Electrophysiological Evaluation of the Incidence of Martin-Gruber Anastomosis in Healthy Bosnian Population Background: Martin-Gruber anastomosis (MGA) is the well known anostomosis that occur at the various levels between the median and ulnar nerves. This anastomosis involves axons leaving either the main trunk of median nerve or the anterior interosseous nerve, crossing through the forearm to join the ulnar nerve. Knowledge of the incidence of this anastomosis is necessary because MGA can cause confusion in the assesment of nerve injuries and compressive neuropathies. Aim: We aimed to assess the occurance and motor velocities of median to ulnar nerve communication (MGA) in the forearm of Bosnian population by electrophysiological examinations. Material and Methods: One hundred and twenty forearms from a series of 60 volunteers (25 females, 35 males, 23-78 years of age) were studied electrophysiologically using needle recording electrodes. Volunteers with peripheral neuropathies were excluded from the study. Needle recording electrodes were places on the thenar and hypothenar muscles. The median and ulnar nerves were stimulated supramaximally at the wrist and the elbow and compound muscle action potentials (CMAPs) were recorded as well as motor conduction velocities of median and ulnar nerves. Results: Martin-Gruber anastomosis was found in 27 of 120 forearms; it was bilateral in 7 and unilateral in 13, on the right side in nine and on the left side in four forearms. There were no significant sexual differences in the incidence. In MGA, when stimulating median nerve the respond of abductor digiti minimi was registered in 11, whereas the respond of opponens pollicis when stimulating ulnar nerve was registered in 18 subjects. This finding was statistically significant. Conclusion: With high incidence of MGA in Bosnian population, it is necessary to be aware of the existance of this anomaly, location and its possible presentation.

Background: Many apparent advantages of the magnetic resonance imaging (MRI) in establishing diagnosis of lumbar disc herniation are counter parted by its relatively high cost and sparse availability in developing countries. Thus, a significant portion of patients are still subjected to lumbar disc surgery based solely on computed tomography (CT) findings. Aim: The aim of this study was to compare diagnostic characteristics of afore mentioned radiological tests (CT and MRI) and to investigate if the choice of diagnostic test influences outcome of discectomy. Methods: Basic demographic, clinical and radiological variables were evaluated in a group of 70 patients operated on for disc herniation of whom 30 were operated based on MRI findings and the remainder were operated based on CT scan alone. Outcome was assessed using Visual Analogue Scale (VAS) and Roland-Morris (RM) scale 6 months postoperatively and correlated to the type of neuroradiological examination. Basic diagnostic characteristic of the two diagnostic modalities (MR and CT) were compared. Results: The type of radiological investigation was shown to be statistically poor predictor of outcome after microdiscectomy. Even though MR scan was more sensitive in detecting disc extrusion than CT (sensitivity of 100% versus 65%, respectively), the presence of preoperative MR scan did not influence the outcome. Conclusion: We conclude that although the presence of preoperative MR scan does not influence outcome, higher sensitivity and specificity in detecting disc extrusions and superior ability to detect nerve root compression warrant an introduction of MR scan prior to any disc surgery.

Trigonocephaly denotes the calvarial deformity caused by premature closure of the metopic suture (metopic synostosis). The frequency of craniosynostosis in general is estimated to be 0.4 per 1000 live births, and trigonocephaly accounts for 5% of all craniostenoses, meaning that this condition is fairly rare. Several studies disclosed that craniosynostosis in twins is a very rare occurrence among craniofacial anomalies. We present a rare case of trigonocephaly in twins where surgery yielded cosmetically satisfactory results.

INTRODUCTION The aim of our study was to determine the impact of clinical signs and symptoms on CT ordering policy in minor head injuries. PATIENTS AND METHODS The study encompassed 1830 patients that have sustained minor or mild head injury, as assessed by clinical criteria. Basic clinical variables were recorded and a subset of patients meeting either Canadian or New Orleans criteria were subjected to CT. Outcome in terms of "positive" CT scans and number of patients requiring surgery was recorded. RESULTS The mean age was 30.4 years (ranging from 10 days to 80 years). 176 patients were subjected to CT scan (based on clinical criteria). CT scan revealed intracranial pathology in 29 patients (16.5% of patients subjected to CT scan) and 19 patients were subsequently subjected to surgery (accounting for 10.8% of patients subjected to CT scan and 1.0% of all patients with mild or minor head injuries). Brain contusions were detected in 10 (5.7%) patients, followed by epidural hematomas (10 patients or 5.7% were found to harbor an epidural hematoma) and subdural hematomas, that were found in 7 patients or 4.0% of patients subjected to CT scan. DISCUSSION Despite numerous studies that have analyzed the importance of clinical signs and CT in the diagnosis and treatment of minor head injuries, there is still much controversy about the mode of treatment of these patients. Canadian protocol really reduces the need for CT of the brain in relation to the New Orleans protocol, which suggests more observation in hospital patients with minor or mild head injury. CONCLUSION The authors conclude that minor or mild head injuries should prompt a CT as recommended by Canadian or New Orleans guidelines and that the strongest scientific evidence available at this time would suggest that a CT strategy is a safe way to triage patients for admission.

