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114

HELLENIC NEUROSURGERYSEPTEMBER - DECEMBER 2007, Volume 14, Number 3

CONTENTS

ReviewsSnow sports head injuries: contemporary data and review of the literature ....................................................... 115P. Selviaridis

Spinal infections ........................................................................................................................................................... 121A. Christodoulou, P. Antonarakos

Clinical StudyEvaluation of surgical results of cervical discectomy and osteophytectomy with NDI index .......................... 132V. Christodoulou, D. Peios, A. Filippidis, N. Skoulios, I. Achoulias, I. Baltas

Case ReportsAnaplastic astrocytoma - representation with the latest techniques of magnetic resonance ........................... 138B. Lallas, T. Geroukis, A. Petridis, C. Tzikas, K. Anastasiadou, C. Grigoriadis, . Baltas, S. Baroutas, P. Palladas

Sacral insufficiency fracture ....................................................................................................................................... 145C. Tzikas, V. Lallas, K. Anastasiadou, T. Geroukis, C. Grigoriadis, D. Peios, P. Paladas

Long-term survival of a glioblastoma multiforme patient: Case Report ............................................................. 150G. Tsermoulas, P. Sioutos, K. Mataliotakis, A. Seretis

TO ThE EDITORA. Kougialis ................................................................................................................................................................. 155

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2007, 14(3):115-120HELLENIC NEUROSURGERY 2007, 14(3):115-120

REVIEW

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SUMMARY

Snow sports head injuries: contemporary data and review of the literature

Selviaridis P.1st Neurosurgical Department, AHEPA University hospital, Thessaloniki

The popularity of skiing and snowboarding has been growing rapidly throughout the world. The purpose of this study is to review the contemporary literature and to present the recent epidemiological data regard-ing the incidence, pattern and severity of head injuries. We reviewed the literature in Pubmed using the key-words: ski and/or snowboard and head injury. An additional search was performed of Internets largest search engine using the same terms. Head injuries constitute 3 to 29% of all injuries in winter sports. Injury rates are relatively low, ranging from 2 to 3 and 4 to 6 head injuries per 1000 skier days for ski and snowboard respectively. Collision, usually on a stationary object is the most common mechanism (4888%) and fall is the second. Head injury after major fall, usually after jumping, presents itself as an important mechanism of injury among snowboarders. Although head injury represents only a small fraction of skiers and snowboarders injuries overall, it is the leading cause of death and serious injury on the slopes. The difference in technique and age distribution between skiers and snowboarders may account for the differences in the incidence and mechanisms of head injury.

Key-words: head injury, ski, snowboard

1. Bladin C, McCrory P. Snowboarding injuries. An overview.

Sports Med 19:358-364, 1995. 2. Burtschner M, Philadelphy M. Skiing collision accidents:

frequency and types of injuries. In: Mote CD Jr, Johnson RJ, Hauser W, et al., eds. Skiing Trauma and Safety, 10th Vol. ASTM STP 1266. Philadelphia, PA: American Society for Testing and Materials. 73-76, 1996.

3. Chissell HR, Feagin Jr JA, Winston J, et al. Trends in ski and snowboard injuries. Sports Med 22:141-145, 1996.

4. Davidson TM, Laliotis AT. Alpine skiing injuries: a nine-year study. West J Med 164:310-314, 1996.

5. Deibert MC, Aronsson DD, Johnson RJ, et al. Skiing injuries in children, adolescents and adults. J Bone Joint Surg Am 80: 25-32, 1998.

6. Diamond TP, Gale DS, Denkhaus KH. Head injuries in skiers: an analysis of injury severity and outcome. Brain Injury 15:429-434, 2001.

7. Earle AS, Moritz JR, Saviers GB. Ski injuries. JAMA

120 , . 14, 3, 2007

180:285-288, 1962. 8. Fukuda , Tabaka M, Saito T, et al. Head injuries in

snowboarders compared with head injuries in skiers. A prospective analysis of 1076 patients from 1994 to 1999 in Niigata, Japan. Am J Sports Med 29(4):437-440, 2001

9. Furrer M, Erhart S, Frutinger A, et al. Severe skiing in-juries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury and mortality. J Trauma 39:737-741, 1995.

