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The authors present their own experience in the treatment of tuberculum sellae meningiomas. The presented series includes 14 patients operated on during past 7 years. Visual loss was the first symptom in 78% of patients. The period between the onset of symptom and surgical treatment was long and in the majority of patients exceeded 2 years. Monocular blindness was found in 71% of cases prior to surgery. The authors present the results of surgical treatment with special attention directed to visual function after surgery. In conclusion, the authors stress the still unacceptably long period between the onset of symptoms and correct diagnosis. When the size of tumour exceeds 4 cm and compressing of adjacent important neurovascular structures is evident, possibilities of total removal are limited and the chance for visual improvement is low.

Report concerns 6 uncommon cases of cerebral ganglioglioma in adult patients, the majority of whom (4) demonstrated typical classic features, others were anaplastic. Both types presented neuronal and glial components characterized either by NF, NSE and Syn or GFAP immunoreactivity. Only the tumor of the youngest patient presented moderate desmoplasia. Observations indicate at an easy classification of glial component contrary to neuronal component in relation to the origin of neuronal changes.

Authors present the results of surgical treatment of 63 patients with Cushing's disease. They evaluate various diagnostic procedures, applied to define the aetiology of endogenous hypercortisol. The petrosal sinus sampling for ACTH level is described. In the series in only 32% of patients; radiological examinations (including CT and MRI) showed the pituitary adenoma. Among 63 operated persons--43 were subjected to surgery based on endocrinological data alone. All the patients were operated by transsphenoidal route. Good result--endocrinological recovery in the treatment of Cushing's disease was achieved in 80% of patients.

Problem of surgical treatment in the elderly is still discussed in the literature. This group of patients needs especially clear criteria of qualification for extensive intracranial procedures. The authors present their own experience with 35 patients over 70 years old with intracranial tumours and intracranial aneurysms treated in Department of Neurosurgery, Warsaw Medical School between 1992-1993. Among 11 patients treated conservatively, only 3 patients were in poor physical state with functional limitation which was a contraindication for surgery. Postoperative mortality was 4.2%. On the basis of our experience we think that patients over 70 years can be safely operated on intracranial lesions and the age is not a contraindication for neurosurgical procedures.

The authors evaluate in the presented prospective study the incidence of late epilepsy after aneurysm surgery. 121 consecutive patients were operated on for ruptured aneurysm and were discharged home without any prophylactic anticonvulsant treatment and were followed-up for 12 months. The diagnosis of late epilepsy was made, if two or more seizures occurred during that time. Epilepsy occurred in 8 patients, so the incidence was 7%. Additionally in 3 patients a single seizure was observed during follow-up time but any anticonvulsant treatment was installed and the seizures did not recur for up to 24 months. The analysis of epileptic patients showed that in most of them the aneurysm was located on MCA and SAH was complicated by intracerebral haematoma or symptomatic vasospasm. On the basis of own experience and review of the literature the authors discuss the necessity of anticonvulsant prophylaxis after aneurysm surgery.

New diagnostic possibilities make possible a more precise localization of epileptogenetic foci and surgical treatment of epilepsy is associated presently with minimal risk. This was the reason of a surge of interest in recent years even in those countries where this method has not been used. In our country operations for chronic refractory epilepsy have been performed since over 35 years and the gathered experience is sufficient to reach conclusions about the results. The results depend in a certain degree on the location of the focus and the surgical possibility of its removal. In about 50% of the cases cure was effected, and in 15% improvement was achieved near cure. Considering that the treated patients had long-standing and refractory epilepsy with very frequent seizures the results of surgical removal of epileptogenic focus were very good. The authors believe that patients with chronic, focal and refractory epilepsy should be treated surgically, and conservative treatment without considering this possibility is erroneous.

The authors present palliative therapy of severe epilepsy, i.e. callosotomy. Experimental studies and numerous clinical trials indicate possible use of this technique. However, there are no precise indications and contraindications to the treatment with this technique. The authors discuss own experience with 8 epileptic patients refractory to preservative therapies. These patients were treated surgically with anterior callosotomy. Small number of patients and relatively short period of the follow-up do not allow more general conclusions to be drawn. However, in 3 out of 4 operated patients an improvement was noted within one year or more, including one case of significant improvement. No improvement was seen in one case. The authors will collect other cases. However, it is worth emphasizing that callosotomy is performed in Poland, already.

