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Introduction: It is unclear how obstruction and stenosis in different parts of craniospinal space affect the CSF movement and distribution of substances within the CSF and interstitial fluid (ISF). Material and methods: In experimental animals with acute and subchronic blockage or stenosis of the aqueduct of Sylvii and/or cervical subarachnoid space, changes in dye distribution, size of ventricles and CSF pressure were examined. Contrast dynamics and changes in the CSF system anatomy were investigated in patients with obstruction or severe aqueductal stenosis. Results: According to the classic concept, obstruction or severe stenosis of unidirectional CSF circulation should lead to an increase in CSF pressure and dilation of ventricles proximal to the site of obstruction. Experimental acute aqueductal blockage showed lack of increase in the CSF pressure and ventricular dilatation. Long- term blockage and stenosis of the cervical space resulted in slight enlargement of ventricles. The obstructions within CSF system limited the distribution of the dye along the CSF system and increased its penetration into the tissue. MR studies in some patients showed the existence of aqueductal obstruction or stenosis, without development of clinical and radiological signs of the three-ventricular hypertensive hydrocephalus. Conclusion: Classical hypothesis of constant CSF secretion inside the ventricles, unidirectional circulation, and dominantly passive absorption through the arachnoid granulations of the dural sinuses cannot explain the described results, while they can be easily explained by a new concept of CSF/ISF physiology.

In our new experimental model of cervical stenosis without inflammation we have tested hypothesis that cranio-spinal communication impairment could lead to hydrocephalus development. Spinal and cranial cerebrospinal fluid (CSF) space separation was obtained with positioning of plastic semiring in epidural space at C2 level in cats. Brain ventricles planimetry, and CSF pressure recording in lateral ventricle (LV) and lumbar subarachnoid space (LSS) were performed in acute and subchronic experiments. In all experiments opening CSF pressures were normal. However, in acute experiments, an infusion of artificial CSF into the LV led to increase of CSF pressure and significant gradient pressure development between LV and LSS due to limited pressure transmission. After 3 or 6 weeks spinal cord atrophy was observed at the site of cervical stenosis, and pressure transmission from LV to LSS was improved as a consequence of spinal tissue atrophy. Planimetry of both the coronal brain slices and the ventricles’ surface showed that control ventricular surface was 0.6 ± 0.1% (n = 5), and 1.6 ± 0.2% (n = 4) in animals with subchronic cervical stenosis (P

Pituitary adenomas frequently invade the cavernous sinus. The standard transsphenoidal approach does not provide satisfactory visualization of the cavernous sinus structures. The transcranial approach has no advantages, and increases the operative trauma and complications. The oblique transsphenoethmoidal approach, a modified standard transsphenoidal approach, was used to treat 19 patients with pituitary adenomas invading the cavernous sinus. Complete tumor removal was achieved in 15 patients and subtotal removal in 4 patients. The patients tolerated this modified transsphenoethmoidal approach well and the postoperative results were satisfactory. Although the number of patients was too small to allow any statistical analysis, the results, compared with other series, are encouraging.

Svijest je zbir svih psihičkih funkcija u određenom trenutku te sposobnost orijentacije pojedinca prema sebi i drugim osobama u prostoru i vremenu. U teže kvantitativne poremećaje svijesti ubrajamo semikomu, komatozno stanje, vegetativno stanje, locked - in sindrom i stanje minimalne svjesnosti. Medicinske sestre svakodnevno skrbe za ove bolesnike pa je iznimno važno da poznaju različitosti poremećaja, njihove specifičnosti ali i komunikaciju i individualni pristup bolesniku i njegovoj obitelji. U skrbi za komatozne pacijente važna je emocionalna inteligencija i kritičko razmišljanje medicinskih sestara posebice kod izrade planova zdravstvene njege, oblikovanje sestrinskih dijagnoza i odabira prikladnih i dostižnih ciljeva i intervencija. Pacijent u komi „na prvi pogled“ nije aktivni subjekt, ne komunicira sa svojom okolinom pa medicinska sestra na temelju znanja i iskustva prepoznaje njegove potrebe. Svrha rada je prikazati zahtjevnost skrbi i komunikacije bolesnika poremećene svijesti te procjenu zadovoljstva medicinskih sestara u radu te potrebu uvođenja novih nastavnih sadržaja na studij sestrinstva. Metode: Koristila se deskriptivna metoda s pregledom domaće i strane literature, te bibliografskih baza podataka, a u empiričnom dijelu kvantitativna tehnika prikupljanja podataka. Instrument istraživanja je upitnik je izrađen na temelju teoretskih znanja, pregleda literature i višegodišnjeg radnog iskustva s bolesnicima s težim poremećajem svijesti. Rezultati i rasprava: U istraživanje su uključene medicinske sestre i tehničari srednje stručne spreme i prvostupnici sestrinstva Opće bolnice Varaždin koji rade na odjelu neurokirurgije i kirurške jedinice intenzivnog liječenja. Analizirajući zahtjevnost sestrinske skrbi rezultati su pokazali da je komunikacija s bolesnicima bez svijesti zahtjevna za većinu medicinskih sestara. Iznimno je zahtjevno pružati psihičku podršku obitelji bolesnika, komunicirati s obitelji bolesnika i educirati iste, dok je fizičko pružanje skrbi manje zahtjevno. Ovi podaci su temelj za edukaciju studenata studija Sestrinstva kao i dodatnu edukaciju medicinskih sestara. Zaključak: Potrebno je izraditi i implementirati specifične sadržaje u edukaciju medicinskih sestara o komunikaciji s bolesnicima bez svijesti. Poučavanje putem radionica, malih grupa i individualan rad sigurno su izazov i prijedlog za poboljšanje skrbi.