10. Hagel B, Goulet C, Platt WR, et al. Injuries among skiers and snowboarders in Quebec. Epidemiology 15:279-286, 2004.

11. Hagel B, Pless IB, Goulet C, et al. Effectiveness of helmets in skiers and snowboarders: case-control and crossover study. BMJ 330(5):281, 2005.

12. Harris J. Snowboarding and head injury. J Neurosurg 98:932. Author reply 932-933, 2003.

13. Health Statistics Section, Colorado Department of Public Health and Enviroment. Recreational fatalities in Colo-rado, 1996-1998. Denver, CO: Colorado Department of Public Health and Enviroment. Health Statistics Brief, 2000.

14. Heller MF. World Ski Atlas. London, Cavendish, 1978. 15. Hunter ER: Skiing Injuries. Am J Sports Med 27:381-389,

1999. 16. Johnson RJ, Ettlinger CF, Shealy JE. A method to help

reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med 23:531-537, 1995.

17. Levy AS, Hawkes AP, Hemminger LM, et al. An analysis of head injuries among skiers and snowboarders. J Trauma nj 53:695-704, 2002.

18. Levy AS, Smith RH. Neurologic injuries in skiers and snowboarders. Semin Neurol 20:233-245, 2000.

19. Macnab AJ, Smith T, Gagnon FA, et al. Effect of helmet wear on the incidence of head/face and cervical spine

injuries in young skiers and snowboarders. Inj Prev 8:324-327, 2002.

20. Moritz JR. Ski injuries. Am J Surg 98:493-505, 1959. 21. Morrow PL, McQuillen EN, Eaton LA Jr, et al. Downhill

ski fatalities: the Vermont experience. J Trauma 28:95-100, 1988.

22. Nakaguchi H, Fujimaki T, Ueki K, et al. Snowboard head injury: prospective study in Chino, Nagano, for two sea-sons from 1995 to 1997. J Trauma 46:1066-1069, 1999.

23. Nakaguchi H, Tsutsumi K. Mechanisms of snowboard-ing-related severe head injury: shear strain induced by the opposite-edge phenomenon. J Neurosurg 97:542-548, 2002.

24. Shealy JE, Ettlinger CF. Gender-related injury patterns in skiing. In: Mote CD Jr, Johnson RJ, Hauser W, et al., eds. Skiing Trauma and Safety, 10th Vol. ASTM STP 1266. Philadelphia, PA: American Society for Testing and Ma-terials. 45-57, 1996.

25. Sherry E, Clout L. Deaths associated with skiing in Aus-tralia: a 32-year study fo cases from the Snowy Mountains. Med J Aust 149:615-616, 1988.

26. Sulheim S, Holme I, Ekeland A, et al. Helmet use and risk of head injuries in alpine skiers and snowboarders. JAMA 295(22):919-924, 2006.

27. U.S. Consumer Product Safety Commission. Skiing helmets: an evaluation of the potential to reduce head injury. Washington DC: U.S. Government Printing Of-fice; 1999.

28. Wakabayashi T, Fujiwara N, Mori K, et al. Snowboarding injury: Comparison with skiing injuries. Clin Sports Med 13:1187-1192, 1996.

29. Wilderness Medical Society Summer Conference and Annual Meeting, Park City, Utah, Aug 2000.

30. Zacharopoulos A. 16th International Symposium of the ISSS, Mount Arai, Japan, April 2005.

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2007, 14(3):121-131HELLENIC NEUROSURGERY 2007, 14(3):121-131

REVIEW

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129

SUMMARY

Spinal infections

Christodoulou A., Antonarakos P.1st Orthopaedic Department, University of Thessaloniki, General Hospital G. Papanikolaou