Somatosensory evoked potentials (SEP) were recorded from the scalp in 47 patients and intraoperatively from the exposed cortex in 30 persons with various forms of focal epilepsy. SEP from stimulation of the median nerve were recorded from the standard derivations: F3, F4, C3, C4, T3, T4, P3, P4 and/or electrodes placed on the exposed cortex. Primary cortical negative (N20) and positive (P20) responses were analyzed. Surface recordings were normal in majority of cases (79%). The most common abnormality was the lack of cortical waves in the damaged area (mostly frontal region) or the absence of cortical responses in the whole hemisphere when central area was involved. Comparing cortical responses obtained before and during operation we found that they were similar (polarization, latency) in the majority of cases there was no response before and intraoperatively. SEP are primarily influenced by organic brain damage symptoms, but not by functional brain changes.

An incidence of tumors of the brain as a cause of drug-resistant epilepsy have been analysed. The analysis included patients operated for epilepsy at the Department of Neurosurgery, Medical Academy in Warsaw between 1987 and 1991. Malignant tumors were found in 21 out 85 patients (24.7%) treated surgically, 22.4% were benign tumors, and 52.9%--lesions of cicatricial character. The most frequent malignant tumor was fibrillary astrocytoma, noted in 57.1% of cases. Neurological examination has revealed discrete symptoms only in 2 out of 21 patients. CT scans have showed non-characteristic focus of decreased density in 12 patients (57.1%). Differentiation of tumor-produced epilepsy and those due to other focal lesions could not be made with the clinical course of seizures and EEG records. Actually, an incidence of tumors of the brain causing seizures refractory to pharmacologic treatment is increasing. Not characteristic clinical course and EEG records as well as CT scans are the main causes of delays in the surgery.

A case of the 18-year-old boy suffering from epilepsy since 8 years and suspected of microangioma is presented. The craniotomy revealed left parietal parasagittal superficially located neoplasm and arteriovenous malformation beneath. Unexpected fibrillary astrocytoma associated with vascular tumor was the diagnostic problem, solved histologically after the operation. The problem of coexistence of various neoplasms with arteriovenous malformations is discussed.

A new dural prosthesis was prepared by bilateral coating of polyester net with radiation-modified collagen. Prosthesis is smooth highly flexible, water resistant and 0.3 mm thick. In the Department of Neurosurgery, Warsaw Medical Academy, Poland, 11 patients had a new dural prosthesis implanted, 1 with posttraumatic CSF-leakage and 10 with intracranial neoplasms. Early observation (2 to 4 weeks) and delayed (7 to 23 months) were performed. Neither allergic nor inflammatory reactions were observed. No CSF-leakage was observed. A new Polish dural substitute seems to be better than other ones because of its similarity to natural dura mater and low price.

The dangers connected with postoperative wound infection, especially in neurosurgery, are discussed, together with various methods of reduction in the pertinent literature and used in various clinical centres. The review shows that properly used perioperative prophylaxis has reduced markedly the incidence of wound infection, even to zero in elective clean neurosurgical operations. The antibiotics used for this purpose are described, and indications are given concerning the selection of proper antibiotics.

A 30-year-old man suffered for a year of a typical syndrome of cerebellar tumor. At suboccipital craniectomy a soft tumor infiltrating both hemispheres and vermis, filling up part of the IV ventricle was found. After subtotal removal of the neoplasm the postoperative course was poor and the patient died 5 weeks later. Biopsy material consisted of three types of tissue: 1. large nests of carrot-shaped, hyperchromatic cells, 2. fields of "halo" cells presenting myelin basic protein (MBP) immunoreactivity and 3. fields and scattered strongly GFAP-positive cells. The histological and immunocytochemical pattern of the neoplasm indicates differentiation of the tumor into oligodendrogliomatous and astrocytomatous line being an uncommon example of dual glial differentiation capability in medulloblastoma.

