Učinak ultrazvuka visoke energije na tkivo intervertebralnog diska [The application of the high energy ultrasound on intervertebral disc tissue]

Surgical treatment of the herniated lumbar disc is one of the most common neurosurgical procedures. In the last few decades there has been a vast improvement in neurosurgical treatment of the lumbar disc herniation, and a lot of new treatment options have been devel-oped. There has been an expansion of endoscopic procedures like percutaneous endoscopic discectomy, laparoscopic discectomy, stereotactic guided discectomy, and an endoscope as-sisted discectomy, all of which are often used in our Department. The idea of using an ultrasonic aspirator for emulsification and aspiration of the lumbar and cervical intervertebral disc is not new. Current experiences in high energy ultrasound application yielded good results in neurosurgery, but so far only its application on the brain tissue was analyzed. The application of the high energy ultrasound on intervertebral disc tis-sue remains to be explored. The aim of this research is to display the effect of the high energy ultrasound application on the intervertebral disc tissue, and to analyze its application in lumbar disc herniation treatment. The final ultrasonic effect depends on the shape and intensity of the ultrasonic field, du-ration of its application and the amount of the ultrasonic energy as well as the characteristics of the tissue on which the ultrasound is applied. This research initially determined the acoustic characteristics of the contact ultrasound probe during its application on the intervertebral disc tissue. The acoustic power output measurement was analyzed using three types of experiments: calorimetric measurements, acoustic power deployment in the free acoustic field, and tip-displacement amplitude of the probe. The mechanism of high-intensity ultrasound effects on the tissue is still poorly under-stood, but the potential mechanisms include acoustic cavitation, shock-wave induced stress-es, acoustic microstreaming, direct jackhammer effect, and thermal lesion. All results meas-ured in free acoustic field are expected to vary in real situations. Acoustic parameters like the acoustic power and the acoustic cavitation shape are modi-fied during ultrasound application because of the damaging cavitational effects upon the flat surface of the contact probe tip. The investigation was carried out on 189 intervertebral discs extracted during autopsy on 63 cadavers. An ultrasonic contact probe with 2.2 mm diameter was used to perform point lesions in the disc tissue with modifying the electric power of the ultrasonic generator (The tuning button of the generator was 50%, 75% and 100% of the electric power level respec-tively) with the insonification duration of 20 seconds. The results showed that the size of necrotic area depends on the level of the acoustic power and intensity. The higher the acoustic power the wider the area of the necrotic nucleus pulposus tissue. The difference in the level of destruction between discs in younger cadavers (younger than 55 years) and in older ones was observed which was attributed to different amount of water in the tissue. Finally the efficacy of the tissue fragmentation caused by high energy ultrasound is higher in calcified tissue comparing to cartilage tissue

Clinical and neurophysiological changes in patients with pineal region expansions [Kliničke i neurofiziološke značajke u bolesnika s ekspanzivnim tvorbama pinealne regije]

In the last 20 years neurological and neurosurgical follow up of our patients with pineal region expansions (118 patients) pointed to certain clinical and neurophysiological regularities. We performed retrospective study which included 84 patients with pineal region expansions in the period from 1992 to 2009. The study included 55 women and 29 men, mean age 30.08 +/- 13.93 years, with positive brain magnetic resonance imaging (MRI)--70 patients (83.4%) had simple pineal gland cysts, and 14 patients (16.67%) had expansive process in pineal region with compressive effect. All patients had headache, while 32 patients (38%) had epileptic phenomena--primary generalized seizures. Patients had common electroencephalography (EEG) pattern with paroxysmal discharges of 3Hz (or more than 3 Hz) spike-and-wave complexes. Operation with supracerebellar infratentorial approach was performed in 70 patients. In most of our patients indication for the operation was established based on the size of the cyst (15 mm or more), with the signs of compression on the quadrigeminal plate and compression of the surrounding veins, which could result in seizures and EEG changes verified in our group of patients. Pathohistological analysis revealed pineocytomas in 11 cases (15.71%), pinealoblastomas in 2 cases (2.86%), one case of teratoma (1.43%), while 56 patients had pineal gland cysts (80%). Following surgery clinical condition improved in all patients--patients became seizure-free and headaches significantly decreased. Other symptoms including diplopiae, nausea, vomiting, vertigo as well as blurred vision also disappeared. There were no complications after surgical procedures. This study points to often appearance of seizures that clinically and neurophysiologically present as primary generalized epilepsy in patients with pineal region expansions. Our hypotheses are that mass effect on the surrounding veins that affects normal perfusion, compressive effect on the quadrigeminal plate and the aqueduct of the midbrain, hemosiderin deposists, as well as secretion disturbances of anticonvulsive agent melatonin can be involved in the pathogenesis of seizures. We suggest to perform high resolution brain MRI with special demonstration of pineal region in all young patients that have seizures and specific EEG changes

