5.5-6.0 hours, p = .041) as an important prognostic factor. Acute and late toxicity is not increased. Longer follow-up and more patients are needed to evaluate tumor control and toxicity in AA patients.
American Journal of Clinical Oncology 11/1995; 18(5):449-53. · 2.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Forty-eight patients with malignant glioma were treated with hyperfractionated radiation therapy followed by multiagent chemotherapy to explore feasibility and toxicity of such combined modality treatment.
There were 34 males and 14 females with a median age of 53 years (range, 32-74 years) and median Eastern Cooperative Oncology Group performance status score of 1 (range, 0-3). Histology included anaplastic astrocytoma in 11 patients and glioblastoma multiforme in 37 patients. Radiation was given at 1.2 Gy per fraction, two fractions per day, for a total dose of 72 Gy, with a reduction in field size after 52.8 Gy. Four weeks after completion of hyperfractionated radiation therapy multiagent chemotherapy was introduced with bischlorethyl nitrosourea (BCNU) 50 mg/m2, days 1-3, vincristine 1.4 mg/m2 (max. 2 mg), day 1, procarbazine 50 mg/m2, days 1-7 and cisplatin 20 mg/m2, days 1-3. Cycles were repeated every 4 weeks to a maximum of six cycles or until tumor progression was noted.
Median survival time for all patients was 52 weeks (range, 16-185 weeks) and median time to tumor progression was 30.5 weeks (range, 12-131 weeks). Besides age, histology, performance status, and extent of surgery, interfraction interval and location of tumor influenced survival in glioblastoma multiforms patients on univariate analysis: Patients treated with shorter intervals (4.5-5 h) did better than those treated with longer intervals (5.5-6 h); also, glioblastoma multiforme patients with frontal tumors did better than those with tumors of the other locations. Multivariate analysis confirmed that the performance status, interfraction interval, and tumor location were significant prognostic factors in glioblastoma multiforme patients. Acute toxicity was mild. No cases of brain necroses were observed.
Hyperfractionated radiation therapy followed by multiagent chemotherapy was well tolerated with mild acute and virtually no late toxicity. More patients and longer follow-up are needed for further evaluation of its activity and late effects in anaplastic astrocytoma patients.
International Journal of Radiation OncologyBiologyPhysics 01/1995; 30(5):1179-85. · 4.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: During 1992. 19357 patients were examined at the Department for Neurosurgery of the Emergency Centre, Clinical Center of Serbia, out of which 15879 had head injury. In addition to those necessitating hospitalisation, there was also a large number of patients with mild head injury that were not admitted for hospital management and were sent home following initial first aid. The average incidence of these patients was 45 patients per day during 1992. During 1992. a total of 1,978 patients were hospitalised, out of which 1,520 (84%) were injured. A total of 633 patients (25%) were hospitalised due to injuries sustained in traffic accidents. All patients were examined and evaluated according to the standard protocol including GCS as well.