Browsing by Author "Rasulić, Lukas (6507823267)"

Peripheral nerve surgery in Serbia has become the most fruitful subsection of national neurosurgery, with international recognition of Serbian surgeons and institutions. We chronicle landmark events in the history of the field in Serbia, highlighting the development of the field over time and outlining future prospects. This manuscript provides an example of the development of peripheral nerve surgery and associated training in a challenging social, political, and economic context and may guide the development of peripheral nerve surgery care and training in other settings. © 2022

Localization of lumbar discs in magnetic resonance imaging (MRI) is a challenging task, due to a vast range of shape, size, number, and appearance of discs and vertebrae. Based on a review of the cutting-edge methods, the majority of applied techniques are either semi-automatic, extremely sensitive to change in parameters, or involve further modification of the results. All of the above represents a motivation for implementing deep learning-based approaches for automatic segmentation and classification of disc herniation in MR images. This paper proposes a complete automated process based on deep learning to diagnose disc herniation. The methodology includes several steps starting from segmentation of region of interest (ROI), in this case disc area, bounding box cropping and enhancement of ROI, after which the image is classified based on convolutional neural network (CNN) into adequate classes (healthy, bulge, central, right or left herniation for axial view and healthy, L4/L5, L5/S1 level of herniation in sagittal view). The results show high accuracy of segmentation for both axial view (dice = 0.961, IOU = 0.925) and sagittal view (dice = 0.897, IOU = 0.813) images. After cropping and enhancing the region of interest, accuracy of classification was 0.87 for axial view images and 0.91 for sagittal view images. Comparison with the literature shows that proposed methodology outperforms state-of-the-art results when it comes to multiclassification problems. A fully automated decision support system for disc hernia diagnosis can assist in generating diagnostic findings in a timely manner, while human mistakes caused by cognitive overload and procedure-related errors can be reduced. © 2021 IEEE.

Localization of lumbar discs in magnetic resonance imaging (MRI) is a challenging task, due to a vast range of shape, size, number, and appearance of discs and vertebrae. Based on a review of the cutting-edge methods, the majority of applied techniques are either semi-automatic, extremely sensitive to change in parameters, or involve further modification of the results. All of the above represents a motivation for implementing deep learning-based approaches for automatic segmentation and classification of disc herniation in MR images. This paper proposes a complete automated process based on deep learning to diagnose disc herniation. The methodology includes several steps starting from segmentation of region of interest (ROI), in this case disc area, bounding box cropping and enhancement of ROI, after which the image is classified based on convolutional neural network (CNN) into adequate classes (healthy, bulge, central, right or left herniation for axial view and healthy, L4/L5, L5/S1 level of herniation in sagittal view). The results show high accuracy of segmentation for both axial view (dice = 0.961, IOU = 0.925) and sagittal view (dice = 0.897, IOU = 0.813) images. After cropping and enhancing the region of interest, accuracy of classification was 0.87 for axial view images and 0.91 for sagittal view images. Comparison with the literature shows that proposed methodology outperforms state-of-the-art results when it comes to multiclassification problems. A fully automated decision support system for disc hernia diagnosis can assist in generating diagnostic findings in a timely manner, while human mistakes caused by cognitive overload and procedure-related errors can be reduced. © 2021 IEEE.

Objective: Although the studies have shown the beneficial effects of diet, nutrition, and supplementation as an independent treatment modality, their roles are underestimated in the treatment of peripheral nerve injuries. This is in great part due to the development of efficient nerve repair techniques, combined with physical treatment and stimulation. To achieve the best possible functional recovery diet, nutrition, and supplementation should be implemented within a multidisciplinary approach. The aim of the study is to provide insight into the potentially beneficial effects of diet, nutrients, and supplementation, in the limitation of nerve damage and augmentation of the functional recovery after surgery in a review of human and animal studies. Methods: The data relating to the diet, nutrients, and supplementation effects on peripheral nerve injuries and their treatment was extracted from the previously published literature. Results: General balanced diet as well as obesity influence the initial nerve features prior to the injury. In the period following the injury, neuroprotective agents demonstrated beneficial effects prior to surgery, and immediately after the injury, while those potentiating nerve regeneration may be used after the surgical repair to complement the physical treatment and stimulation for improved functional recovery. Conclusions: Standardized diet, nutrition, and supplementation recommendations and protocols may be of great importance for better nerve regeneration and functional recovery as a part of the multidisciplinary approach to achieve the best possible results in surgically treated patients with peripheral nerve injuries in the future. 2022 Lepić, Lepić, Banjanin, Mandić-Rajčević and Rasulić.