UNLABELLED Assessment of depth of anesthesia is the basis in anesthesiologists work because the occurrence of awareness during general anesthesia is important due to stress, which is caused in the patient at that moment, and due to complications that may arise later. There are subjective and objective methods used to estimate the depth of anesthesia. The aim of this study was to assess the depth of anesthesia based on clinical parameters and on the basis bispectral index, and determine the part of bispectral monitoring in support to clinical assessment. MATERIAL AND METHODS Sixty patients divided into two groups were analyzed in a prospective study. In first group (group 1), the depth of anesthesia was assessed by PRST score, and in the second group (group 2) was assessed by bispectral monitoring with determination PRST score concurrently. In both groups PRST score was assessed in four periods, while bispectral monitoring is used continuously. For analysis were used the BIS index values from the equivalent periods as PRST scores. PRST score value 0-3, and BIS index 40-60 were considered as adequate depth of anesthesia. The results showed that in our study were not waking patients during the surgery. In the group where the depth of anesthesia assessed clinically, we had a few of respondents (13%) for whom at some point were present indicators of light anesthesia. Postoperative interview excluded the possibility of intraoperative awareness. In the second group of patients and objective and clinical assessment indicated at all times to adequate depth of anesthesia. CONCLUSION The use of BIS monitoring with clinical assessment allows anesthesiologists precise decision-making in balancing and dosage of anesthetics and other drugs, as well as treatment in certain situations.

Objective – The aim of this study was to analyse the clinico-pathological characteristics, treatment, complications and outcome in patients with low grade astrocytomas (grade I and II). Patients and Methods – This study was a retrospective analysis of 50 consecutive patients younger than 15 years who were hospitalized for surgical treatment of posterior cranial fossa tumours. The intracranial hypertension, neurological status, radiological CT or MRI findings, tumour localization, type of resection, hydrocephalus treatment, histopathology, complications and outcome were analyzed. Results – There posterior cranial fossa tumours 25 (50%) children with astrocytoma among the posterior cranial fossa tumours. Of this number, there were 18 (72%) pilocytic astrocytomas and 7 (28%) ordinary histopathological subtypes of grade II astrocytomas. The average age in patients was 78.5±40 months, patients with pilocytic astrocytoma 84±43 months and patients with grade II astrocytomas 64±27 months. The average size of pilocytic astrocytoma was 48 mm and the remaining grade II astrocytomas was 37 mm. The most common neurological deficit before and after surgery was ataxia. Paediatic patients with posterior cranial fossa low grade astrocatomas have evaluated postoperatively between 4 months to 98 months, in average 47.7±25.9 and patients with grade II astrocytomas between 6 months to 103 months, in average 57.2±38.4.  Conclusion – Have a good prognosis after tumor total grose resection.

The aim of this study was to determine whether early rehabilitation from the first postoperative day after lumbar disc herniation surgery improved functional status of patients compared to the rehabilitation that started 3 weeks after surgery. Oswestry index was used for functional status assessment before surgery and after rehabilitation in 60 patients divided in 2 groups, i.e., early and control group of rehabilitation strated 3 weeks after surgery, 30 in each. Oswestry index values before surgery and after rehabilitation in the early rehabilitation group were 78.4 +/- 17 and 19.6 +/- 9.9, respectively (p < 0.0001) and in the control group the values were 79 +/- 13 and 37 +/- 14, respectively (p < 0.0001). The difference of Oswestry index before operation and after rehabilitation in the early rehabilitation group was 58.7 +/- 18.9, and in the control group 41.6 +/- 13.2 (p = 0.0001). Onset of rehabilitation from the first post operative day lead to better functional recovery compared to delayed rehabilitation 3 weeks after lumbar disc herniation surgery.