The application of ultrasound in neuroendoscopic procedures: first results with the new tool »NECUP-2« [Upotreba ultrazvuka u neuroendoskopskim procedurama: prvi rezultati s novim uređajem »NECUP-2«]

In this paper, our experience with originally constructed Neurosurgical Endoscopic Contact Ultrasound Probe »NECUP-2« in neuroendoscopy is reported. Between June 1997 and June 2007, 132 neuroendoscopic procedures have been performed: 102 endoscopic thrid ventriculostomies (ETV), 15 arachnoid cysts and 5 intraventricular tumours operations. The »NECUP-2« was applied effectively in all cases in which blunt perforation was not possible: 38/102 ETV, 10/10 septostomies, 15/15 arachnoid cysts. In five cases of intraventricular tumours, neuroendoscopic procedure was combined with open microsurgery for tumour removal with preservation of vascular structures. There were no »NECUP-2« related complications. Of postoperative complications, we had liquorrhea (9 patients), and symptoms of meningitis (6 patients). In the follow-up period (6 months to 6 years), we had a patency rate of 80% (50/63 patients). All patients improved in clinical status. According to the first results, it seems that ultrasonic contact probe NECUP-2 presents a new device in neurosurgical armamentarium that can be used in various fields of neurosurgery. With minimal and controlled lesion that is produced at the tip of the probe, it can be used in highly demanding operations such as third ventriculostomy and tumour resection