Thessaloniki, Greece

Spinal infections still remain a serious medical problem associated with high rates of morbidity and mortal-ity. All the advances occurred within this century have certainly improved the clinical outcomes but many factors have also contributed to the increase of the number of new cases with spinal infection such as the increase of the mean life expectancy, the number of patients suffering from immunocompression and lung tuberculosis as well as the wide popularization of spine surgery itself. Patients symptoms can last for weeks or months before the diagnosis is made. Early diagnosis is of outmost importance for a good clinical outcome. From the time the diagnosis is made the mainstay of treatment remains antimicrobial therapy based on the cultures obtained and immobilization of the spine with rest and orthotics. In most of the cases conserva-tive treatment will be adequate to eradicate the infection and prevent the development of spinal deformity, abscess formation or neural compromise. However still many cases will need further surgical intervention, especially cases which present with severe neural compression and neurological compromise, mechanical instability of the spine or severe abscess formation. The type of surgical procedure depends on the specific indications and advantages of each procedure as well as the preferences of the surgeon. Anterior procedures give the advantage of the radical eradication of the infection and a more stable reconstruction of the anterior column against the increased rate of morbidity. On the other hand posterior procedures have the disadvantage of the limited approach and a less stable fixation of the spine with the apparent advantage of decreased rate of morbidity. Recently minimal access procedures have emerged and are expected to play an important role to the treatment of spinal infections

Key words: diagnosis, infection, incidence, spinal, treatment

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2007, 14(3):132-137HELLENIC NEUROSURGERY 2007, 14(3):132-137

KINIKH CLINICAL STUDY

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1. Bertalanffy , Eggert R. Complications of anterior

cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien) 99:41-50, 1989.

2. Boni M, Cherubino P, Benazzo F, et al. Multiple subtotal somatectomy. Technique and evaluation of a series of 39 cases. Spine 9:358-362, 1984.

3. DuBois CM, Bolt PM, Gupta P, et al. Static versus dynamic plating for multilevel anterior cervical discectomy and fusion. Spine J 7:188-193, 2007.

4. Eck JC, Humphreys SC, Hodges SD, et al. A comparison of outcomes of anterior cervical discectomy and fusion in patients with and without radicular symptoms. J Surg Orthop Adv 15:24-26, 2006.

5. Frymoyer GW. The adult spine Second Edition Volume 3, p 1357-1371. Lippincott-Raven Pub. 1997.

6. Garvey TA, Transfeldt EE, Malcolm JR, et al. Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain. Spine 27:1887-1895, 2002.

7. Greenberg MS. Handbook of Neurosurgery, 5th edition, p 322-327, Thieme 2001.

8. Hacker RJ. A randomized prospective study of an anterior cervical interbody fusion device with a minimum of 2 years of follow-up results. J Neurosurg 93(2 Suppl):222-226, 2000.

9. Hillard VH, Apfelbaum RJ. Surgical management of

cervical myelopathy: indications and techniques for mul-tilevel cervical discectomy. Spine J 6(6 Suppl):242S-251S, 2006.

10. Lunsford LD, Bissonette DJ, Zorub DS. Anterior surgery for cervical disc disease. Part 2: Treatment of cervical spondylotic myelopathy in 32 cases. J Neurosurg 5:12-19, 1980.

11. Nandoe Tewarie RD, Bartels RH, Peul WC, et al. Long-term outcome after anterior cervical discectomy without fusion. Eur Spine J, pub ahead of print, 2007.

12. Peolsson A, Vavruch L, Oberg B. Predictive factors for arm pain, neck pain, neck specific disability and health after anterior cervical decompression and fusion. Acta Neurochir (Wien) 14:167-173, 2006.

13. , , . - : ; 12:97-100, 2005.

14. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 14: 409-415, 1991.

15. Yue WM, Brodner W, Highland TR. Long-term results after anterior cervical discectomy and fusion with allo-graft and plating: a. 5- to 11-year radiologic and clinical follow-up study. Spine 30:2138-2144, 2005.

