Central nervous system hydatidosis in Turkey: a cooperative study and literature survey analysis of 458 cases

Primary cerebral intraventricular hydatid cyst: a case report and review of the literature

Intracranial hydatid cysts, which are common in certain areas worldwide, almost always develop at an intraparenchymal site. However, the literature on intraventricular hydatid cysts consists of only 6 independent case reports and about 30 cases that are described in large series. We report on a 10-year-old girl who was admitted with an intracranial cyst. She complained of headache of 10 months' duration that had intensified significantly over the 3 weeks immediately before her admission. The results of a neurologic examination showed bilateral papilledema and slight left hemiparesis. Magnetic resonance imaging revealed a right temporo-parieto-occipital cystic lesion that was causing the shifting of the midline structures to the contralateral side. The giant cyst was successfully removed without rupture. The possibility of infection with Echinococcus granulosus should be included in the differential diagnosis of unspecific neurologic symptoms such as a progressively worsening headache, especially in pediatric patients from the geographic areas in which that parasite is endemic.

Emerging drugs for spinal cord injury

BACKGROUND

This review summarizes several promising pharmacological approaches for the therapeutic management of traumatic spinal cord injury (SCI), which are either in early-phase clinical trials or nearing clinical translation.

OBJECTIVE

This review provides the reader with an understanding of the key pathophysiological mechanisms that contribute to neurological deficits after SCI. Through discussion of the mechanism(s) of action of the selected therapeutic approaches potentially important targets to aid further drug discovery will be highlighted.

METHODS

Systematic literature review of the pre-clinical literature and clinical SCI trials related to neuroprotective, immunomodulatory and regenerative therapeutic approaches.

RESULTS/CONCLUSION

The next decade will witness an unprecedented number of clinical trials which will seek to translate key biomedical research discoveries. The promising drug-based therapeutic approaches include regenerative strategies to neutralize myelin-mediated neurite outgrowth inhibition, neuroprotective strategies to reduce apoptotic triggers, the targeting of cationic/glutamatergic toxicity, anti-inflammatory strategies and the use of approaches to stabilize disrupted cell membranes.

Ankylosing spondylitis and spinal cord injury: origin, incidence, management, and avoidance

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that primarily affects the vertebral column and sacroiliac joints. Over time, the disease process promotes extensive remodeling of the spinal axis via ligamentous ossification, vertebral joint fusion, osteoporosis, and kyphosis. These pathological changes result in a weakened vertebral column with increased susceptibility to fractures and spinal cord injury (SCI). Spinal cord injury is often exacerbated by the highly unstable nature of vertebral column fractures in AS. A high incidence of missed fractures in the ankylosed spine as well as an increased incidence of spinal epidural hematoma also worsens the severity of SCI. Spinal cord injury in AS is a complex problem associated with high morbidity and mortality rates, which can be attributed to the severity of the injury, associated medical comorbidities, and the advanced age of most patients with AS who suffer an SCI. In this paper the authors outline the factors that increase the incidence of vertebral column fractures and SCI in AS and discuss the management of SCI in patients with AS. Primary prevention strategies for SCI in patients with AS are outlined as well.

Multiple cerebral hydatid cysts

A case of 19 years old female patient with 24 large primary cerebral hydatid cysts, in different localisations is presented. Cysts were removed unruptured by five separate operations in 6 months. The patient was observed to be in good health 1 year after the last operation. This case is the first case presented that contains such high number of cysts to our knowledge. The importance of MRI examination in localizing the cysts and designing the operative plan is emphasized. Interestingly, albendazole, which is an antiparasitic drug, was reported to be ineffective by infectious disease department of our hospital, because of large diameter of the cysts, in this case.

Therapeutic neutralization of CXCL10 decreases secondary degeneration and functional deficit after spinal cord injury in mice

Inflammation plays a critical role in the secondary degenerative response to spinal cord injury (SCI). The influx of inflammatory cells following SCI is preceded by the expression of specific chemoattractants, including chemokines. The chemokine CXCL10 is a potent T lymphocyte recruiter and has been strongly implicated in the pathology of many CNS disorders. We have previously demonstrated that CXCL10 exacerbates secondary degeneration by blocking the function of CXCL10 prior to SCI. Here we administered neutralizing antibodies against CXCL10 1 h after SCI in order to investigate the efficacy of this therapeutic intervention in abating histologic and functional deficit following acute SCI and further assess the functional role of CXCL10 in secondary degeneration. Neutralization of CXCL10 significantly reduced inflammation, apoptosis, neuronal loss and whole tissue loss. Notably, this therapeutic treatment also promoted revascularization of the injured spinal cord and functional recovery. These data suggest that anti-CXCL10 antibody treatment is a viable therapeutic strategy for acute SCI.