Own experience is presented in the administration of prophylactic antibiotic treatment in clean neurosurgical operations. The clinical material comprised 131 patients subjected to 138 operations. For prophylaxis ceftriaxone (Rocephin "Roche") was given by the so called short term programme in which 2 g of the drug was given intravenously before the operation, and 1 g after 24 hours. The frequency of postoperative infections was 0.7% in the group. The effectiveness is stressed of the short-term programme of prophylactic antibiotic treatment in the prevention of postoperative infections in neurosurgery emphasizing that operations in emergency cases, perioperative steroid therapy, tumours, craniotomy with free bone flap do not reduce the effectiveness of the method.

The authors present a clinical analysis of 42 patients with vertebro-basilar aneurysms considering symptoms, course and complications of subarachnoid haemorrhage and localization of aneurysms: 88% were admitted after SAH, 47.6% had basilar bifurcation aneurysm. The ischaemic deficits due to vasospasm were observed in 5.4% of cases. Rebleeding occurred in 29.7% of patients, most of them died. 23 patients were operated on. In 69.9% of cases the operation was successful. The operative mortality was 17.4%. Temporary third nerve palsy was the most often postoperative complication.

The study was performed on cerebral tissue resected during temporal lobectomy in 16 patients whose long-standing cryptogenic epilepsy did not submit to anticonvulsive drugs. Cases presenting definite etiological factors such as CNS trauma, infection or neoplasm were excluded. Neuropathological investigations disclosed microangiomas and focal vascular malformations in the meninges and tissue in 7 patients. Neuronal heterotopias in the white matter and of the white matter in the cortex were observed in 3 cases. Main cortical changes were: neuronal loss, chronic neuronal degeneration, perineuronal satellitosis, and GFAP-positive submeningeal gliosis, especially at the bottom of sulci, perivascular gliosis and laminar or diffuse gliosis. The changes in the hippocampus were most enhanced in the end-plate and in the sector H3 of the pyramidal layer. Astrocytic gliosis in the white matter presented distinct GFAP and S-100 immunostaining; the latter involved in some cases a wider area than the GFAP reaction. The above named changes are analysed with regard to the presumed epileptogenic factors and to the postepileptic damage.

Preoperative recording of evoked potentials after stimulation of the tibial nerve was followed by similar intraoperative recording in 6 patients with cauda and conus terminalis tumours and 2 patients with intervertebral disc prolapse at lumbar level. The shape and latency of these potentials were sensitive indicators of the level and degree of damage to the nervous elements in this area. The selectivity of the method was significantly higher during intraoperative recording. Monitoring of these potentials may serve for control of the integrity of sensory pathways during neurosurgical interventions.

Spinal cord stimulation (SCS) is a method enabling the control of increased muscle tonus to be achieved in various spinal cord injuries. Polyelectromyographic (PEMG) methods were used for neurophysiological assessment of the degree of cord damage and persistent spinal reflexes as well as supramedullary influences. The analysed material comprised 40 PEMG records in 19 patients with spastic paraparesis or paraplegia after cord injury, cord tumour or multiple sclerosis. In 15 cases tentative epidural cord stimulation was done and 11 patients received implantation of a system for long-term stimulation. In most cases the epidural electrodes were implanted below the damaged segment, usually in the thoracic part of the cord. Before and after SCS beginning PEMG was done with a 16-channel Mingograph Siemens Elema with simultaneous recording of the responses from the symmetric muscles: quadriceps, semitendinous, adductor femoris, anterior tibialis and triceps surae. The effect of SCS was analysed on exteroceptive and proprioceptive reactions during testing of knee and ankle reflexes, and on the response of the muscles to vibration. In most patients a reduction was observed of the intensity of tendon reflexes, particularly the spread of the reflex to the contralateral extremity was no longer seen. The vibration reflex had a tonic character persisting in 48% of the studied muscles, even in patients with clinically complete transsection of the cord. The change of the character of monosynaptic reflexes and the presence of the vibration reflex suggest that SCS modifies the proprioceptive segmental spinal reactions.