Background: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. Case Report: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. Why Should an Emergency Physician Be Aware of This?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions. © 2019 Elsevier Inc.

Background/Aim. Duchenne muscular dystrophy (DMD) and its allelic form Becker muscular dystrophy (BMD) are X-linked diseases that affect males, characterized by progressive muscle and cardiopulmonary weakness, especially in DMD as a severe form of the disease. They result from mutations in the dystrophin gene, and the most common changes are large intragenic deletions and duplications (80%). One third of patients have de novo mutation and 2/3 of the mothers are estimated as carriers. The aim of the study was to analyze the frequency of duplications versus deletions in the dystrophin gene in patients with dystrophinopathies, as well as to analyze the phenotypic effect of large mutations obtained and to determine the carrier status of female relatives in probands with duplications. Methods. We examined 22 DMD and 35 BMD unrelated patients and 6 female relatives of the probands where duplications were found. We used polymerase chain reaction (PCR) and multiplex ligation-dependent probe amplification (MLPA) methods, according to the protocol, to detect or confirm mutations in probands and female carriers. Results. In probands, there were 34 (59.6%) large deletions (mostly affected exons 44–60) and 6 (10.5%) large duplications in 4 DMD and 2 BMD patients. Also, duplications were found in 3 out of 4 (75%) tested mothers. The distribution of duplications was heterogeneous, affecting N-terminal and central rod domain, and included more exons, except for one DMD patient who had duplication of exon 2. An exception from the Monaco rule was present in 9.5% of DMD and 15.8% of BMD probands, i.e. in 12.5% of DMD/BMD cases. Conclusion. In 57 DMD/BMD probands, we found 59.6% of large deletions and 10.5% of large duplications. The most affected region of the DMD gene was the central rod domain. An exception to Monaco's rule was present in 12.5% of DMD/BMD cases. Three out of 4 examined proband's mothers were confirmed as carriers. © 2020 Inst. Sci. inf., Univ. Defence in Belgrade. All rights reserved.

Introduction/Objective Increasing incidence of spinal cord injuries presents a very important issue. These patients are usually very young, treatment is very difficult, long, expensive, and, in general, of little success. The aim of this study was to evaluate the angiogenic potential of the omental graft in spinal cord revascularization after the injury. Methods The study included 19 patients, who underwent a recurrent surgical procedure for pain syndrome or surgical complication, and one patient in whom angiography revealed no flow in the distal part of an omental graft. Results Our study confirmed angiogenic capabilities of the omental graft placed in the course of omentomyelopexy, for the injured spinal cord revascularization, macroscopically and histopathologically. Study results are limited due to including patients only when the postoperative period was complicated. Conclusion Our study provides some invasive insight into the angiogenic capabilities, although further (likely less invasive) studies are needed to elucidate more clearly omental angiogenesis in spinal cord injury, and to include patients in whom the procedure went well. © 2018, Serbia Medical Society. All rights reserved.

Background: Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. Method: This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. Results: Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. Conclusions: In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon. © 2021, The Author(s), under exclusive licence to Springer-Verlag GmbH, AT part of Springer Nature.

We analyzed aneurysm morphology, demographic and clinical characteristics in patients with anterior communicating artery (ACoA) aneurysms to investigate the risk factors contributing to aneurysm rupture. A total of 219 patients with ACoA aneurysms were admitted to our hospital between January 2016 and December 2020, and morphological and clinical characteristics were analyzed retrospectively in 153 patients (112 ruptured and 41 unruptured). Medical records were reviewed to obtain demographic and clinical data on age, gender, presence of hemorrhage, history of hypertension, diabetes, heart disease, and kidney disease. Morphological parameters examined on 3-dimensional digital subtraction angiography included aneurysm size, neck diameter, aspect ratio, size ratio, bottleneck ratio, height/width ratio, aneurysm angle, (in)flow angle, branching angle, number of aneurysms per patient, shape of the aneurysm, aneurysm wall morphology, variation of the A1 segment, and direction of the aneurysm. Male gender, aspect ratio, height/width ratio, non-spherical and irregular shape were associated with higher odds of rupture, whilst controlled hypertension was associated with lower odds of rupture, when tested using univariate logistic regression model. In multivariate model, controlled hypertension, presence of multiple aneurysms, and larger neck diameter reduced the odds of rupture, while irregular wall morphology increased the risk of rupture. Regulated hypertension represented a significant protective factor from ACoA aneurysm rupture. We found that ACoA aneurysms in male patients and those with greater aspect ratios and height/width ratios, larger aneurysm angles, presence of daughter sacs and irregular and non-spherical shapes were at a higher risk of rupture. © 2022, Dr. Mladen Stojanovic University Hospital. All rights reserved.