Echinococcosis presenting as an otogenic brain abscess: an unusual lesion of the middle ear cleft and temporal lobe

This paper presents a case of a 28-year-old male with a seizure episode and a 4-year history of intermittent tinnitus on the left ear. On computed tomography and magnetic resonance imaging, a density with rim enhancement was found at the temporal lobe, associated with mastoid tegmen destruction and middle ear mass, indicating cholesteatoma with complicating brain abscess. Evacuation of the brain abscess was performed with a combined otolaryngologic and neurosurgical procedures (canal wall-down mastoidectomy and temporal craniotomy). The pathology turned out to be infestation with Echinococcus granulosus.

Association of atlanto-occipital dislocation and retroclival haematoma in a child

INTRODUCTION

The authors present the case of a 5-year-old girl with traumatic hydrocephalus secondary to a retroclival haematoma associated with atlanto-occipital dislocation (AOD) after a motor vehicle accident. Clinical history and neuroimaging of the patient are described.

DISCUSSION

Computed tomography (CT) imaging of the head revealed a retroclival haematoma with secondary hydrocephalus. The cranio-cervical junction showed an AOD that was initially overlooked. Traumatic AOD is a rare diagnosis although in the recent years it has become an emergent entity due to the improvement of emergency medical treatment on the field.

CONCLUSION

An initial diligent imaging study and interpretation should be made to avoid misdiagnosis and to provide adequate treatment. This is the first case reported of the association of AOD, hydrocephalus and retroclival haematoma. A brief review of the literature is also presented.

[Multilevel costovertebral echinococcosis: effectiveness of a combined approach]

Hydatid disease generally involves the liver and the lung, but rarely can be encountered in bones. The disease predominantly occurs in vascularized areas, involving in descending order: vertebrae, long bones, ilium, skull, and ribs. Vertebral and rib hydatidosis may result from vascular or lymphatic migration of a fertile cell from a hepatic focus. In humans, the two main forms are due to Echinococcus granulosis and less frequently, E. multilocularis (alveolaris). The hydatid cysts usually grow slowly asymptomatically and compression of the involved or the neighboring organ causes clinical manifestations. In this patient, hydatid disease occurred in the chest wall with secondary spinal canal involvement successfully treated by removal of cysts via T7, T8, T9, T10, and T11 laminectomies via a posterior approach, followed by resection of the involved ribs. Total removal of cysts without rupture appears to provide effective protection against late recurrences.

Spinal hydatidosis accompanied by a secondary infection. Case report

Spinal hydatid disease is rarely encountered in nonendemic regions. It is a progressive disease that is associated with risks of serious morbidity. The authors report a case of an isolated primary hydatid cyst of the spine in a 34-year-old woman who presented with back pain, which had lasted for 3 months, as well as lower-extremity pain and fatigue, which had persisted for 2 months. A neurological examination yielded findings indicative of upper motor neuron involvement with complete sensory loss below the level of T-11. Magnetic resonance imaging of the spine showed multiple extradural cystic lesions with an abscess formation at T-11 and involvement of the paraspinal muscles. The patient underwent spinal decompression in which stabilization and total excision of the multiple epidural and psoas abscesses and paraspinal multiloculated cysts were performed. The diagnosis of hydatid disease associated with another infection was confirmed by histopathological evaluation. Albendazole was administered during the postoperative period. Previous reports of secondary infections accompanying this disease in extraspinal locations have been published. However, to the best of the authors' knowledge, there have been no publications about a secondary infection associated with hydatidosis in the spinal cord. One should bear in mind that spinal hydatidosis may be accompanied by other infections in endemic regions. Antihelminthic treatment should be administered for a long period following early decompressive surgery and adequate stabilization.

Microsurgery in the removal of a large cerebral hydatid cyst: technical case report

OBJECTIVE

Surgery is presently the mainstay in the treatment of cerebral hydatid cysts, but removal without perforation of the cyst wall is critical. The Dowling-Orlando technique has been the main surgical choice for the intact removal of intracranial hydatid cysts. Dowling described his technique in 1929, well before the introduction of the microscope in neurosurgery. Using the operating microscope has not been reported in the removal of a large hydatid cyst.

CLINICAL PRESENTATION

The case of a 16-year-old male with a large, right parieto-occipital hydatid cyst is presented.

INTERVENTION

In this case, surgery was greatly aided by the use of the microscope in the initial stage of the removal of the cyst. Cyst extraction during the delivery process was continued without the aid of the microscope. The cyst was successfully removed intact.

CONCLUSION

The use of the magnification during the early part of the surgery of a hydatid cyst is extremely helpful because, at a crucial stage of the procedure, it prevents inadvertent damage of the very thin cyst wall and allows development of the critical surgical plane.