Unlabelled: Stereoencephalotomy remains often the only therapeutic method in severe cases of drug-resistant epilepsy in which it is not possible to use the classic resection methods. In the light of literature data we chose Forel's field as the site for producing stereotaxic lesions since it is the most strategically situated site in the pathways of propagation of epileptic seizures., Surgical Technique: we used Leksell's stereotaxic apparatus for the operations. The contrast medium for filling the ventricular system was Dimer X. The parameters used in accordance with Jinnnai were calculated from the intercommissural line. The clinical and electrophysiological features of these cases are reported. Eleven patients were operated upon who could not be qualified for other surgical treatment methods because of generalized EEG changes. The main criterion accepted for qualification of patients by us were frequent seizures (at least 1 daily) despite systematic treatment conducted under control of serum drug levels. The indication for selecting the side of the operation was preponderance of EEG changes or presence of any lateralizing signs in the seizures. The duration of follow-up sufficient for evaluating the effectiveness of the operation was obtained in 7 patients. The following results were achieved: very good in 1 case, good in 3, improvement in 2 and poor in 1. In the light of these preliminary observations we consider that unilateral destruction of Forel's field is an operation indicated in severe generalized seizures, especially in the primary generalized form.

The aetiopathogenesis of spasmodic torticollis has not yet been explained. The problem of surgical treatment selection is also at issue. The authors present own observations in 5 cases treated by operations on the peripheral nervous system. In 3 cases a very good therapeutic results was obtained, in 2 cases the results was not satisfactory. A characteristic fact was appearance of ultimate improvement only several months after the operation, similarly as it is observed after stereotactic operations. In the light of own observations and a survey of the literature the authors reach the conclusion that operations on the peripheral nervous system as the first stage of surgical treatment give good results in most cases.

The authors describe a case of a 53-year-old woman with recurrent episodes of high-grade amblyopia leading to blindness of the left eye and considerable impairment of the visual acuity of the right eye. Laboratory investigations ruled out presence of a tumour in this area. In view of possible adhesive arachnitis in the region of the chiasma exploratory craniotomy was done finding an evident compression of the visual nerves closely at the optic foramina by the dilated and atherosclerotic internal carotid arteries. The authors review the literature on the problem stressing the rarity of the syndrome.

The authors describe a case of syringobulbia in a 52-year-old patient treated surgically. Atlanto-occipital decompression and longitudinal medullotomy was done. A significant clinical improvement followed, deglutition disturbances disappeared and the general locomotor activity became much better.

The authors report a patient aged 58 years with a history of two episodes of subarachnoid haemorrhage and with arteriographic finding of four intracranial aneurysms: two on the internal carotid artery, one on the trifurcation of the middle cerebral artery, and one on the anterior communicating artery. Despite rather poor general and local condition (III clinical group) during the operation all four aneurysms were closed with clips. After a stormy postoperative course the condition of he patient improved and 6 months later he was feeling well, had no paresis, and only some memory disturbances remained. This case shows that multiple intracranial aneurysms should be treated in one-step operation, if this can be done from one surgical approach. This is important particularly in these cases in which it is difficult to say which aneurysm is bleeding.

The authors describe a 7-year-old boy with severe epilepsy cured by means of two-stage hemispherectomy. Epileptic seizures occurred in the left extremities and recurred several tens of times daily despite intensive pharmacological treatment. EEG investigations demonstrated seizure activity in the right motor-parietal-temporal area. Stereotaxic destruction of Forel's field and thalamus on the right side gave only brief improvement lasting several days. In view of this the frontal, temporal and a part of the parietal lobe were removed according to electrocorticographic investigations. During 6 months after the operation epileptic attacks were absent, than they recurred with increasing frequency. After 10 months full hemispherectomy was done. The child tolerated the operation very well, and control examination after 2 years showed disappearance of epileptic attacks and considerable compensation of motor power loss and sensory disturbances in the left extremities. The authors believe that hemispherectomy carried out in two stages at an interval of several months is better tolerated by the patients and makes possible better compensation of functional disturbances than classic hemispherectomy. In the discussion the authors stress the importance of extrapyramidal pathways for compensation of motor disturbances.