The dilemma of whether to apply surgical or drug treatment to prolactinomas has been ongoing for the past 30 years. The aim of this study is to compare the early postoperative values​​ of prolactin (PRL) in two groups of patients with prolactinomas: those who underwent primary surgical-treatment, and those who underwent surgery after a dopamine agonist (DA) therapy. We present the results of surgical treatment on a series of 161 patients with prolactinomas. Surgery was the primary treatment in 65 patients, while 96 patients had surgery following a long-term treatment with a DA. All surgically treated prolactinomas were operated in the standard transsphenoidal, microsurgical approach. The criteria for hyperprolactinemia remission was a PRL level under 25 ng/ml. Early normalization of PRL was achieved in 92% of those patients who underwent primary surgical-treatment, yet it was achieved in only 42% of patients who were operated on after receiving a long-term drug treatment with a DA. The highest prevalence of postoperative normalization of PRL was achieved in a group of patients with microadenomas who were primarily operated on (98%). The worst results in postoperative normalization of PRL were found in the group of patients with macroadenomas who received a long-term drug treatment with a DA first. These results show our surgical experience in treating prolactinomas. Using surgical treatment, the best clinical outcome was acieved with microprolactinomas and intrasellar, well-confined macroprolactinomas. Nevertheless, we stress the need of an individualized approach and recommend treatment in multidisciplinary centres for pituitary diseases.

U posljednjih 10 godina Hrvatskom zavodu za javno zdravstvo prijavljeno je 15 bolesnika oboljelih od Creutzfeldt-Jakobove bolesti (CJB). Tijekom lipnja 2012. godine u Općoj bolnici Varaždin (OBV) preminuo je 58-godišnji bolesnik premješten s Klinike za neurologiju KBC Zagreb pod sumnjom na sporadični oblik CJB. Nakon obdukcije bolesnika, koja je provedena u našoj ustanovi, dijagnoza CJB potvrđena je patohistološkom analizom mozga u Kliničkom institutu za neurologiju Medicinskog fakulteta u Beču. Povjerenstvo za sprječavanje i suzbijanje bolničkih infekcija OBV izradilo je upute o mjerama i načinu postupanja s prostorima, opremom i instrumentima koji su bili potencijalno kontaminirani prionima. Obzirom da se radilo o bolesniku koji je 2,5 mjeseca prije postavljene dijagnoze bio neurokirurški operiran u našoj ustanovi, a upotrijebljeni neurokirurški instrumenti nisu bili tretirani po principu dekontaminacije priona, postavljeno je pitanje potencijalnog prijenosa priona kontaminiranim instrumentima na 29 bolesnika koji su naknadno neurokirurški operirani. Analizom neurokirurškog zahvata utvrdili smo da su neurokirurški instrumenti bili u kontaktu s kožom, potkožjem, fascijama mišića, kostima i intervertebralnom hrskavicom bolesnika, ali ne i s tvrdom moždanom ovojnicom, niti je za vrijeme operacije bilo likvoreje. Zaključili smo da tijekom neurokirurškog zahvata nije došlo do kontakta instrumenata s tkivima visokog i srednjeg rizika za prijenos priona te je rutinski postupak s neurokirurškim instrumentima (rutinsko čišćenje i sterilizacija) bio dostatan za sprječavanje prijenosa priona, sukladno smjernicama britanske i kanadske grupe za kontrolu CJB. Naknadnim praćenjem nije registriran niti jedan slučaj sekundarne CJB u 29 bolesnika operiranih nakon ovog bolesnika u našoj bolnici., In the last 10 years there have been 15 cases of Creutzfeldt-Jakob disease (CJD) reported to the Croatian Institute of Public Health/Department of Epidemiology. In June 2012, a 58-year-old patient that had been relocated from the Department of Neurology of the University Hospital Centre Zagreb to General Hospital Varaždin, died from a suspected sporadic form of Creutzfeldt-Jakob disease. After autopsy was performed in our hospital, CJD was confirmed by histopathological analysis of the brain in the Clinical Institute of Neurology/Medical University of Vienna. The Hospital Infection Control Committee drafted guidelines for infection control measures regarding work areas, equipment and instruments that were potentially contaminated with prions. Since the patient had undergone a neurosurgical operation in our institution 2.5 months prior to CJD diagnosis, and the neurosurgical instruments used during this procedure were not processed according to the prion decontamination principles, a question was raised regarding a potential prion transmission via contaminated instruments to the 29 patients who subsequently underwent neurosurgical operation. By analyzing the neurosurgical procedure that the patient underwent, we established that neurosurgical instruments were in contact with the patient's skin, subcutaneous tissue, fascia muscle, bones and intervertebral cartilage and not with the dura mater and that there was no cerebrospinal fluid drainage during surgery either. Therefore, we concluded that during neurosurgery the instruments did not come into contact with tissues of higher or medium risk for transmission of prions and that routine procedure for cleaning and sterilization of neurosurgical instruments was sufficient for preventing prion transmission, which is in accordance with the British and Canadian CJD infection control guidelines. Subsequent follow-up recorded not a single case of secondary CJD among the 29 patients who underwent surgery after the infected patient in our hospital.