16. Zoega B, Karrholm J, Lind B. Outcome scores in degenera-tive cervical disc surgery. Eur Spine J 9:137-143, 2000.

SUMMARY

Evaluation of surgical results of cervical discectomy and osteophytectomy with NDI index

Christodoulou V., Peios D., Filippidis A., Skoulios N., Achoulias I., Baltas I.Neurosurgical Department G. Papanikolaou Hospital, Thessaloniki

To evaluate the surgical results of cervical discectomy and osteophytectomy we studied 116 patients with the Neck Disability Index. Group A (score 5-14) included 14 patients and improved 8 (57%). Group B (score 15-24) included 41 patients and improved 38 (92%). Group C (score 25-31) included 33 patients and improved all. Group D (score >34) included 28 patients and improved all. From the 116 patients, 104 presented with radiculopathy and improved 96 (92,4%). 12 presented with myelopathy and improved six (50%), four (33%) remained stable and two deteriorated. The outcome was related to the clinical symptoms. We conclude that outcome from radiculopathy with high disability is better than the outcome of radiculopathy with slight disability, if proper surgical technique is applied. Outcome from myelopathy is less good despite the proper surgical technique.

Key words: cervical discectomy, neck disability index, outcome.

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2007, 14(3):138-144HELLENIC NEUROSURGERY 2007, 14(3):138-144

CASE REPORT

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SUMMARY

Anaplastic astrocytoma - representation with the latest techniques of magnetic resonance

Lallas B.1, Geroukis T.1, Petridis A.1, Tzikas C.1, Anastasiadou K.1, Grigoriadis C.2, Baltas I.2, Baroutas S.2, Palladas P.1

1Department f CT and MRI and 2Department of Neurosurgery, G. Papanikolaou Hospital Thessaloniki

MRI is specific and sensitive and is considered the investigation of choice in the diagnosis of brain tumors. The latest MRI applications aim in differentiating low grade astrocytomas from anaplastic astrocytomas or cerebral ischemia. We describe the case of a 35-year old male patient, presented with headache, seizures and instability of gait. The MRI examination, including T1WI, T2WI, Flair sequences, as well as T1WI after intravenous contrast injection raised the suspicious of astrocytoma. Further examination with DWI, PWI, DTI images and spectroscopy revealed as the most likely diagnosis the Anaplastic Astrocytoma. A stereotactic brain biopsy confirmed this diagnosis. Advanced techniques, like DWI, PWI, DTI and spectroscopy expand the role of the MRI in the diagnosis of brain tumors.

Key words: anaplastic astrocitoma, MRI applications

144 , . 14, 3, 2007

1. Brain Tumor Pathology. Current Diagnostic Hotspots

and Pitfalls. AJNR 28:1832-1833, 2007. 2. Bulakbasi N, Kocaoglu M, rs F, et al. Combination of

Single-Voxel-Voxel Proton MR Spectroscopy and Appar-ent Diffusion Coefficient Calculation in the Evaluation of Common Brain Tumors. AJNR 24:225-233, 2003.

3. Esposito Felice J, Mithalal R, Papa M, et al. Astrocytoma, Brain. WebMD. 2006.

4. Kono K, Inoue Y, Nakayama K, et al. The Role of Diffu-sion-weighted Imaging in Patients with Brain Tumors. AJNR 22:1081-1088, 2001.

5. Ana L, Castillo M, Armao D, et al. Unusual MR Spec-troscopic Imaging Pattern of an Astrocytoma: Lack of Elevated Choline and High myo-Inositol and Glycine Levels. Radiology 241:839-846, 2006.

6. Stanley L, Ahn D, Johnson G, et al. Peritumoral Diffusion Tensor Imaging of High-Grade Gliomas and Metastatic Brain Tumors. AJNR 24:937-941. 2003.

7. Stephan ME, Bogner P, Bajzik G, et al. Normal Brain and Brain Tumor: Multicomponent Apparent Diffusion Coef-ficient Line Scan Imaging. Radiology 219: 842. 2001.

8. Carles M, Juli-Sap M, Alonso J, et al. Brain Tumor Classification by Proton MR Spectroscopy: Comparison of Diagnostic Accuracy at Short and Long TE. AJNR 25:1696-1704. 2004.

9. Mitsuhashi T, Shimizu Y, Ban S. Anaplastic oligoden-droglioma: a case report with characteristic cytologic features, including minigemistocytes. Acta Cytol 51:657-660, 2007.

10. Provenzale M. James, Srinivasan Mukundan, Barboriak DP. Diffusion-weighted and Perfusion MR Imaging for Brain Tumor Characterization and Assessment of Treat-ment Response. Radiology 239:632-649, 2006.