Introduction: It is a well recognized fact that a significant proportion of patients operated on for lumbar disc herniation exhibit a poor outcome, regardless of the apparent technical success of the operative procedure itself. Aim: to identify a set of widely available variables that accurately predict short-term outcome after discectomy and to develop a predictive model based upon those variables. Patients and methods: Basic demographic, clinical and radiological variables were evaluated in a group of 70 patient operated on for disc herniation. Outcome was assessed using VAS and RM scales 6 months postoperatively and correlated to aforementioned variables. Results: Preoperative pain intensity and duration, age and type of disc herniation were all shown to be statistically significant predictors of short-term outcome, unlike sex, type of radiological investigation and preoperative tension sign testing results. Multivariate regression analysis including only variables previously identified as good outcome predictors revealed that the pain intensity exhibited the strongest correlation with outcome, followed by pain duration, type of disc herniation and age. Even though MR scan was more sensitive in detecting disc extrusion than CT (sensitivity of 100% versus 65%, respectively), the presence of preoperative MR scan did not influence the outcome. Conclusion: The study identified a set of widely available and easily attainable variables as fair predictors of short-term outcome after lumbar discectomy. Subsequent logistic regression resulted in a predictive model whose accuracy is to be determined in another prospective study.

Introduction: Till the end of the 1980s, frame-based stereotaxy was the standard method for accurately localizing small brain lesions by introducing catheters into the lesion or for determining the tumor volume in space. The objective of this study was to analyze the caracteristics of frame-based stereotactic localization of brain lesion for excision and to compare the results of frame-based stereotactic localization of brain lesion for excision with results of craniotomy without using stereotaxy. Material and methods: This study analyzed the results of 100 surgically treated patients for brain lesion excision in the period of 2002-2006 at Department of neurosurgery University clinical center of Tuzla. There were 60 patients operated on by a craniotomy without using stereotaxy and 40 patients operated on by using frame-based stereotactic localization of brain lesion for excision. The Karnofsky Performance Score (KPS) was used to estimate the patient every day activity before and after surgery. Length of incision, size of craniotomy and duration of surgery were compared between two groups. Result: An average age in patients operated on by using frame-based stereotactic tumor localization (Group A) was 49.5 (SD +13 years) and in patients operated on by craniotomy without using stereotactic localization (Group B) 53 years (SD +12 years). The mean length of skin incision in Group A was 7 cm (SD +5.5) and in Group B 14.5 cm (SD +4.7). The mean size of craniotomy in frame-based stereotactic localization for brain lesion removal was 10.7 cm2 (SD +9.8), and in craniotomy without stereotaxy 18.5 cm2 (SD +7.7). Duration of surgery in patients of Group A was 68 minutes (SD +43), and in Group B 125 minutes in average (SD +47). In the Group A there was no significant change in Karnofsky, but in the Group B there was drop. Discussion and Conclusion: Frame-based stereotactic localization of brain lesion for excision gives advantages comparing craniotomy without using stereotaxy. Frame-based stereotaxy remains the gold standard for accurate targeting of smaller lesions.

Objective – The aim of this study was to present our experience in managed neural tube defect in a consecutive series of 18 patients.  Material and methods – In the period between October 2003 and October 2007 eighteen patients with neural tube defect (NTD) were operated at Department of neurosurgery of University clinical center Tuzla. Each patient with suspected NTD was evaluated by pediatricians, radiologists and neurosurgeons with clinical findings and ultrasound investigation, computerized tomography and/or magnetic resonance imaging scans of the spine and head.  Results  – The neurosurgical data of 18 patients with NTD who were admitted and treated at our department over the four year period were studied retrospectively. The average age at the time of presentation was 15.7 months, ranging from 1 day to 8 years. Spinal NTD was noticed in 13 (72.2%) patients and cranial in 5 (27.8%) patients. Surgery was performed on emergency basis immediately upon birth for CSF leakage in five patients (38,5%) with spinal dysraphism. No postoperative cerebrospinal fluid leakage was noticed and there was no mortality.  Conclusion  – Patients born with neural tube defect need an interdisciplinary team of specialists to oversee their developmental progress. Once born, a child with NTD must be operated in order to avoid fluid infection.