It was recently proposed that organic anions, such as cerebral acidic metabolites and phenolsulfonphthalein (PSP), are eliminated from cerebrospinal fluid (CSF) by diffusion into the central nervous system (CNS) and further by active transport into capillaries. To test this hypothesis, PSP was injected into cisternal CSF and its distribution into various parts of the CNS was measured 1 and 3 h later in control cats and those pretreated with probenecid, which blocks active transport of organic anions into capillaries. PSP in tissue shows an intensive pink color when exposed to 1 N NaOH. Planimetric analysis of color pictures of coronal CNS slices showed that at the first hour, diffusion and distribution of PSP into the CNS in both groups of animals was similar, while at the third hour, a great reduction of PSP distribution in the CNS in control and only a slight reduction in probenecid pretreated cats was observed. The results support the hypothesis that active transport across the capillary wall in the CNS is the main avenue for elimination of cerebral acidic metabolites from both CSF and CNS and in such a way that central homeostasis is maintained.

Intraventricular neoplasms are uncommon central nervous system lesions that account for only 10% of all neoplasms and are unusual location of metastatic breast cancer. A 73-year-old woman with a medical history of breast carcinoma without any signs of metastatic lesions in the liver, lungs or bones and with an intraventricular tumorous lesion found on multislice computed tomography of the brain is presented. Surgery was indicated in order to confirm the diagnosis histologically and to gain local control of the metastasis. The patient was operated on using the neuronavigation guided transcortical approach. The tumor was removed using the Cavitron ultrasonic aspirator. Histopathologic examination revealed a metastatic breast carcinoma. Postoperative irradiation of the whole brain was performed., Intraventrikularni tumori predstavljaju svega 10% svih tumora središnjega živčanog sustava. Još je rjeđa intraventrikularna lokalizacija metastatskog karcinoma dojke. Prikazujemo slučaj 73-godišnje bolesnice s karcinomom dojke bez znakova metastaskih promjena u jetri, plućima ili kostima. Neuroradiološka obrada (MSCT, višeslojna kompjutorizirana tomografija) je pokazala intraventrikularnu tumorsku tvorbu. Radi potvrde histološke dijagnoze te lokalne kontrole rasta tumora indicirano je operacijsko liječenje. Bolesnica je operirana transkortikalnim pristupom uz pomoć neuronavigacijskog sustava. Tumor je uklonjen uz primjenu kavitronskog ultrazvučnog aspiratora. Patohistološka analiza je pokazala metastatski karcinom dojke. Poslijeoperacijski je provedeno ozračivanje cijelog mozga.