11. Higano S, Yun X, Kumabe T, et al. Malignant Astrocytic Tumors: Clinical Importance of Apparent Diffusion Coefficient in Prediction of Grade and Prognosis. Ra-diology 241:839-846; published online before print as 10.1148/radiol.2413051276. 2006.

12. Melissa Y, Fisch C, Lamarche JB. AFIP Archives: Glioma-tosis Cerebri Affecting the Entire Neuraxis. Radiographics 23:247, 2003.

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2007, 14(3):145-149HELLENIC NEUROSURGERY 2007, 14(3):145-149

CASE REPORT

146 , . 14, 3, 2007

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SUMMARY

Sacral insufficiency fracture

Tzikas C.1, Lallas V.1, Anastasiadou K.1, Geroukis T.1, Grigoriadis C.2, Peios D.2, Paladas P.11Department of CT and MRI G. Papanikolaou Hospital Thessaloniki, 2Department of Neurosurgery

G. Papanikolaou Hospital Thessaloniki

Sacral insufficiency fractures are very rare and they might be confusing in their diagnosis. The aim of this assignment is to present a similar case and to outline its difficulty in approaching imaging findings. A female patient aged 55, after lumbar injury presented with ache in the lumbar area. The X-ray was normal and she received anti-inflammatory treatment. One year later, there was no improvement, so she had a CT of pelvis and hips which did not revealed any specific findings except of degeneration of L5-S1 and facets. Due to inconsistency of CT-findings and the clinical presentation, an MRI scan was performed. Axial sagital semi coronal T1-T2-STIR were taken. T2 and STIR sequences revealed hyper tense signal of marrow with char-acteristic bilateral distribution sparing sacral-iliac joints giving an H pattern. There was no linear fracture as this usually appears up to three months after the injury. In T1 sequence the signal was hypotense. Sacral insufficiency fractures are stress fractures resulting from normal physiological stress on demineralized bone with decreased elastic resistance. They are difficult to be diagnosed as they do not usually need high stress pressure. The patients are usually treated for different medical conditions as degeneration of intravertebral disc, spinal stenosis and hip arthritis. These fractures usually present to postmenopausal women aged 60 to 80 years old, who may have osteoporosis, rheumatoid arthritis, renal osteodystrophy, corticosteroid excess, radiation therapy, Paget disease and other osteopenic reasons. The most common reason is osteoporosis and almost always the history of the injury is detected after the diagnosis. Differential diagnosis includes sacral

149

metastases, primary sacral neoplasm, sacral osteomyelitis, sacroiliitis and osteoarthritis. MRI is specific and sensitive and the investigation of choice in diagnosing sacral insufficiency fractures, as there is no other way to reveal the marrow bone edema with the characteristic H shaped pattern.

Key words: marrow bone edema, sacral fracture

1. Anderson MW and A Greenspan Stress fractures. Radiol-

ogy 199: 1-12, 1996. 2. Berger PE, Ofstein RA, Jackson DW, et al. MRI demon-

stration of radiographically occult fractures: what have we been missing? Radiographics 9: 407-436, 1989.

3. Blomlie V, Lien HH, Iversen T, et al. Radiation-induced insufficiency fractures of the sacrum: evaluation with MR imaging. Radiology 188: 241, 1993.

4. Bogost GA, Lizerbram EK, Crues JV, 3rd MR imaging in evaluation of suspected hip fracture: frequency of

unsuspected bone and soft-tissue injury. Radiology 197: 263-267, 1995.

5. Diel J, Orlando O, Richard A, et al. The Sacrum: Patho-logic Spectrum, Multimodality Imaging, and Subspecialty Approach. Radiographics 21: 83-104, 2001.

