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Computed tomographic angiography (CTA) and magnetic resonance angiography (MSA) have been used recently for evaluation of intracranial aneurysms. If they are to replace conventional digital subtraction angiography (DSA), their sensitivity and specificity should be equal to the latter. In order to determine whether computed tomographic angiography and magnetic resonance angiography can provide the necessary information for presurgical evaluation we compared blindly the results of helical CT angiography and MR angiography with the results of digital subtraction angiography and the intraoperative findings. We evaluated 35 patients with the possible clinical diagnosis of intracranial aneurysm. Our data suggest that both CTA and MRA can provide valuable preoperative information concerning the location, the characteristics and the relationships of most intracranial aneurysms. Both original and reconstructed images should be evaluated together for higher accuracy. In addition helical CT, being a fast, inexpensive and noninvasive method, can be used as a reliable alternative to DSA in emergency situations demanding immediate operation.

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An unusual case of an intradural, extramedullary spinal cord tuberculoma, as a complication of tuberculous meningitis caused by a strain susceptible to major anti-TB drugs, is described in a previously healthy, HIV-negative, 27-year-old male. The tuberculoma was detected by magnetic resonance imaging (MRI) while the patient was under conventional anti-tuberculous (anti-TB) therapy. Histopathology confirmed the diagnosis. Despite the anti-TB treatment and the surgical resection, intramedullary spreading occurred. Finally, a favorable response was achieved by prolongation of treatment accompanied by the administration of ofloxacin and cycloserine.

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INTRODUCTION: The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension. METHOD AND MATERIAL: In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS. RESULTS: Patients have been operated on post-trauma median day 3, mean age 26+/-9, GCS 7+/-3.7, mean APACHE II 16+/-6.4, mean ISS 27.8+/-16.1, mean preoperative ICP 37.7+/-10.0, mean postoperative ICP 18.1+/-16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%. DISCUSSION: Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy.

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Two cases with fusiform aneurysm in the posterior cerebral artery are presented: The first one is a large fusiform aneurysm of the P(2) segment of posterior cerebral artery (PCA) in a 58 years old patient and the second a fusiform aneurysm of the P(3) segment of PCA in a 43 years old patient. The aneurysms were successfully treated the first by proximal ligation and the second by trapping of the aneurysm. The patients had no additional neurological deficits postoperatively and they are in an good condition, in four years and one year follow up respectively. The operative approaches and the radiological investigation in relation to the micro-anatomy of the posterior cerebral artery, as well as the outcome in these cases are discussed.

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The relationships among the fetal biophysical profile, umbilical cord blood pH, and Apgar scores were investigated in 124 patients undergoing cesarean section before the onset of labor. Based on a standard for the diagnosis of fetal acidosis of an umbilical cord arterial pH less than 7.20, the sensitivity, specificity, and positive and negative predictive values of the fetal biophysical profile score were 90%, 96%, 82%, and 98%, respectively. When the combination of a nonreactive nonstress test and absent fetal breathing was used as the "abnormal test," the sensitivity, specificity, and positive and negative predictive values were 100%, 92%, 71%, and 100%, respectively. The efficacy of the fetal biophysical profile to indicate fetal acidosis was found to be superior to the 1- and 5-minute Apgar scores in sensitivity and positive predictive value. These data suggest that the biophysical profile is very accurate in the identification of the fetus with acidemia. The first manifestations of fetal acidosis are nonreactive nonstress testing and loss of fetal breathing; in advanced acidemia fetal movements and fetal tone are compromised. A new protocol of antepartum fetal evaluation is suggested based on individual biophysical components rather than the score alone.