During the past 25 years, we came across 60 patients with corticotroph pituitary adenomas and Cushing's disease. Neuroradiological examination showed prominent volume loss of the brain parenchyma, unexpected for the patient's age. This "brain atrophy" appeared to regress after surgical removal of pituitary adenoma and normalization of cortisol level. Observed difference between degree of "brain atrophy" in the Cushing's disease group and in the control group was statistically significant (p0.001). The degree of "brain atrophy" correlated well with the duration of Cushing's disease. Partial reversibility of "brain atrophy" was noticed during the 2nd, 3rd and 4th year after surgery and normalization of cortisol level. Increased cortisol level is one of the causative factors in pathogenesis of "brain atrophy". Loss of brain volume is at least partially reversible after normalization of cortisol levels.

Sacral perineurial (Tarlov) cysts are rare lesions. Over a seven year period 4000 patients underwent surgery for lumbar disk herniation. In three patients neurological symptoms were caused by large sacral perineurial cysts. Methods of choice for diagnosis of Tarlov cysts are lumbosacral magnetic resonance imaging and computerized tomography myelography. The majority of Tarlov cysts are asymptomatic. In case of large (> or = 1.5 cm) and symptomatic perineurial cyst, as in three patients reported in this article, microsurgical treatment was successful. Although rare, perineurial (Tarlov) cysts must be taken into consideration when approaching to patient with low back and radicular pain. Authors review the medical literature, pathological and pathophysiological features and treatment options of sacral perineurial cysts.

During the past 25 years, we came across 60 patients with corticotroph pituitary adenomas and Cushing’s disease. Neuroradiological examination showed prominent volume loss of the brain parenchyma, unexpected for the patient’s age. This »brain atrophy« appeared to regress after surgical removal of pituitary adenoma and normalization of cortisol level. Observed difference between degree of »brain atrophy« in the Cushing’s disease group and in the control group was statistically significant (p

Transsphenoidal approach to pituitary tumors was for a long time reserved for sellar region tumors, whereas tumors expanding into extrasellar region were treated by transcranial approach. With the development of surgical equipment and gaining surgical experience, indications for the transsphenoidal approach and its modifications have become wider and ever more frequently used for pituitary tumors with extrasellar expansion. During the twenty-five years of performing pituitary surgery, we have operated on more than 1400 tumors of the sellar region using the transsphenoidal approach and its modifications. The novel transsphenoidal endoscopic approach is strongly taking more place in pituitary surgery, advancing the possibilities of the standard transsphenoidal approach. A review is presented of surgical approaches to pituitary tumors., Transsfenoidni pristup tumorima hipofize dugo je bio rezerviran za intraselarne neoplazme, dok se ekstraselarno proširene tumore rješavalo transkranijskim pristupom. Zahvaljujući razvoju kirurške opreme i instrumentarija te većem iskustvu operatera indikacije za ovaj pristup i njegove modalitete postale su šire pa se češće rabe i za ekstraselarno proširene tumore. Tijekom 25 godina bavljenja kirurgijom hipofize operirali smo preko 1400 tumora selarne regije rabeći transsfenoidni pristup i njegove modalitete. Novi endoskopski transsfenoidni pristup zauzima sve više mjesta u kirurškom liječenju hipofize te tako povećava lepezu mogućnosti proširenog transsfenoidnog pristupa. Prikazani su kirurški pristupi liječenju tumora hipofize.

Aim: To estimate the incidence of intracranial tumors in the adult population of the Varazdin County, Croatia, for the 1996-2004 period. - - - - - Methods: Setting: Varazdin County General Hospital and four university hospitals in Zagreb, the capital of Croatia. Study period: January 1, 1996 to December 31, 2004. Incident patients: county residents admitted for newly diagnosed intracranial tumors according to the WHO diagnostic criteria. Demographic data were extracted from the 2001 Croatian census. Incidence rates (IRs) per 100,000 person-years (p-y) and annual IRs (per 100,000 persons) were determined and compared as incidence rate ratios (IRRs) with 95% CI. - - - - - Results: For primary intracranial tumors (PITs), IR was 12.1/100,000 p-y (95% CI: 10.3-14.2), comparable in men and women. The highest incidence was recorded for glioblastoma (IR 4.8, 3.7-6.2) and meningioma (IR 3.1, 2.2-4.2). The incidence of PIT was somewhat greater than that of metastatic tumors (IRR 1.58, 95% CI: 1.22-2.05, P < 0.001). Metastatic tumors were more frequent in men than in women, especially metastatic lung tumors (IRR 6.08, 2.32-20.16, P < 0.001). IRs of all PIT taken together, neuroepithelial tumors cumulatively, nonepithelial tumors cumulatively, glioblastoma and meningioma were higher in the population aged >= 40 vs. population aged