Promjene ličnosti nakon operacije aneurizme moždanih arterija

Neuropsychological testing of patients in the course of their recovery from brain injuries enables analysis of cognitive deficiencies and/or emotional changes. The principle study objective was to define organic and/or reactive personality changes and the course of these changes in the function of the time span following brain artery aneurysm surgery in both female and male patients. The study was carried out at the Clinical Department of Neurosurgery, Zagreb University Hospital Center in Zagreb. The data refer to the period from 1989 to 2012 collected in two time intervals, i.e. 11 months and 12-48 months following brain artery aneurysm surgery. Of 72 patients included in the study, there were 28 male and 44 female patients. Neuropsychological testing consisted of clinical interview, clinical assessment of frontal lobe syndrome, Cornell personality questionnaire and Emotional Profile Index. Study results showed evidence of frontal lobe syndrome in 32% of patients on first testing and significant recovery on retesting, when only 17% of patients presented with frontal lobe syndrome. The reactive personality changes found in both testing intervals indicated increased neuroticism. In the first testing period, asthenic syndrome occurred most often, followed by conversion and aggressive-antisocial syndromes, while in the second testing interval asthenic syndrome was most pronounced and conversion and antisocial syndromes showed the same level of expression. The results also showed higher depressive and disorganizing states, which were even more pronounced in the second testing interval. As regards sex differences, the inclination toward cardiovascular somatization and destructiveness was more expressed in females than in males, showing a tendency of aggravation with increasing the time span following surgery. It may be concluded that the study has contributed to better understanding of organic and/or reactive personality changes in patients undergoing brain artery aneurysm surgery.Neuropsihologijsko testiranje tijekom praćenja oporavka bolesnika s moždanim oštećenjima omogućuje uvid u postojanje kognitivnih deficita i/ili emocionalnih promjena. Cilj istraživanja bio je utvrditi postojanje organskih i/ili reaktivnih promjena ličnosti te tijek tih promjena u funkciji vremena proteklog od operacije aneurizme moždanih arterija u bolesnika oba spola. Istraživanje je provedeno u Klinici za neurokirurgiju Kliničkog bolničkog centra Zagreb. Podaci su prikupljani u razdoblju od 1989. do 2012. godine u dva vremenska intervala, 11 mjeseci i 12-48 mjeseci nakon operacije aneurizme moždane arterije. U istraživanje su bila uključena 72 bolesnika, od toga 28 muškog i 44 ženskog spola. Neuropsihologijsko testiranje sastojalo se od kliničkog intervjua, kliničke procjene frontalnog sindroma te primjene Cornellova upitnika ličnosti i Profila indeksa emocija. Rezultati istraživanja upućuju na postojanje frontalnog sindroma kod 32% bolesnika u prvom testiranju te na značajan oporavak pri ponovnom testiranju, kada je samo 17% bolesnika imalo frontalni sindrom. Utvrđeno je i postojanje reaktivnih promjena ličnosti koje u oba vremenska intervala upućuju na povišeni neuroticizam. U prvom testiranju je najizraženiji bio astenički sindrom, slijedi konverzivni, a zatim agresivno-asocijalni sindrom, dok je u drugom testiranju najizraženiji bio astenički sindrom, a konverzivni i agresivno-asocijalni sindrom su bili podjednako izraženi. Rezultati ukazuju i na povišenu depresivnost i dezorganiziranost, što je u drugom testiranju bilo još naglašenije. Vezano uz spol, rezultati upućuju na promjene vezane uz sklonost kardiovaskularnoj somatizaciji i agresivnosti koje su izraženije kod osoba ženskog spola te se pogoršavaju s protokom vremena od operacije. Zaključno, provedeno istraživanje je doprinijelo boljem razumijevanju organskih i/ili reaktivnih promjena ličnosti u bolesnika nakon operacije aneurizme moždanih arterija

Polymethylmethacrylate cranioplasty using low-cost customised 3D printed moulds for cranial defects – a single Centre experience: technical note

We report our experience with 3D customised cranioplasties for large cranial defects. They were made by casting bone cement in custom made moulds at the time of surgery. Between October 2015 and January 2018, 29 patients underwent the procedure; 25 underwent elective cranioplasties for large cranial defects and four were bone tumour resection and reconstruction cases. The majority of patients (96.5%) reported a satisfactory aesthetic outcome. No infections related to the surgical procedure were observed in the follow-up period. The method proved to be effective and affordable

Clinical and Neurophysiological Changes in Patients with Pineal Region Expansions

In the last 20 years neurological and neurosurgical follow up of our patients with pineal region expansions (118 patients) pointed to certain clinical and neurophysiological regularities. We performed retrospective study which included 84 patients with pineal region expansions in the period from 1992 to 2009. The study included 55 women and 29 men, mean age 30.08±13.93 years, with positive brain magnetic resonance imaging (MRI) – 70 patients (83.4%) had simple pineal gland cysts, and 14 patients (16.67%) had expansive process in pineal region with compressive effect. All patients had headache, while 32 patients (38%) had epileptic phenomena – primary generalized seizures. Patients had common electroencephalography (EEG) pattern with paroxysmal discharges of 3Hz (or more than 3 Hz) spike-and-wave complexes. Operation with supracerebellar infratentorial approach was performed in 70 patients. In most of our patients indication for the operation was established based on the size of the cyst (15 mm or more), with the signs of compression on the quadrigeminal plate and compression of the surrounding veins, which could result in seizures and EEG changes verified in our group of patients. Pathohistological analysis revealed pineocytomas in 11 cases (15.71%), pinealoblastomas in 2 cases (2.86%), one case of teratoma (1.43%), while 56 patients had pineal gland cysts (80%). Following surgery clinical condition improved in all patients – patients became seizure-free and headaches significantly decreased. Other symptoms including diplopiae, nausea, vomiting, vertigo as well as blurred vision also disappeared. There were no complications after surgical procedures. This study points to often appearance of seizures that clinically and neurophysiologically present as primary generalized epilepsy in patients with pineal region expansions. Our hypotheses are that mass effect on the surrounding veins that affects normal perfusion, compressive effect on the quadrigeminal plate and the aqueduct of the midbrain, hemosiderin deposists, as well as secretion disturbances of anticonvulsive agent melatonin can be involved in the pathogenesis of seizures.We suggest to perform high resolution brain MRI with special demonstration of pineal region in all young patients that have seizures and specific EEG changes

