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Introduction. Juvenile nasopharyngeal angiofibroma are benign tumors, with locally aggressive behavior. Preoperative tumor embolization with polyvinyl alcohol particles can reduce intraoperative blood loss and facilitate surgical resection. Case outline. A 16-year-old male was admitted to hospital due to profuse epistaxis and sense of nose fullness. Multidetector computed tomographic angiography examination showed a tumor mass in the right nasal cavity with extension to the right maxillary sinus and ethmoidal cells on the right, and in the left nasal cavity. It rested on the nasal septum, but without bone destruction. After application of contrast agent, described mass became intensely opacified. Preprocedural digital subtraction angiography of external and internal carotid arteries of both sides showed extensive pathological vascularization, which received main contribution from branches of maxillary artery on right and, to a lesser extent, on left side. Due to danger of penetration of a particle embolization agent of smaller diameter into orbital branches and possible retrograde migration into carotid artery, we decided to apply particle embolization agent of larger diameter (500–700 μm) than prescribed by modern standards. Tumor was completely surgically removed third day after embolization, and patient was discharged without any neurological deficit. Control contrast enhanced multidetector computed tomographic angiographies were performed at third and seventh month after surgery and showed no tumor residue or recurrence. Conclusion. The use of particles of larger diameter gave satisfactory results during operation – surgical excision of tumor, when dangerous anastomoses do not allow use of particles of smaller diameter and can be safely performed without significant neurological nor systemic complications.

Introduction. Patients with severe spasticity are effectively treated with intrathecal baclofen therapy (ITB), but because of their invalidity, in case of infection, prognosis is poor. Case outline. We present three cases (two men and one woman) of patients treated with baclofen intrathecal therapy due to spasticity of all four extremities who underwent SARS-CoV2 virus infection. Two of them have multiple sclerosis, and one has trauma of the cervical segment of the spinal cord. In all three patients, the clinical presentation of COVID-19 infection occurred within six months of implantation of the pump for ITB. They were successfully treated in hospital with same dose of the drug and without exacerbation of neurological status. Barthel index (BI) and modified Rankin score were same before and after COVID-19 infection. In two cases BI was 20, and in one 69; and modified Rankin score (mRS) was 3 in one case, and 5 in two cases. Conclusion. Patients with severe spasticity who require intrathecal baclofen therapy can be safely treated regardless of the pandemic.

Introduction. Intracranial aneurysms with a radiological sign of a donut are a medical priority and have been described in a small number of cases. This radiological sign occurs in aneurysms in which there is partial thrombosis inside aneurismal sac and circular laminar flow between the aneurismal wall and the thrombus in its center. Consequently, there is a central contrast-filling defect of the aneurysm sac observed on different angiographic imaging methods. Case outline. We present a 35-year-old female patient admitted for examination due to frequent headaches, visual disturbances on the left and loss of sight on the right eye. Digital subtraction angiography (DSA) showed an aneurysm on the right internal carotid artery measuring 25.6 × 25 mm, while neck measured 11 mm and included part of the C6 and C7 segments. Treatment decision was made that placing a flow-diverting stent across the aneurysm neck would be most beneficial in this case. After the procedure, the patient was discharged in the same general condition as she was before admission to the hospital. Seven months after the intervention, she reported for her first DSA control examination. Normal position of the left A1 segment was demonstrated, suggesting shrinkage of the aneurysm sac. An improvement of vision on both eyes was stated. Conclusion. We present a patient with a “donut” aneurysm on the internal carotid artery, successfully treated with a flow-diverting stent.

Introduction. Anomalies of the middle cerebral artery (MCA) are very rare. “Rete MCA,” “twig-like MCA” (T-MCA), “aplastic MCA,” “unfused MCA,” and others are all synonyms for unilateral embryological anomaly of the M1 segment of the MCA, where, due to an unknown cause, fusion of primordial arteries of the M1 segment did not happen. As a result, the M1 segment of the affected side consists of a mesh of small arteries from which arise normal perforators and cortical branches. Moyamoya disease, moyamoya-like syndrome, atherosclerotic steno-occlusive disease, vasculitis, and dissection of the MCA should be considered in differential diagnosis. Case outline. We present a 60-year-old female patient with twig-like left MCA, incidentally diagnosed due to persistent headaches six days prior to admission. Non-contrast computed tomography head examination was without peculiarities. Computed tomography angiography showed a network of small vessels in place of the left M1 segment, bridging internal carotid artery terminus with branches of the MCA bifurcation and giving rise to lenticulostriate arteries. Fourteen months later, on physical examination, the patient was in good general condition, without a neurological deficit, with occasional episodes of headache no stronger than 3–4/10 on the visual analogue scale. Conclusion. We report a patient with extremely rare variation of the M1 segment of the left MCA, incidentally diagnosed due to headaches.