The authors present 6 patients with brain abscesses treated conservatively. There were multiple brain abscesses in 4 patients. The patients were in good general condition without marked symptoms of high intracranial pressure. The conservative treatment lasted 4 to 11 weeks under CT control and careful observation of clinical status. 5 patients were cured, 4 of them without any neurological deficit and 1--with visual field defect after bilateral brain abscesses in occipital lobes. 1 patient died in spite of drainage of the biggest of multiple abscesses. The authors confirmed the value of conservative treatment in selected cases of brain abscess, specially in multiple brain abscesses. The early beginning of such treatment seems to be specially important.

The authors report a statistical analysis of the levels of phenobarbital (PH) and diphenylhydantoin (DPH) in a group of 100 patients with different types of epilepsy mostly resistant to pharmacological treatment. The mean values of PH and DPH were compared with the types of epilepsy, duration of the disease, additional treatment, EEG changes and therapeutic results. The following conclusions have been reached: a) therapeutic ranges of the PH and DPH levels in this group of patients were greater than those reported by others. b) no significant correlation is found between the levels of these drugs and the type of epilepsy, disease duration and EEG changes, with the exception of a positive correlation with PH level. c) Clonazepam, diazepam and mysodin raised the serum PH level in the serum, while only amizepine raised the DPH level. d) higher levels of PH and DPH were found in patients with poor therapeutic results.

Terminal ventriculostomy is one of the methods used in surgical treatment of syringomyelia. The procedure is well tolerated and may be used in cases in which atlanto-occipital decompression is too serious an operation. The author used the method in treatment of 10 patients with different stages of syringomyelia. In 5 cases the time of follow-up was 12--20 months, in 2 of them the result was very good with very great improvement, in 3 improvement was slight but the progression of the disease was halted. In 5 cases with shorter follow-up improvement was observed in 3 and no improvement immediately after the operation in 2 cases. Further follow-up of these patients will show whether the results of the operation will be permanent.

In 10 out of 63 patients with intracerebral haematomas treated conservatively the authors measured approximately the volume of haematomas by means of serial CT examinations during observation of their resorption. These were large and medium-size haematomas, from 20 to 70 ml in volume. The mean rate of resorption was from 0.7 to 1.0 ml daily. Gradual regression of mass effects was noted. All patients were on admission in a relatively good condition, conscious or only somnolent, with focal neurological signs. In some cases signs of increased intracranial pressure were present. Improvement of the general condition and neurological status was relatively rapid, even pronounced paresis and aphasia regressed in most cases. Two patients (3%) died of non-cerebral causes. It is believed that most intracerebral haematomas may be treated conservatively. The presence of mass effects, increased intracranial pressure or even a major neurological syndrome are not regarded as indications to operation if the state of consciousness is good and is not deteriorating. Even large and deeply situated haematomas may be resorbed without leaving a gross neurological deficit. A careful observation of the state of the patient, control CT investigations and the possibility of carrying out emergency operation in case of deterioration of the level of consciousness are indispensable for safe conservative treatment of these patients.

The authors report their preliminary experiences with early (within 72 hours after haemorrhage) operations in cases of intracranial aneurysms. Out of 131 patients operated on from April 1985 to March 1986 in the Department of Neurosurgery, Medical Academy in Warsaw 20 were qualified for surgical intervention immediately after haemorrhage. In 13 cases Nimodipine (Nimotop) was given locally during the operation and in the postoperative period. The schedule of drug administration is shown. In 15 cases (75%) a very good result was noted, in 3 (15%) major signs of focal brain damage were observed within 6 months after the operation. Two patients (20%) died. In 4 cases neurological focal signs developed 4-5 days after subarachnoid haemorrhage due to ischaemia confirmed with CT. The operative conditions during early operations, and the approach to the vessels at the base of the brain were as good as during delayed operations.