Background/Aim. Nerve transfers in cases of directly irreparable, or high level extensive brachial plexus traction injuries are performed using a variety of donor nerves with various success but an ideal method has not been established. The purpose of this study was to analyze the results of nerve transfers in patients with traction injuries to the brachial plexus using the thoracodorsal and medial pectoral nerves as donors. Methods. This study included 40 patients with 25 procedures using the thoracodorsal nerve and 33 procedures using the medial pectoral nerve as donors for reinnervation of the musculocutaneous or axillary nerve. The results were analyzed according to the donor nerve, the age of the patient and the timing of surgery. Results. The total rate of recovery for elbow flexion was 94.1%, for shoulder abduction 89.3%, and for shoulder external rotation 64.3%. The corresponding rates of recovery using the thoracodorsal nerve were 100%, 93.7% and 68.7%, respectively. The rates of recovery with medial pectoral nerve transfers were 90.5%, 83.3% and 58.3%, respectively. Despite the obvious differences in the rates of recovery, statistical significance was found only between the rates and quality of recovery for the musculocutaneous and axillary nerve using the thoracodorsal nerve as donor. Conclusion. According to our findings, nerve transfers using collateral branches of the brachial plexus in cases with upper palsy offer several advantages and yield high rate and good quality of recovery.

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Computed tomography (CT) is an essential tool in diagnosing and treating traumatic brain injury (TBI). Marshall CT classification, Rotterdam and Helsinki CT scores were consecutively developed as prediction outcome scales by computing TBI CT abnormalities. None of them classifies the pathological CT findings in the same manner. We aimed to determine which one is most accurate and has the best grading discriminatory power in determining early outcome. All TBI patients treated at a single center in a one-year period having undergone a CT scan on admission were retrospectively included. After calculation of all three scores, comparison among scale performances, as well as their accuracy in predicting patient 6-month outcome by the Glasgow Outcome Scale (GOS) was made. We used the Receiver Operating Characteristic curves to analyze correlation between all scales and early outcome. We calculated the area under the curve (AUC) to determine the power of each system while paired samples T-test was used to determine correlation among the scales. Mann-Whitney U test was performed to determine difference in outcome groups. A total of 1006 patients were included in final analysis. The mean patient age at presentation was 55.6 (±20.1) years, overall mortality was 6.4%, mean GOS was 3.00 (±1.4), and mean Glasgow Coma Score (GCS) was 13.9 (±0.2). Mortality was higher among patients with lower scores (p<0.01 all). The AUCs indicated that all scoring systems had a similarly high discriminative power in predicting early unfavorable outcome (Marshall AUC 0.86 vs. Rotterdam AUC 0.82 vs. Helsinki AUC 0.84). High correlation was found between Marshall and Rotterdam grading, r = 0.78, and moderate correlation between the other two pairs (Marshall vs. Helsinki, r=0.62, and Rotterdam vs. Helsinki, r=0.51). Additionally, low GCS and high injury severity score (ISS) could be identified as strong predictors of early death and poor outcome. In conclusion, all classification systems demonstrated a similar, strong predictive power for early outcome, but even greater discrimination results could be obtained if GCS and ISS were incorporated in the calculation. Helsinki CT score was least predictable of all three, and had the lowest correlation with the other two. Although Marshall CT classification was the oldest and simplest, it had at least the same prediction power as the newer scoring scales and should remain in use. Therefore, for prognostic purposes, this study recommends using one individual scale in clinical application to get the best possible prediction for TBI. © 2024, Dr. Mladen Stojanovic University Hospital. All rights reserved.