Introduction. Natural course of aneurysms that occur on blood vessels of the brain singles out the need for understanding the mechanism of the occurrence of aneurysm wall rupture and identification of anatomic characteristics as predictive factors for hemorrhage to occur. Objective. In this study we comparatively present results of our researches and experimental models on animals. Methods. We made a comparative analysis of anatomical characteristics of blood vessels of the brain and aneurysms obtained on the basis of digital subtraction angiography and intraoperative finding. In this article we review recent research in the anatomic characteristics of intracranial aneurysms and parent blood vessels. We present a series of 185 aneurysms (ruptured and unruptured) dissected at the Neurosurgical Clinic of Clinical Center of Serbia in Belgrade. Results. Inclination angle may be considered as the vital predesposing factor for intracranial aneurysm rupture. In aneurysms that ruptured it was 139.748±27.242°, while in unruptured aneurysms it was considerably smaller and amounted to 100.882±22.001° (p

Introduction. Intraventricular hemorrhage occurs in almost one fifth of prematurely born children. Due to present complications, such as hydrocephalus and neurological deficit, it endangers the child’s life, therefore there is the need for understanding and prevent risk factors as well as the need for finding most optimal methods of treatment. Objective. The aim of the study was to point out the current therapeutic modalities of the treatment of posthemorrhagic hydrocephalus in prematurely born children. Methods. The study included 60 patients divided into two groups of 30 patients treated at the University Children’s Hospital of Belgrade in the period 2003-2008. Results. Treatment outcome of the control group of patients treated by standard methods was influenced by gestational age (p=0.024), head circumference on birth (p=0.043), body mass on birth (p=0.006), Apgar score on birth (p

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.

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 treat- ment 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.

Introduction: The size of meningioma and its relation with neurovascular structures in petroclival region stipulate the degree of surgical radicalism and determine an operation risk. In spite of progress of surgical technology, the rate of surgical morbidity in view of cranial nerves deficit is 30%-50%. Objective: The objective of our study was to present the results of treatment of patients with petroclival meningiomas and to point to correlation of preoperative radiological findings and intraoperative results as well as neurological status of patients before and after surgical treatment. Method: Retrospective analysis of 35 operated petroclival meningiomas at the Institute of Neurosurgery, CCS, in the period from 1995 to 2004 was presented. The following parameters were analyzed: size of tumor, relation with bone and neurovascular structures, preoperative condition, degree of surgical radicalism and postoperative outcome. Results: The size of tumor was classified in four groups. There were 20 tumors at the right, and 15 at the left side. At the time of diagnostic procedures (based on CT and MRI), 20 tumors were in contact with brainstem, 9 compressed the brainstem, and 6 obstructed the IV ventricle. Preoperative patient condition was evaluated by Karnofsky index. Mean value for group I was 90, II - 80, III - 70 and IV - 50. In 9 cases, liquor drainage was performed preoperatively. In 3 cases, external liquor drainage was carried out postoperatively, and in one case it was replaced by permanent liquor drainage. Radical operation was performed in 44%, and significant reduction was done in other cases. In the postoperative period, 11% patients died, 28% had cranial nerves deficit, and pyramid deficit was recorded in 14% of the patients. The tumor size (III-IV) and brainstem compression were found to be statistically significant (p

INTRODUCTION Hydrocephalus is one of the most significant complications of spontaneous subarachnoidal haemorrhaging that can be treated surgically. OBJECTIVE We analyzed risk factors that caused spontaneous subarachnoidal haemorrhaging. Patients were divided into two groups: shunt-dependent and shunt-independent. METHOD We retrospectively analyzed 174 patients (63 men and 111 women), surgically treated at the Institute of Neurosurgery of Clinical Center of Serbia in the period from January 2002 to January 2004. RESULTS The prevalence of hydrocephalus in patients with a shunt (shunt-dependent) was most significant in women (18%:9.5%), but not statistically significant (p>0.05). Concerning the significance of age (years), we found that hydrocephalus in patients with a shunt was most significant in older patients (p0.05%). In patients with intraventricular haemorrhaging (29.3%:10.5%) and vasospasms (34.6%:6.5%), the prevalence of shunt-dependent hydrocephalus was statistically very significant (p0.05). The prevalence of shunt-dependent hydrocephalus with aneurysms in the a. basillaris basin was 47.4%, with multiple aneurysms 17.2%, and with aneurysms of the anterior segment 9.5%, which represents a statistically significant difference (p