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A protocol using daily fetal biophysical assessment was applied in 73 consecutive patients with premature rupture of the membranes and no clinical signs of infection or labor. A persistently low biophysical score (7 or less on two examinations 2 hours apart) in the presence of a nonreactive nonstress test and absence of fetal breathing was used as an indication for delivery. Measures of pregnancy outcome included the presence of amnionitis or neonatal infection. The outcome of pregnancy in this group of patients was compared with the outcomes of two historic groups: one managed conservatively (control group) and the other managed with amniocentesis on admission to the hospital (amniocentesis group). Infection outcome, maternal as well as neonatal, and low 5-minute Apgar scores were significantly less in the study than in the control group. The frequency of neonatal sepsis was significantly less in the study than in the amniocentesis group. These data suggest that management of premature rupture of the membranes with daily fetal biophysical profiles improves pregnancy outcome by reducing the incidence of maternal and neonatal infection.

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This experimental study presents the ultrastructure of regenerating sciatic nerve of the rabbit, after transection and immediate end to end anastomosis, using perineural fascicular nerve autograft, in a sterile environment. Twenty-four hours, 1, 2, and 6 weeks after the anastomosis, the treated sciatic nerves were exposed and three segments were excised and studied. The first at the region of the graft and the others from the proximal and distal stump of the nerve, in the vicinity of the graft suture. The sections taken from the proximal part showed that the nerve structure was identical with the control. Degeneration and regeneration of nerve fibres were observed on the sections taken from the region of the grafts and from the distal parts. Macrophagic activity appeared mainly one week after the operation. Fibroblastic invasion started 24 hours after operation. A moderate amount of collagen fibres was gradually formed. The fibres were disposed in parallel with the neuraxon. Schwann cells were slightly affected initially but consequently they fully recovered and showed signs of extra-activity of the cytoplasm organelles, e.g., enlargement of the granular endoplasmic reticulum cisternae. The present study showed that the bridging of experimental gaps of rabbit's sciatic nerve, by means of autograft and by use of perineural suturing, was successful. The regenerating nerve fibres were growing through the graft towards the distal part of the nerve. In this process Schwann cells and fibroblastic activity play a key role, which is most favourably influenced by using the technique described in this paper.

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Twenty-five women who had intrauterine adhesions were treated under hysteroscopic control and with ancillary medical therapy. Preoperatively, 18 patients complained of amenorrhea secondary to a curettage of a recently pregnant uterus. Following therapy described in this report, 11 of them subsequently conceived, 6 delivered at term, 2 had premature deliveries, and 3 other pregnancies ended in abortions. All patients resumed normal menses following treatment. A system for staging the severity of intrauterine adhesions is suggested so that results of therapeutic regimens can be compared.

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Twenty-six New Zealand White rabbits were randomly assigned to control or treated groups. In the treated group, the rabbits were medicated with either dexamethasone or ibuprofen. The injuries were made as standard as possible for each animal. The animals were killed 2 to 3 weeks postoperatively and the extent of adhesions was evaluated. Ibuprofen appeared to inhibit the formation of significant adhesions as compared with adhesion formation in untreated control animals, and the results seemed as effective as in the dexamethasone-treated animals. Further studies should be performed to substantiate these initial observations and to determine the most effective dosage. Ibuprofen may have a potential place in tubal surgery.

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One hundred and sixty tubal reconstructions were analyzed according to a classification which describes the type of tubal repair and the tubal segment treated. The results in 80 women who were operated upon just prior to the application of microsurgical principles were compared with those in 80 women in whom these techniques were employed. In expressing the results, no patients were excluded for any reason. Anatomical patency was not evaluated, and functional patency was measured by conception (abortion, tubal, or term pregnancy). Of the 80 women who had tuboplasty with conventional surgery, 10 (12.5%) successfully delivered at term, but 14 (17%) had tubal gestations. Almost 28% of the women (22) had successful pregnancies after microsurgery, but in 9 (11%) extrauterine pregnancies resulted. The three women with current intrauterine pregnancies could improve the microsurgical series to 31% successful pregnancies. Our initial experience with microsurgical techniques seems to show an increased number of term pregnancies, principally in patients who have undergone anastomosis.

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