Introduction. Complex defects of skull bones with different etiology, still present the challenge in reconstructive surgery. The goldstandard for cranioplasty is the autologous calvarial bone graft removed during surgery which cannot be always applied, especially in gunshot wounds for sometimes complete bone destruction. Autologous reconstruction with split calvarial, rib bones or iliac bone graft is also possible. Materials routinely used for reconstructions like titanium mesh, polymethyl metacrylate (PMMA), and other have numerous dis-advantages and limitations. Case report. We presented a patient with gunshot injury to the head with residual large bone defect in the frontal region, with involvement of the skull base, and open frontal sinus. After conservative treatment, six months after the injury, reconstruction of the residual bone defect was performed. The chosen material was computer-designed PEEK-OPTIMA® implant, manufactured on the basis of MSCT scan. This material has not been used in this region so far. The postoperative and follow-up period of the next 12 months passed without surgical complications, neurological deficit, with satisfactory functional and aesthetic results. Conclusion. Implanted bone replacement was designed and manufactured precisely according to the skull defect, and we found it suitable for the treatment of complex defects of the cranium. Early results are in favor of this cranioplasty method over standardized materials. Therefore, this material is expected to become a method of choice for reconstructive surgery of bony defects of the face and skull especially in complex cases. © 2016, Institut za Vojnomedicinske Naucne Informacije/Documentaciju. All rights reserved.

Introduction/Objective Hair transplantation is one of the fastest evolving procedures in aesthetic surgery and is accompanied by continuous improvement of new techniques. Hairline planning is one of the most important steps in hair transplantation. The shape of the hair also varies depending on the variation of facial shape so it is very important when determining hair direction and making holes for future grafts. Methods We used ordinary 18 gauge injection needles whose number was the same as the number of micrographs we planned for transplantation. Needles are administered in pile growth direction and angle, starting from the first row, and then proceeding to the second one and so on, until we insert all prepared needles. We insert them one in front of the other with a precision ease for future follicles. Results In all 56 patients, we obtained natural hair growth. Inserting the needles reduced bleeding and the average time of the operation was three hours. The success of grafting was 95%. We only had one infection in one patient. Hair growth corresponded to the needle insertion. After a year of transplantation at the last control, the patient’s satisfaction was 100%. Conclusion By using the same number of needles as the number of grafts we reduced operating time, we had a better determination of the direction of hair growth, we can prevent follicular extraction that can be caused by new needle insertion, and this technique achieved a good aesthetic result. © 2019, Serbia Medical Society. All rights reserved.

Patients with brain arteriovenous malformation (AVM) have a certain risk to bleed, and the goal of this study was to examine the effect of radiological and clinical predictive characteristics of AVM hemorrhage using multidetector computed tomographic (MDCT) angiography. The study included a series of 57 patients, mean age 35.46 years, who were diagnosed during their hospitalization at Clinical Department of Neurosurgery, Clinical Center of Serbia, in the period from January 2008 to March 2016. In all patients, the diagnosis was made using MDCT angiography. Two groups of patients were observed. The first group included patients who did not initially present with hemorrhage, while the second group initially presented with hemorrhage. Both groups were treated with medical therapy or a combination of medical therapy with embolization/surgery/radiotherapy. Deep venous drainage (p < 0.05), combined arterial supply from different basins (p < 0.05) with a length > 60 mm, venous dilatation present in the drainage vein (p < 0.01), and the angle of casting supply arteries in the nidus (p < 0.01) carry a risk of repeated bleeding. In the group of patients who had initial hemorrhage, the mean value of the casting angle size was 130°, while in the group that did not have initial bleeding the mean value of the measured angle size was 103.81° with standard deviation of 17.21° (p < 0.01). In conclusion, AVMs with deep venous drainage from the carotid and vertebrobasilar basin, the length of the feeding arteries > 60 mm, the angle of the casting feeding arteries in the nidus ≥130° and dilatation and/or venous aneurysm of drainage vessel are predictive for clinical presenting by hemorrhage.

Developmental venous anomalies are cerebral vascular malformations that present normal venous drainage of cerebral tissue. With increased and accessible usage of modern diagnostic tools, they are now one of the most commonly diagnosed cerebral vascular malformations. Although developmental venous anomalies are considered to be benign lesions, association with arteriovenous malformation renders malignant potential to this combined pathology. In the case presented, these malformations were clinically silent and diagnosed accidentally, so they were not treated either with surgery, endovascular surgery or radiosurgery, considering the possible complications such as venous infarction of the brain, and because there was no obvious neurologic deficit related to this pathology. The patient presents for regular neurosurgical follow up examinations and has been free from symptoms that were present on admission.

