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A herniated disc occurs when an intervertebral disc displaces and compresses a spinal nerve root. Nerve stretch tests or provocative tests have a great diagnostic value and are quite specific for the pathology of lumbar disc herniation. The nerve stretching tests that are most often used to prove or rule out compression on the spinal nerve are the following: Lazarević's test, Cram's, Bragard's, crossed-contralateral Lazarević's test, inverted Lazarević's or Fajerstein's test, Bekhterev's, Neri's, Govers' and Kernig's tests, Lhermite's sign, Dendy's test, Milgram's and Nafciger's test, bowstring sign, Trandelenburg sign, Hoover's simulation test, Menel's test, Genslen's test and Patric-faber's test. This article describes the techniques of performing all the mentioned tests, as well as their clinical significance.

Introduction. Staphylococcus (S.) aureus is one of the most omnipresent and dangerous human pathogens, whose main characteristic is the production of the enzyme coagulase. This characteristic serves to identify and assess the pathogenicity of the bacteria. In addition to skin infections, endocarditis, osteomyelitis, and infectious arthritis, it is a common cause of pneumonia both in children and adults. Case report. We described a case of a 65-year-old woman with a dry cough and malaise with patchy areas of consolidation on the chest X-ray and “ground-glass” opacity with bronchial wall thickening and unilateral mediastinal lymphadenopathy on chest computed tomography imaging. Methicillin-resistant S. aureus was isolated from the bronchoalveolar aspirate taken during bronchoscopy. The woman was empirically treated with azithromycin, and later, based on the antibiogram findings, azithromycin was replaced with meropenem, after which her health improved. Conclusion. We presented a rare case of pneumonia with unconvincing symptomatology and laboratory and radiological findings. Paying more attention to such cases in the future is crucial, especially to the use of antibiotics to which staphylococci are increasingly developing resistance.

Introduction. Angiomyolipomas represent neoplasms of mesenchymal origin, made up of abnormal thick-walled blood vessels, smooth spindle muscle cells, and mature adipose cells. The most common site of origin are kidneys, and other localizations are extremely rare. We represent a case of a spermatic cord angiomyolipoma misdiagnosed as incarcerated inguinoscrotal hernia, and to our prudence this is second described case of an angiomyolipoma localized in the spermatic cord. Case outline. We present a case of a 63-year-old man presented with high fever and difficulty in walking due to pain and swelling in the right groin. According to the clinical examination and laboratory tests, presumptive diagnosis was incarcerated inguinoscrotal hernia, so the patient was immediately operated on. The exploration of the inguinal canal showed a timorous mass, 9 × 9 cm in size, with the origin from the spermatic cord, so radical inguinal orchiectomy was performed with the removal of the tumor mass. Histopathological and immunohistochemistry examination suggested angiomyolipoma of the spermatic cord. The postoperative course was uneventful. Conclusion. Although rare, an angiomyolipoma of the spermatic cord must be included in the differential diagnosis of scrotal masses. Also, we advocate additional diagnostic procedures (ultrasound or computed tomography) for every inguinoscrotal mass before undertaking surgery, since a variety of different causes can be found. After definitive angiomyolipoma diagnosis is obtained, further investigation is needed, especially brain computed tomography due to possible tuberous sclerosis coexistence.

Introduction. The spine is involved in less than 1% of all tuberculosis (TB) cases, and it is a very dangerous type of skeletal TB as it can be associated with neurologic deficit and even paraplegia due to compression of adjacent neural structures and significant spinal deformity. The spine TB is one of the most common causes for an angular kyphotic deformity of spine. Patients with kyphosis angle ≥ 60° at dorsolumbar spine are at great risk to develop late onset neurological deficit and paraplegia due to chronic compression and stretching of the spinal cord over bonny ridges. In a small number of cases, other conditions may lead to neurological deficit in patients with long standing angular kyphosis which also alters the treatment strategy that otherwise involves prolonged and mutilant surgery. Case outline. We present a case of a 61-year-old male patient with concomitant 90° dorsolumbar spine kyphosis due to spinal TB and ligamentum flavum hypertrophy which led to spinal canal stenosis with myelopathy, and consequent paraplegia. The patient underwent dorsal decompression with hypertrophic yellow ligament removal after which he recovered to the level of walking. Conclusion. Many authors propose guidelines for treatment of spinal TB, taking into account the stage of the disease, the age of the patient, the angle of kyphosis, and other factors. We find that personalized medical approach is the best approach for each patient.