Background. Posterior fossa epidural hematomas represent 7-14% of all traumatic intracranial epidural hematomas. They are most frequently encountered posttraumatic mass lesions in the posterior fossa. The aim of this study was to identify clinical features that could lead to the early diagnosis of posterior fossa epidural hematoma. Methods. Between 1980 and 2002, 28 patients with epidural hematoma of the posterior fossa were operated on at the Institute for Neurosurgery, Belgrade. Clinical course neuroradiological investigations, and the results of surgical treatment of the patients with posterior fossa epidural hematomas were analyzed retrospectively. Results. Almost two thirds of patients were younger than 16 years of age. In 20 cases injury was caused by a fall, in 6 cases by a traffic accident, and in 2 by the assault. Clinical course was subacute or chronic in two thirds of the patients. On the admission Glasgow Coma Scale was 7 or less in 9 injured, 8-14 in 14 injured, and 15 in 5 injured patients. Linear fracture of the occipital bone was radiographically evident in 19 patients, but was intraoperatively encountered in all the patients except for a 4-year old child. In 25 patients the diagnosis was established by computer assisted tomography (CAT) and in 3 by vertebral angiography. All the patients were operated on via suboccipital craniotomy. Four injured patients who were preoperatively comatose were with lethal outcome. Postoperatively, 24 patients were with sufficient neurologic recovery. Conclusion. Posterior fossa epidural hematoma should be suspected in cases of occipital injury, consciousness disturbances, and occipital bone fracture. In such cases urgent CAT-scan is recommended. Early recognition early diagnosis, and prompt treatment are crucial for good neurological recovery after surgery.

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This article reports that posterior fossa epidural hematomas represent 7-14% of all traumatic intracranial epiduraI hematomas. They are most frequently encountered post-traumatic mass lesions in the posterior fossa. The aim of this study was to identify clinical features that could lead to the early diagnosis of posterior fossa epidural hematoma. Between 1960 and 2002, 28 patients with epidural hematoma of the posterior fossa were operated on at the Institute for Neurosurgery in Belgrade. Clinical course, neuroradiological investigations, and the results of surgical treatment of the patients with posterior fossa epidural hematomas were analyzed retrospectively. Almost two thirds of patients were younger than 16 years of age. Posterior fossa epidural hematoma should be suspected in cases of occipital injury, consciousness disturbances, and occipital bone fracture. In such cases urgent CAT-scan is recommended. Early recognition, early diagnosis, and prompt treatment are crucial for good neurological recovery after surgery.

Unlabelled: In spite of the progress made in diagnostic procedures and development of the operating rooms technology, considerable neurological deficit after operation of tumors localised in the brain motor zone commits one to direct intraoperative identification of the motor zone. By introducing direct electrocortical stimulation into the routine intraoperative application the primary goal has been achieved -reaching the maximum degree of radicalness of surgical resection while preserving motor centres in the cerebral cortex., Method: We are hereby demonstrating a series of 60 patients operated for primary brain tumors localised in the area in the front and around the central sulcus. All operations have been performed under the general anesthetics. During the operations the method of direct electrostimulation (ES) was used for the purpose of identifying motor centres., Results: Intraoperatively a level of subtotal resection was achieved in 22 cases, while radical resection was possible in 38 cases. Significantly higher level of radicalness of surgical resection of the low grade glioma tumor was confirmed statistically in relation to the group of patients with glioblastoma multiforme by applying the ES cortex (p < 0.05). Patients with slow developing brain glioma have statistically considerably higher KI value in relation to the KI values in the group of patients with glioblastoma multiforme (p 0 < 0.01). Difference in the measured values of distance from the coronal suture based on the results of MRI measuring and finding obtained by ES, has shown a statistically considerably higher difference with a glioblastoma multiforme 8.26 +/- 4.288 mm when compared to slowly developing astrocitoma 5.88 +/- 3,080 (p < 0.05)., Conclusion: Electrostimulation of the brain cortex is a safe, simple and precise method for identification of the brain motor zone which enables prevention of additional postoperative deficit and higher level of surgical radicalness.

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.

Introduction: Hydrocephalus is one of the most significant complications of spontaneous subarachnoidal haemorrhaging that can be treated surgically., Objective: We analysed risk factors that caused spontaneous subarachnoidal haemorrhaging. Patients were divided into two groups: shunt-dependent and shunt-independent., Method: We retrospectively analysed 174 patients (63 men and 111 women), surgically treated at the Institute of Neurosurgery of Clinical Centre of Serbia in the period from January 2002 to January 2004., Results: The prevalence of hydrocephalus in patients with a shunt (shunt-dependent) was most significant in women (18%:9.5%), but not statistically significant (p > 0.05). Concerning the significance of age (years), we found that hydrocephalus in patients with a shunt was most significant in older patients (p < 0.025). The HiH and Fisher gradings were not statistically significant in our study (p > 0.05%). In patients with intraventricular haemorrhaging (29.3%:10.5%) and vasospasms (34.6%:6.5%), the prevalence of shunt-dependent hydrocephalus was statistically very significant (p < 0.005; p < 0.001). The frequency of ventriculomegalia in the initial CT scan was greater for patients with a confirmed diagnosis, but of no statistical significance (p > 0.05). The prevalence of shunt-dependent hydrocephalus with aneurysms in the a. basillaris basin was 47.4%, with multiple aneurysms 17.2%, and with aneurysms of the anterior segment 9.5%, which represents a statistically significant difference (p < 0.001)., Conclusion: We discovered that hydrocephalus, as a complication of spontaneous subarachnoidal haemorrhaging, was most frequent in patients older than 50 years, manifesting in ventricular haemorrhaging, vasospasm, and aneurysms of the posterior segment.

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.