IMPACT OF INVASIVE EEG MONITORING AND RESECTIVE NEUROSURGICAL TREATMENT ON THE QUALITY OF LIFE IN PATIENTS WITH DRUG RESISTANT EPILEPSY - PRELIMINARY RESULTS

Background: Neurosurgical treatment is one of important way to cure drug resistant epilepsy. After invasive EEG monitoring and the invasive neurosurgical treatment (resective surgery) there are possible complications (intracranial haemorrhage, cortic al lesions and infections), however there are possible neuropsyhologic outcomes such as memory outcomes, language outcomes and psychiatric outcomes. The quality of life in epilepsy (QOLIE-31) scale is a self-completed questionnaire which contains seven subscales which address the following aspects: emotional well-being, social functioning, energy/fatigue, cognitive functioning, seizure worry, medication effects and overall quality of life. Our study aimed to examine the quality of life in patients with drug resistant epilepsy who had undergone invasive EEG monitoring and resective neurosurgical treatment through the application of t he QOLIE-31 scale. Subjects and methods: The study included 9 patients with drug resistant epilepsy who had undergone invasive EEG monitoring followed by resective neurosurgical treatment in the period from 2010 to 2016, and the control group of 15 patients with drug resistant epilepsy who had not undergone neurosurgical procedures. Clinical variables of interest for this study were obtained through phone contact, and the QOLIE-31 scale was applied. Results: In the domaine of seizure worry, patients in the examined group were more concerned about the seizures (54.7) compared to the examined group (80), as well as in the overal quality of life (examined group 57.5; control group 77.5). Patien ts in the control group complained more in the domain of antiepileptic therapy (score 70.7) than patients in the examined group (scor e 100). In the other domains: emotional well-being, energy/fatigue, cognitive functioning, and social functioning there were mino r deviations between the examined and control groups. Conclusion: There was no statistically significant difference between individual QOLIE-31 questionnaires, as well as between the two groups of respondents

Effect of adjunctive lidocainebased scalp block and laryngotracheal local anesthesia vs general anesthesia only on plasma and cerebrospinal fluid pro-inflammatory cytokine concentrations in patients with cerebral aneurysm: a randomized controlled trial

Aim To compare the effect of adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia vs general anesthesia only on pro-inflammatory cytokine concentra - tions in patients with non-ruptured brain aneurysms under - going elective open surgery. Methods This parallel, randomized, controlled, open-label trial was conducted at Clinical Hospital Center Zagreb be - tween March 2019 and March 2020. At the beginning of an - esthesia, lidocaine group received 40 mg of 2% lidocaine for laryngotracheal topical anesthesia and 4 mg/kg for the scalp block. Control group underwent general anesthesia only. Plasma concentrations of IL-6, TNF-α, and IL-1β were mea - sured before anesthesia (S0); at the incision (S1); at the end of surgery (S2); 24 hours postoperatively (S3). Cerebrospinal fluid (CSF) cytokine concentrations were measured at the in - cision (L1) and the end of surgery (L2). Results Forty patients (each group, 20) were randomized; 37 were left in the final analysis. IL-6 plasma concentrations increased significantly compared with baseline at S3 in li - docaine group, and at S2 and S3 in control group. In both groups, changes in TNF-α and IL-1β were not significant. CSF cytokine concentrations in lidocaine group did not change significantly; in control group IL-6 and IL-1β were significantly higher at L2 than at L1. CSF IL-6 in control group significantly increased at L2, but TNF-α and IL-1β did not. No differences in clinical outcome and complication rates were observed. Conclusion Adjunctive lidocaine-based scalp block and lar - yngotracheal local anesthesia might attenuate CSF IL-6 con - centration increase in patients with brain aneurysm