Introduction. Osseous metaplasia is a heterotopic formation of bone and its appearance in benign gastrointestinal polyps is exceedingly rare. The mechanism responsible for this type of metaplasia is not fully understood, however it seems to be an innocent rare phenomenon. Case outline. We present a case of a 31-year-old male with mesenchimal osseal metaplasia in a large inflamatory polyp measuring 57 × 23 × 20 mm in diameter, located in the anal canal region. Conclusion. According to our knowledge, this is the largest gastrointestinal polyp with osseous metaplasia described so far. Although a rare phenomenon, there are certain characteristics of this disease, so we conducted a literature review and summarized these characteristics.

We report an extremely rare case of an endodermal cyst of the cranio-cervical junction located dorsally to the brainstem and upper cervical spine in a 27-year-old female presented with occipital headache, vertigo and pain in both shoulders. Neurological examination showed neck stiffness with bilateral XIth nerve palsy. Magnetic resonance imaging revealed a cystic lesion at the cranio-cervical junction and slight compression of the brain stem. The lesion was totally removed through the posterior approach. The histological diagnosis was endodermal cyst. To our knowledge, the only one such case has been reported in the literature.

Dual antiplatelet therapy (clopidogrel and acetylsalicylic acid) is a standard for the embolization of planned intracranial aneurysms with CNS stent due to the possibility of stent thrombus formation. All anti-aggregation drugs, including those listed, have bleeding as a side effect. Three patients with aneurysm had an elevated response to antiplatelet therapy with clopidogrel, which was confirmed by a multiplate test on the "VerifyNow" system. After reducing the dose of clopidogrel or after interrupting it, with the introduction of low molecular weight heparin for the duration of five days, aneurysms were successfully resolved by intracranial implantation of the stent. Perioperative angiograms and postoperative CT angiograms have verified hematomas at the place of punction of the femoral artery. Bleeding was resolved by the femoral artery suture by a vascular surgeon. All patients were discharged home without further complications and with dual antiplatelet therapy. By measuring the platelet function in vitro, the degree of inhibition of platelet activity achieved by the action of the drug can be assessed. A specific test can identify those patients who are highly responsive to the drug with increased platelet reactivity and the possibility of increased risk of bleeding. Our suggestion is to reduce the dosage of clopidogrel or to leave it out for 24 hours with preventive doses of low molecular weight heparin or to change the strategy of treatment of intracranial aneurysm, i.e. avoiding implantation of CNS stent.

Introduction. Arachnoid cysts are common among the general population. Best treatment option is still the subject of much debate. Surgical options include open-craniotomy or endoscopic cyst fenestration, cysto-peritoneal shunt insertion, or marsupialization via craniotomy. The aim of this article was to present a patient with an extremely large arachnoid cyst which occupied almost the entire left hemisphere. Case outline. The patient with a large symptomatic arachnoid cyst was treated by craniotomy and open fenestration. The patient suffered multiple postoperative complications, such as imidiate intracerebral hemorrhage due to hypertension, obstructive hydrocephalus, and a fresh ulcer in the bulbus duodeni. All the complications were successfully treated. Conclusion. Since the best treatment option is still the subject of much debate, we think that personalized medical approach is the best one, taking into account patient symptoms, localization and size of the cyst, patient’s general condition, and surgeon’s familiarity with the procedure.

Introduction. Intracranial extension is rarely seen with craniofacial dermoid cysts, with few cases reported in the literature. Case Outline. We report a case of a 30-year-old woman who was initially seen with a subcutaneous mass of the frontotemporal region. The patient underwent a right craniotomy by a frontal approach. Histopathologic analysis confirmed the diagnosis of a dermoid cyst. Conclusion. Craniofacial dermoid cysts may be associated with an intracranial extension.