Background and objective Factors associated with the developmentof acute hydrocephalus following subarachnoidhemorrhage are not fully elucidated. The goal of this studywas to present the relative predictive values of Hunt-Hessgrade and Fischer score in determining the propensity fordeveloping post-hemorrhage hydrocephalus and to documentthe frequency of acute and chronic hydrocephalus followingsubarachnoid hemorrhage. Patients and methodsOur study encompassed 102 patients with anurismal subarachnoidhemorrhage. The Hunt-Hess scale was used forthe initial neurological status assessment and the extent ofsubarachnoid hemorrhage was graded based on the Fisherscale. Assessment of hydrocephalus was made on the basisof the size of both temporal horns, the ratio of FH/ID andEvan’s ratio. Results Thirty-two percent of patients exhibitedhydrocephalus requiring CSF diversion procedure. Externalventricular drainage was performed in 29 % of patients forearly hydrocephalus. Seventy percent of patients with acutehydrocephalus requiring external ventricular drainage weregraded as 3, 4 or 5 according to the Hunt and Hess scale onadmission, in contrast to 58 percent of patients without hydrocephalus.Ninety-three percent of patients with hydrocephaluswere graded as 3 and 4 according to Fisher grade oninitial CT scan, in contrast to 83% of patients without hydrocephalus.Conclusion Even though an increased frequency ofhydrocephalus was noted among patients that presented withhigher Fisher and Hunt-Hess grades, none of these gradeswere shown to bear a statistically significant predictive valuein determining the propensity for the development of hydrocephalus.

PURPOSE The aneurysmal subarachnoid hemorrhage (SAH) is a syndrom with an extremely complex pathophysiological course. Although treatment outcomes in patients with intracranial aneurysms of the circle of Willis and SAH have improved over time, the mortality and morbidity rates remain unacceptably high. The clinical course and the outcome were evaluated in a group of patients who underwent surgery. METHODS Patient characteristics, including age, sex, preexisting medical conditions, aneurysm location and size, time to admission, admission neurological status, computerized tomography and angiography findings were analyzed to determine relationship to outcome. A total of 67 patients with the intracranial aneurysms were treated by the microsurgical technique for a direct aneurysm surgery. The data were analyzed in two aspects: the overall management and the surgical results. RESULTS An occlusion of aneurysm neck was done in 97% and 3% of patients were treated by aneurysm wrapping. There was a significant relationship between the neurological status on admission and the outcome (p < 0.005). Out of 67 patients, 50% had a good result, 16% were moderately disabled, 18% were severely disabled, and 12% were dead at the six month post-SAH evaluation. The results were significantly better according to the better neurological status on admission (p = 0.0001). CONCLUSION The disastrous natural history of subarachnoid hemorrhage secondary to ruptured intracranial aneurysm has largely remained unaffected by even the best medical and surgical care because of the natural history of the disease, as well as mistakes in diagnosis and delays in treatment. Among the patients who were underwent surgery, 50% returned to their premorbid state, and 12% died. The factors associated with poor results were direct effects of the initial hemorrhage, vasospasm and rebleeding. Although the results of management of patients with ruptured aneurysms seem to be improved with time, there is opportunity for substantial additional improvement.

AIM The endovascular treatment of an intracranial aneurysm using the Guglielmi detachable coil (GDC) becomes more and more treatment of choice which is based on aneurysm configuration, aneurysm location, the patient's medical and neurological condition and age, available surgical and interventional abilities at the treatmant center, and patient preference. METHODS Out of 73 patients with the intracranial aneurysm, 9 were treated by the endosaccular embolization using the Guglielmi detachable coil. Subarachnoid hemorrhage (SAH) occured in 8 patients and a spacio-compressive effect caused epilepsy in one patient. Three patients with multiple aneurysms were treated by the combination of microsurgical clipping and endosaccular embolization. The outcome was obtained after 6-12 months on the basis of Glasgow outcome scale. RESULTS Out of five patients treated in acute phase of severe subarachnoid hemorrhage (Hunt-Hess grade 4 and 5), one patient died for an inicial hemorrhage, one had a severe disability, and three patients had a good recovery or moderate disability. Two patients with the multiple aneurysms returned to the same quality of life as before the SAH, and one patient had moderate disability. CONCLUSION Microsurgical clipping of the neck of aneurysm is an optimal way of treatment for the most of ruptured intracranial aneurysms. Endosaccular embolization becomes more and more the treatment of choice in selected cases.

People have abused drugs from the moment they found out about them. Abuse of substances increased during crises (war, displacement, catastrophes, different stress-induced circumstances, fear for existence, absence of prospects and hope). Benzodiazepines are most frequently abused psychopharmaceuticals due to their easy accessibility. The war and aggression on Bosnia and Herzegovina have made unforeseeable consequences, they have caused great migration of population, deaths, wounding, separation of families, unemployment and social poverty. All these factors have had influence on mental health of people. The most frequent psychological consequence of war and displacement is PTSP. The survey has shown that there is a difference in drugs abuse between the interviewees in collective centres and local population. A great percentage of interviewees who are accommodated in collective centres are traumatised (63%) and they mostly misused benzodiazepines to alleviate fear, nervousness, mood disorder and pain. Due to a long-term and uncontrolled use of benzodiazepamines, 50% of interviewees who abused benzodiazepamines have become addicted to them.