Diagnosis and treatment of multiple hydatid cysts at the craniovertebral junction. Case report

Echinococcosis, or hydatid disease, of the craniovertebral junction and skull base is rare. The authors report the occurrence of multiple hydatid cysts at this anatomical location in a young woman who was previously misdiagnosed with tuberculosis. The patient underwent transoral excision of the hydatid cysts followed by posterior decompression and occipitocervical fusion. She was treated postoperatively with albendazole for 12 weeks with a good outcome. The management of spinal hydatid disease is reviewed.

Hydatid cysts of the internal acoustic canal and jugular foramen

Brain involvement with hydatid disease occurs in 1-2% of all Echinococcus granulosus infections. Cerebral hydatid cysts are usually supratentorial, whereas infratentorial lesions are quite rare. Here we report a 19-year-old man with hydatid cysts in the right cerebellopontine cistern with the involvement of internal acoustic canal and jugular foramen. The patient presented with signs of increased intracranial pressure and multiple cranial nerve palsies. Surgery was performed in the semi-sitting position using a lateral suboccipital approach for a right-sided craniotomy. Magnetic resonance imaging clearly demonstrated cisternal, neural and vascular relationships which aided in intact surgical removal of the lesion using microsurgical techniques. Total removal without rupture should be the surgical goal in all hydatid cysts.

Unusual dumbbell tumours of the mediastinum and thoracic spine

Due to a lack of large clinical series in the literature of chondrosarcomas and hydatid disease presenting as mediastinal dumbbell tumours, clinicians have limited experience on this topic. We present three unusual cases of dumbbell tumour involving the spinal canal; two patients had chondrosarcoma originating from Th8-Th9 and Th10-Th12; one patient had a hydatid cyst at Th5-Th6. We performed a single-stage combined thoracic-neurosurgical approach in two patients, and a double-staged approach in one patient. During the intraspinal dissection, an operating microscope was used under electrophysiological monitoring. Spinal canal reconstruction was not required for any of the cases. Preoperative knowledge of neuroforaminal extension and the relations between the tumour and adjacent neural-vascular structures is essential to prevent spinal cord damage and plan the surgical approach. In chondrosarcomas, prognosis depends on patient age, histological grade, extent of surgery and response to radiotherapy and/or chemotherapy. In this article, the diagnostic and surgical difficulties of these unusual tumours and current treatment modalities are discussed with a review of the relevant literature.

[Cerebral hydatid cysts in children: 4 cases]

The cerebral localization of the hydatid disease is rare, under 2%, and it primarily affects children. We report 4 cases of children presenting with a cerebral hydatid cyst (2 boys and 2 girls, mean age 9 years). Clinical symptoms were very progressive, the disease was frequently diagnosed several months (1-12 months) after onset of symptoms most often headaches and vomiting. One patient presented with a right tonic-clonic seizure 3 days before hospitalization. The diagnostic was confirmed in all cases by Cerebral CT scan. All the patients were screened for other localizations. One patient also presented with pulmonary and hepatic hydatid cysts. Hydatid blood tests were positive in only one case. The treatment was surgical for all the patients (using hydropulsion) without complications in 2 cases. One child presented with meningitis, and the other child with signs of secondary ICHT related to residual mass which required its puncture.

Methylprednisolone causes minimal improvement after spinal cord injury in rats, contrasting with benefits of an anti-integrin treatment

Spinal cord injury (SCI) leads to complex secondary events that expand and exacerbate the injury. Methylprednisolone (MP) has been considered a standard of care for acute SCI. The purpose of this study was to test the effects of MP, in severe and more moderate severe clip-compression models of SCI, on the measures of neurological function and lesion sparing that we used previously to assess a highly effective anti-inflammatory therapy, a monoclonal antibody (mAb) to the CD11d integrin. Intravenous treatment with the anti-CD11d mAb blocks the infiltration of leukocytes into the lesion, limits secondary cord damage, and improves neurological outcomes. We also undertook a 2- week study of effects of these two therapies in combination. To permit direct comparison, the new findings with MP are presented together with reference to the previously published effects of the mAb. The severe SCI was at the 4(th) thoracic segment (T4), causing extensive motor dysfunction; the more moderate SCI was at T12 and caused less locomotor loss but the induction of mechanical allodynia. Neither MP alone nor the combination treatment improved Basso, Beattie, and Bresnahan 21-point open-field locomotor scores at 2-12 weeks after SCI. These scores were ~4 points in the control, MP, and combination treatment groups, respectively, at 2 weeks after severe SCI at T4. By 6 weeks after T4 SCI, scores in the control and MP groups were ~7. At 12 weeks after the more moderate T12 injury, scores were ~8 in both control and MP treatment groups. MP treatment had no consistent effect on mechanical allodynia during 12 weeks after SCI. Control and MP-treated rats responded to approximately five of 10 stimuli to their backs and three of 10 stimuli to their hind paws. MP treatment increased areas of neurofilament and myelin near the injury site at T4 and T12. Thus, MP treatment spared tissue, but had no corresponding effect on neurological function. In contrast, the combination treatment did not spare myelin significantly. These neurological outcomes after treatment with MP contrast with the consistent and significant improvements after treatment with the anti-CD11d mAb. Effects of MP on the lesion were significant, but myelin sparing was less than that caused by the anti-CD11d mAb. The presence of MP in the combination therapy appeared to reverse the positive effects of the mAb. The poor neurological outcome after MP treatment may relate to the long-lasting reduction in hematogenous monocyte/macrophages within the injury site that it causes and to the prolongation of a neutrophil presence. These findings demonstrate that the non-selective and enduring effects of immunosuppressive therapy with MP not only fail to improve neurological outcomes, but also can block the beneficial actions of selective therapies such as the anti-CD11d mAb. Combination treatments that cause intense immunosuppression should be viewed with caution.