Introduction: Radial nerve lesions present a clinical entity that may lead to disability, psychological distress, and job loss, and thus requires great attention. Knowledge of the etiology and exact mechanism of the nerve impairment is of great importance for appropriate management of these patients, and there are only a few papers that focused on these features in patients with surgically treated radial nerve lesions. The lack of studies presenting the etiology and injury mechanisms of surgically treated radial nerve lesions may be due to a relatively small number of specialized referral centers, dispersion to low-flow centers, and a greater focus on the surgical treatment outcomes. Aim: The aim of this study was to describe the etiological and epidemiological characteristics of patients with surgically treated radial nerve lesions of various origins. Methods: This retrospective study evaluated 147 consecutive patients with radial nerve lesion, treated in the department during the last 20 years, from January 1, 2001, until December 31, 2020. Results: The majority of patients belonged to the working population, and 70.1% of them were male. Most commonly, the etiology of nerve lesion was trauma (63.3%) or iatrogenic injury (28.6%), while the less common origin was idiopathic (4.1%) or neoplastic (4.1%). The most frequent location of the lesion was in the upper arm, followed by the elbow and forearm. Fracture-related contusion was the most common mechanism (29.9%), followed by postoperative fibrosis (17.7%), lacerations (17.7%), and compression (15.6%). Conclusion: Based on the fact that traumatic or iatrogenic injuries constitute the majority of cases, with their relevant mechanisms and upper arm predomination, it is crucial to raise awareness and understanding of the radial nerve injuries among orthopedic surgeons to decrease the numbers of these patients and properly preserve or treat them within the initial surgery. 2022 Rasulić, Djuraskovic, Lakićević, Lepić, Savić, Grujić, Mićić, Radojevic, Cordoba Mosqueda, Visani, Puzovic, Kovačević, Vitošević, Mandic-Rajcevic and Knezevic.

SUMMARY – The aim of this study was to analyze risk factors present in schizophrenic patients with depressive symptomatology. The sample comprised of 76 respondents diagnosed with schizo-phrenia. In the study, we used the Positive and Negative Syndrome Scale (PANSS) and Calgary Depression Scale for Schizophrenia. The prevalence of depression was estimated to be 30%. The mean scores on the negative subscale of the PANSS were significantly higher in patients with schizophrenia and depression compared to control group (U=3.64, p=0.00), and so were those on the General Psy-chopathology Scale (U=4.91, p=0.00). Socio-demographic factors were identified as important factors (p<0.05). Personal and environmental factors such as loneliness, immediate social environment, social support and isolation were statistically significantly different between the groups (p<0.05). There was a correlation of poor compliance with psycho-pharmacotherapy, increased number of hospitalizations and shorter remission period with the severity of clinical presentation (p<0.05). Since the presence of these factors is associated with depression in schizophrenia, their early detection in clinical practice is vital to ensure timely prevention of the development of depressive symptomatology. © 2020, Dr. Mladen Stojanovic University Hospital. All rights reserved.

Background Pneumocephalus is a well-known complication in the surgical treatment of chronic subdural hematomas; however, its influence remains controversial. The amount of subdural air may vary, and it may cause worsening of symptoms, increase reoccurrence rates, and worsen the outcomes. Lethal outcome following acute onset of massive pneumocephalus was not previously reported. Case Report An 81-year-old man with bilateral hematomas underwent surgery under local anesthesia. Both hematomas were approached in the same surgery, and the drains were placed subdurally. After initial improvement, severe hypertension developed, followed by vital function and neurologic deterioration. Massive pneumocephalus with subarachnoid and contralateral intracerebral hemorrhage was revealed, causing a severe midsagittal shift. Emergency irrigation to evacuate subdural air was performed. However, there was no improvement. Further computed tomography confirmed subdural air collection, but it also revealed hemorrhage progression and intraventricular propagation. No further surgery was indicated. Conclusion Pneumocephalus is an underestimated but potentially devastating complication. Both intraoperative avoidance and postoperative prevention should be utilized to avoid subdural air ingress, and thus evade potentially fatal complications. © 2022 Georg Thieme Verlag. All rights reserved.