Cavernomas are benign vascular malformations, and about 50% of all cases are multiple. The hereditary form of brain cavernomas is uncommon, and it is certainly under diagnosed. Another entity is familial cerebral cavernous malformation syndrome. It is defined as the occurrence of multiple cavernomas or the occurrence of cavernomas in at least two members of a family or the presence of a mutation in one of the three genes causing familial cerebral cavernous malformation syndrome. We present a Serbian family in which three consecutive members of family had brain cavernoma. According to our knowledge, this is second case of hereditary cavernoma described in Serbian population.

Introduction. According to the literature, a fusiform aneurysm located in the cerebellopontine angle (CPA) is an extremely rare condition. Case Outline. We report a case of a 59-year-old patient with initial dizziness and left-sided sensorineural hearing loss that had gradually developed over six months. Vertebrobasilar fusiform aneurysm, with intraluminal thrombus, which was displaced to the right cerebellopontine angle, creating mass effect, was diagnosed using brain magnetic resonance imaging and magnetic resonance angiography. Conclusion. Atherosclerosis may be the essential factor in the pathogenesis of a fusiform aneurysm of the basilar artery, especially in elderly patients. The best treatment option is yet to be determined, but in spite of numerous previous large studies, personalized approach is probably the best.

Vascular dementia (VaD) is the second most frequent dementia after Alzheimer’s disease, and is diagnosed during lifetime in 20% of demented patients. Five­year survival rate in VaD is 39%, while it is estimated to be 75% in healthy persons of the same age. It is therefore important to make correct diagnosis of VaD early in the course of the disease. Risk factors for VaD are identical to stroke risk factors, and there are significant possibilities for the prevention of vascular cognitive decline. Cognitive decline develops acutely or step­by­step within three months after stroke, but more gradual progression of intellectual decline is also possible. Neurological examination can reveal pyramidal and extrapyramidal signs, pseudobulbar palsy, gait disturbance and urinary incontinence. Neuropsychological profile comprises the loss of cognitive set shifting, decline in word fluency, verbal learning difficulties, perseverations, difficulties in complex figure copying, and in patients with cortically located lesions also problems with speech and praxia. The basis of the diagnosis is, besides history, neurological examination and neuropsychological assessment, computed tomography and/ or magnetic resonance brain imaging. Vascular risk factors control is the most important measure in VaD prevention. Modern guidelines for the treatment of cognitive decline in VaD emphasize that donepezil can be useful in the improvement of cognitive status at the level of Class IIa recommendation at the level of evidence A, while memantine may be useful in patients with mixed VaD and Alzheimer’s disease dementia. [Projekat Ministarstva nauke Republike Srbije, br. 175022 i br. 175033]

The thoracic duct injury is an extremely rare entity and is sometimes seen in the surgery of the oesophagus or the heart. This injury can result in the formation of chylothorax e.g. chylous pleural effusion and can cause significant patient morbidity and mortality. Thoracic duct injury is an extremely rare complication of thoracic outlet syndrome surgery with only a few cases described in the literature so far. We present a 29-year-old female patient operated on for thoracic outlet syndrome with resection of the anterior scalene muscle on the left side. During the first postoperative day, the patient had more than 1.5 L of chyle leak drainage without signs of chylothorax. The patient was successfully treated conservatively with bed rest and total parenteral nutrition. [ABSTRACT FROM AUTHOR]

Myopericytoma is a benign, soft tissue tumor probably derived from perivascular myoid cells. They are usually found in subcutaneous tissues in the extremities. Intracranial localization of myopericitoma is exceedingly uncommon. We report a 43 years old male patient with incidentally found myopericitoma of the posterior fossa. Patient was operated and tumor was completely removed. Patient was subsequently diagnosed with acquired immunodeficiency syndrome due to human immunodeficiency virus infection. One year after operation tumor showed no signs of recurrence, but patient developed progressive symptoms of AIDS and started highly active antiretroviral therapy (HAART). Connection of intracranial myopericitoma appearance and HIV/AIDS has been reported before, but clear connection is yet to be elucidated. [ABSTRACT FROM AUTHOR]