6. Manaster BJ. Adult Chronic Hip Pain: Radiographic Evaluation. Radiographics 20: S3-S25, 2000.

7. Peh WC, Khong PL, Yin Y, et al. Imaging of pelvic insuf-ficiency fractures. Radiographics 16: 335-348, 1996.

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: : 6947773315e-mail: gtsermoulas@gmail.com

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2007, 14(3):150-154HELLENIC NEUROSURGERY 2007, 14(3):150-154

CASE REPORT

151

. - . grade IV WHO , 60 Gy. - , . , , - (. 1). Karnofsky Performance Score (KPS) 90. ( - ). IV,

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152 , . 14, 3, 2007

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SUMMARY

Long-term survival of a glioblastoma multiforme patient: Case Report

Tsermoulas G., Sioutos P., Mataliotakis K., Seretis A.Neurosurgical Department, Athens General Hospital G. Genimatas

A case of a female patient with glioblastoma multiforme surviving for more than nine years is presented. Factors associated with long term survival in patients with glioblastoma multiforme are: young age at diag-nosis, female sex, gross total resection of the tumor and a high preoperative Karnofsky Performance Score. Pathology findings associated with long-term survival in glioblastoma multiforme include the presence of oligodendroglial cell isles, the presence of giant cells, the absence of small anaplastic cells, and a low prolifera-tive cell rate. Genetic changes associated with long-term survival in patients with glioblastoma multiforme are discussed as well.

Key words: glioblastoma multiforme, long-term survival, malignant glioma.

1. Athanassiou , Synodinou M, Maragoudakis E, et al.

Randomized Phase II Study of Temozolomide and Radio-therapy Compared With Radiotherapy Alone in Newly Diagnosed Glioblastoma Multiforme. Journal of Clinical Oncology 23: 2372-2377, 2005.

2. Back MF, Ang EL, Ng WH, et al. Improved median sur-vival for glioblastoma multiforme following introduction of adjuvant temozolomide chemotherapy. Ann Acad Med Singapore 36:338-342, 2007.

3. Binder DK, Keles GE, Aldape K, et al. Aggressive Glial Neoplasms. In Neurological Surgery. Principles and Practice, Batjer HH, Loftus CM (eds.). Volume 1: Lip-pincott Williams and Wilkins: Philadelphia, 1st ed., pp 1270-1280, 2003.

4. Burger PC, Vogel FS, Green SB, et al. Glioblastoma Mul-tiforme and Anaplastic Astrocytoma: Pathologic Crite-ria and Prognostic Implications. Cancer 56:1106-1111, 1985.

154 , . 14, 3, 2007

5. Chandler KL, Prados MD, Malec M, et al. Long-term survival in patients with glioblastoma multiforme. Neu-rosurgery 32:716-720, discussion 720, 1993.

6. Kelly PJ, Hunt CH. The limited value of cytoreductive surgery in elderly patients with malignant gliomas. Neu-rosurgery 33:62-67, 1994.

7. Krex D, Klink B, Hartmann C, et al. Long-term survival with glioblastoma multiforme. Brain 130:2596-2606, 2007.

8. Phuphanich S, Ferrall S, Greenberg H. Long-term survival in malignant glioma. Prognostic factors. J Fla Med Assoc 80:181-184, 1993.

9. Prabal D, Chand SM, Kumar MA, et al. Glioblastoma multiforme with long term survival. Neurology India 53:329-332, 2005.

10. , , , .

E : - . 20 , , 8-11 , 2006.

11. Santiago P, Silbergerd DL. Malignant gliomas: Anaplastic Astrocytoma, Glioblastoma Multiforme, Gliosarcoma, Malignant Oligodendroglioma. In Youmans Neurologi-cal Surgery, Winn RH (ed.). Volume 1: W.B. Saunders: Philadelphia, 5th ed., pp 969-980, 2004.

12. Shinojima N, Kochi M, Hamada J, et al. The influence of sex and the presence of giant cells on postoperative long-term survival in adult patients with supratento-rial glioblastoma multiforme. J Neurosurg 101:219-226, 2004.

13. Westphal M, Hilt DC, Bortey E, et al. A phase 3 trial of local chemotherapy with biodegradable carmustine (BCNU) wafers (Gliadel wafers) in patients with primary malignant glioma. Neuro-Oncology 5:79-88, 2003.

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2007, 14(3):155-156HELLENIC NEUROSURGERY 2007, 14(3):155-156

TO THE EDITOR

156 , . 14, 3, 2007

Journal of Neurosurgery (2,748) Neurosurgery (2,783). - -, : , , - ( ). , , - , - ( 2 : Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005 Jan 29-Feb 4;365(9457):387-97.)

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