The fundamental tendency to be as minimally invasive as possible and to achieve a maximum of efficacy in the treatment of patients has existed since the beginning of surgery. In treating intracranial aneurysms the most widely used approach is pterional or frontotemporal approach described by Yasargil. The increasing knowledge of microsurgical anatomy, improved preoperative diagnostic techniques, and well adapted microsurgical instruments have led to the development of minimally invasive approaches. The supraorbital keyhole approach via an eyebrow incision is one of these minimally invasive procedures. Since it was first described by Perneczky it has raised debates on its advantages and disadvantages. The authors present their experience in using the supraorbital keyhole approach in treating intracranial aneurysms., Cilj ovoga istraživanja bila je procjena prednosti i nedostataka supraorbitalnog pristupa "ključanice" u neurokirurškom liječenju intrakranijskih aneurizmatskih tvorba. Supraorbitalni pristup "ključanice" predstavlja minimalno invazivni operacijski zahvat u liječenju intrakranijskih aneurizma. Od 2000. do 2003. godine 30 bolesnika s 30 intrakranijskih aneurizma operirano je supraorbitalnim pristupom "ključanice" na Klinici za neurokirurgiju, KB "Sestre milosrdnice". U većini slučajeva bolesnici su dobro podnijeli operacijski zahvat, a poslijeoperacijski oporavak je bio zadovoljavajući. Ukupni pobol iznosio je 16%, dok su zabilježena dva smrtna slučaja zbog komplikacija nevezanih za operacijski zahvat. Supraorbitalni pristup "ključanice" predstavlja razumnu opciju u neurokirurškom liječenju intrakranijskih aneurizma kod bolesnika pažljivo prijeoperacijski odabranih s obzirom na kliničku sliku, neurološki status i lokalizaciju aneurizmatske tvorbe.

Sequestered extrusions of the lumbosacral spine, a type of herniated lumbar disk, with large sequesters located in the spinal canal, so-called sequestered extrusions of the lumbosacral spine, were analyzed. They are mainly located in the L-4-L5 and L5-S1 spinal segments, and less commonly in the L3-L4 spinal segment, and are divided into several groups., Etiologija i patogeneza sekvestriranih diskus hernija slabinskoga dijela kralješnice evidentirana je kod prekomjernih biomehaničkih opterećenja slabinskog modela kralješnice (preko 1000 N). Eksperimentalni model je bio svježi humani model slabinske kralješnice koji je bio izložen kontinuiranim ekscentričnim i centričnim opterećenjima od 1000 do 1500 N. Eksperiment je proveden na 35 svježih modela humane slabinske kralješnice u Zavodu za anatomiju Medicinskoga fakulteta i Zavoda za fiziku Prirodoslovno matematičkog fakulteta u Zagrebu. Sličan mehanizam, tj. jaka biomehanička sila, odgovorna je za nastanak sekvestrirane lumbalne ekstruzije diska koja je dokazana neuroradiološki (kompjutorizirana tomografija i magnetska rezonanca kralješnice) u bolesnika koji traže neurokiruršku pomoć. U pokusima s torzijom sekvestrirane ekstruzije slabinske kralješnice javljale su se i pri opterećenjima manjim od 1000 N (800 N) i uz centrična i uz ekscentrična opterećenja. Prema podacima dobivenim iz bolesničkih povijesti bolesti većina slučajeva ekstruzije slabinskog diska nastali su kod podizanja teškog tereta u kombinaciji s torzijom i rotacijom.

The issue of severe head injuries in alcohol abusers is presented. During the 1993 - 2002 period, 3700 patients with a history of alcohol abuse were treated for severe head injuries at the University Department of Neurosurgery, Sestre milosrdnice University Hospital in Zagreb. The leading injury was brain concussion, followed by acute subdural hematoma. Severe head injury in alcohol abusers results in high mortality and morbidity in both younger and older population. The mortality rate in patients who underwent surgery ranged between 23% and 55%, and in those not operated on between 38% and 85%., U radu su prikazane kraniocerebralne ozljede u populaciji osoba s alkoholnom bolešću. Provedena je retrospektivna analiza bolesnika koji su liječeni u Klinici za neurokirurgiju Kliničke bolnice "Sestre milosrdnice" u razdoblju od 1993. do 2002. godine. U prikazanom materijalu prevladavaju teške kraniocerebralne ozljede koje se najčešće očituju kao akutni subduralni hematomi, često u kombinaciji s teškim nagnječenjem mozga i politraumom. Ove ozljede rezultiraju izrazito visokim stupnjem smrtnosti i pobola kako u mlađim tako i u starijim dobnim skupinama. Kod neoperiranih bolesnika kreću se u rasponu od 23% do 55%, a kod operiranih bolesnika od 38% do 85%.