Cluster headache (CH) is estimated to be the most common primary trigeminal autonomic headache, although it is a rare disabling medical condition. Dominant symptoms of CH include severe unilateral orbital, supraorbital, and/or temporal pain, lasting from 15 to 180 minutes if untreated, associated with at least one of various autonomic symptoms during the headache, such as conjunctival injection, lacrimation, nasal congestion and rhinorrhea, facial sweating, miosis, ptosis, and eyelid edema. Headache is not frequently a symptom of multiple sclerosis (MS). The most commonly reported primary headaches are migraine without aura and a tension-type headache. Several described cases involved complicated migraine, ophthalmoplegic migraine-like headache, and finally cluster-like headache. We present a case of a 45-year-old male patient who had typical CH attacks as the initial and only clinical manifestation of MS, which was diagnosed after cerebrospinal fluid (CSF) isoelectric focusing and brain magnetic resonance imaging (MRI) investigation. He presented as a typical cluster-like headache patient since in the background of the CH symptoms and signs, were MS demyelinating lesions. In a patient with CH symptoms one should always think about the possibility of cluster-like-headache, which presents the CH patient with different underlying diseases, so we proposed a protocol to evaluate such patients and exclude diseases that could be in the background of CH symptoms. [ABSTRACT FROM AUTHOR]

Pallister-Hall syndrome (PHS) is extremely rare autosomal dominant disorder with typical clinical features such as presence of polydactyly, hypothalamic hamartoma, bifid epiglottis, anal, renal, genitourinary and pulmonary abnormalities, mainly located in the midline of the body. Spontaneous cerebrospinal fluid (CSF) rhinorrhea is also a rare condition, and it is used to describe nasal discharge of CSF unrelated to previous trauma, localized tumour, surgery, or previous radiation therapy. The exact cause is not yet fully understood. We report a case of adult female patient previously diagnosed with PHS and late onset of spontaneous nasal liquorrhea, due to defect in the anterior skull base. Although it can be incidental finding, we believe that described defect in the body midline can be another presentation of congenital craniofacial abnormality which are common in PHS.

Multiple brain abscesses are exceedingly uncommon in newborns and represent a serious medical problem associated with high morbidity and mortality. Treatment is also controversial issue, and can require surgery, abscess aspiration, antibiotic therapy, and eradication of the primary source. We report a case of successfully treated multiple brain abscess in a newborn with combined therapy which consisted of abscess aspiration and prolonged antibiotics. Patient developed hydrocephalus as late complication which was also successfully treated with ventriculoperitoneal shunt.

Abstract Wegener's granulomatosis (WG) is a systemic disorder characterized by necrotizing vasculitis involving the respiratory tract, and in most cases, the kidneys. The most common manifestation of WG in the kidneys is segmental necrotizing glomerulonephritis. The presence of a renal mass as a manifestation of WG is rare. We report a patient with WG in whom a CT scan revealed an infiltrating mass in the lower portion of the left kidney. After surgical exploration, we performed an open radical nephrectomy. Histopathology showed clear cell type renal cell carcinoma (RCC). RCC associated with WG has been reported in only a few cases, and in most of them, the diseases started simultaneously, suggesting common pathogenetic pathways. Long-term immunosuppressive treatment is a known risk factor in the development of malignancies, so occurrence of RCC in WG has been proposed as a side effect of cyclophosphamide treatment. Furthermore, it is important to make a differential diagnosis between RCC and pseudotumors in WG as they cannot be distinguished solely on basis of imaging findings. Due to the higher risk of urologic malignancies, more frequent checkups and screening of WG patients should be considered.

Stroke is one of the leading causes of death and probably the greatest cause of adult disability worldwide. Diabetes mellitus (DM) is a state of accelerated aging of blood vessels. Patients with diabetes have increased risk of stroke. Hyperglycemia represents a risk factor for poor outcome following stroke, and probably is just a marker of poor outcome rather than a cause. Lowering of blood glucose levels has not been shown to improve prognosis. Also, prevention of stroke risk among patients with DM is not improved with therapy for reduction of glucose levels. On the other hand, prediabetes, a metabolic state between normal glucose metabolism and diabetes, is a risk factor for the development of DM type 2 and subsequently for stroke. Several methods are known to identify prediabetes patients, including fasting plasma glucose levels, 2-hour post load glucose levels, and glycosylated hemoglobin levels. In this text, we tried to summarize known data about diagnosis, epidemiology, risk factors, pathophysiology, and prevention of prediabetes in relation to DM and stroke., Competing Interests: Disclosure The authors report no conflicts of interest in this work.