In 6 patients the authors performed stereotaxic ventroposteromedial thalamotomy for abolition or reduction of pain. The operation produced lesions in the centrum medianum and parasfascicular nucleus. In 2 cases unilateral operation was performed contralaterally to the side of pain, in the remaining cases the operation was done bilaterally as a one-step procedure. Postoperative follow demonstrated that in 1 case improvement was completely absent, in 4 initial good effect was transient and pain returned after several weeks and in only 1 patient very good effect persists for over 12 months. In the light of these experiences and a survey of the pertinent literature the authors reach the conclusion that limited stereotatic lesion of the so called non-specific pain-transmitting thalamic nuclei produces permanent abolition or alleviation of pain in few cases only. The pathophysiology of pain is discussed in the light of these data.

The authors describe a rare case of chronic bleeding into the syringomyelic cavity treated surgically. Bleeding caused slowly increasing manifestations of disease after 23 years of stationary phase. The cause of such bleedings is unknown.

The frequency of cerebral and cerebellar abscesses was analysed in relation to all intracranial tumours in the material of the Department of Neurosurgery, Medical Academy in Warsaw, and the causes of these abscesses in a group of 62 cases treated in the last ten years. The subject of interest was the variability of these parameters in the era of widely used antibiotic treatment. It was observed that in the last years the frequency of brain abscesses has decreased. They account presently for 2.2% of all intracranial tumours. The first place among the causes of abscesses is taken by otogenic infections with nasal sinusitis, although the percent of these causes is decreasing. Presently, the number of abscesses of unknown origin has been increasing, probably due to the widespread use of antibiotics which eradicate the primary infection focus early after its appearance.

Out of 97 patients with syringomyelia treated surgically, in 63 of them suboccipital decompression was performed. Various kinds of congenital or early acquired abnormalities were found to be the possible cause of the disease. Simple Arnold-Chiari malformation was found in 29 patients. In next 16 cases the Arnold-Chiari malformation was accompanied by partial occlusion of the foramen of Magendie with tiny, translucid membrane, that covered lower 1/2 or 3/4 of the foramen. In another 9 cases of Arnold-Chiari malformation, foramen of Magendie was totally occluded with thick, grayish membrane. In 7 cases lowered cerebellar tonsils were firmly attached to the medulla and joined by adhesions between themselves. In 1 case total atresia of foramen of Magendie was present only. In 1 case no pathological changes were found. The above mentioned findings point out, that in practically all the cases of syringomyelia various kinds of gross pathology, that leads to difficulties in normal outflow of the CSF from the IVth ventricle to cisterns can be found. From that point of view the suboccipital decompression seems to be the most reasonable surgical procedure.

In the years 1973--1975 20 patients with syringomyelia were treated surgically. The surgical interventions were preceded by careful radiological examinations which was often indispensable for confirmation of diagnosis, establishing of indications to operation and choice of surgical method. On plain radiograms in 16 cases cervicothoracic scoliosis was found, in 11 cases the vertebral canal was dilated in its cervical part, in 6 cases atlanto-occipital malformations were disclosed. The basic diagnostic examination was ascending myelography which was performed in 17 cases. In 3 cases the contrast medium failed to pass to the atlanto-occipital junction because of marked dilatation of the spinal cord in the cervical part. In 9 out of the remaining 14 cases radiological findings were compatible with the diagnosis of Arnold-Chiari syndrome which was confirmed during the operation. In 1 case positive contrast central pneumoencephalography was performed demonstrating a communication between the 4 th ventricle and the cavity in the spinal cord. Early detailed neuroradiological diagnosis is indispensable in syringomyelia for early surgical treatment.

The author treated surgically 10 patients with syringomyelia. In 6 cases Arnold--Chiari syndrome was found, in 2 cases platybasia with basilar impression, besides that 2 patients had complete or partial occlusion of Maganide's foramen and in 4 cases a persisting central canal communicated widely with the 4th ventricle. In 3 cases these findings were associated with postinflammatory changes. In only one case the changes in the atlanto-occipital area could not have been defined clearly. The author compares his observation with those reported by others reaching the conclusion that they confirm the hydrodynanic mechanism of syringomyelia. In most cases syringomyelial is a result of congenital or congenital and acquired malformations in the medullo-bulbar area leading to distrubances in the circulation of cerebrospinal fluid.