Hydatid cyst of the craniocervical junction: case report

OBJECTIVE AND IMPORTANCE

Although rare in developed countries, hydatid disease is a serious parasitic infection in endemic areas. Spinal disease most commonly involves the thoracic region, and involvement of the upper cervical spine is extremely rare. In this report, a case of hydatid disease involving the craniocervical junction is presented, along with a review of the literature.

CLINICAL PRESENTATION

A 44-year-old man presented with the complaint of neck pain. The results of his physical and neurological examinations were within normal ranges, except for pain exacerbated by neck motion and spasm of the cervical musculature. Magnetic resonance imaging demonstrated a cystic lesion involving the odontoid process and body of C1 and C2, with thin and regular cyst walls and cyst contents similar in intensity to that of cerebrospinal fluid. The results of serological tests performed with the suspected diagnosis of hydatid disease were positive.

INTERVENTION

The patient initially underwent surgery to provide stabilization of the craniocervical junction, using autogenous bone graft and sublaminar wiring from the occiput to C3 via a posterior approach. The cyst was approached via a transoral route, using a U-shaped pharyngeal incision. There were no neurological deficits after surgery. Postoperative magnetic resonance imaging scans confirmed complete excision of the cyst, and the patient was discharged on the 12th postoperative day. He received six cycles of albendazole treatment, each consisting of 28 days with an intervening drug-free period of 2 weeks. Magnetic resonance imaging scans performed 1 year after surgery revealed the patient was still disease-free.

CONCLUSION

Hydatid disease should be considered in the differential diagnosis of spinal cord compression, especially in endemic areas. Although the chance of obtaining a cure is unlikely, radical surgery coupled with antihelminthic therapy seems to provide long-lasting relief.

A comparison of adenosine A2A agonism and methylprednisolone in attenuating neuronal damage and improving functional outcome after experimental traumatic spinal cord injury in rabbits

Object

Steroid agents remain the lone pharmacological treatment in widespread use for acute spinal cord injury (SCI), although their utility remains in dispute in the neurotrauma literature. Adenosine A2A receptor activation with ATL-146e, a selective A2A agonist, has shown potential benefit in treating SCI; however, it has not been compared with the gold standard, methylprednisolone. The authors of this study evaluated ATL-146e and methylprednisolone for their ability to preserve neuronal viability and motor function in experimental SCI.

Methods

New Zealand White rabbits sustained SCI or sham injury via the Allen weight-drop technique. Ten minutes postinjury, animals received ATL-146e (ATL group, 0.06 μg/kg/min intravenously for 3 hours), methylprednisolone (steroid group, 30 mg/kg intravenously), or saline (trauma control group). Hindlimb motor function was recorded every 12 hours using the Tarlov motor grading scale (0, paralysis–5, normal hop). At 48 hours, fixed spinal cord tissue was evaluated for neuronal viability.

Hindlimb motor function in animals treated with ATL-146e was equivalent to that of sham-injured animals and was significantly better than that of trauma control animals at all time points and that of steroid-treated animals at 12 hours (p = 0.05). Motor function in steroid-treated animals was worse than in those given ATL-146e and better than that of trauma control animals at later time points, but was not statistically significant (both p > 0.05). Neuronal viability (measured in neurons/hpf) was significantly higher in both treatment groups compared with the trauma control group (12.1 ± 1.4 neurons/hpf for the ATL and 13.3 ± 1.4 neurons/hpf for the steroid group compared with 7.5 ± 1.5 neurons/hpf for the trauma control group; both p < 0.04). Neuronal viability did not differ among ATL-146e–treated, steroid-treated, and sham-injured groups.

Conclusions

The use of ATL-146e is at least as effective as methylprednisolone in preserving function and is equivalent to methylprednisolone in preserving the structure of spinal cord tissue after blunt SCI. Adenosine A2A receptor activation may be an effective treatment for acute SCI while avoiding the adverse effects of steroid agents.

Successful Surgical Management of an Intraorbital Hydatid Cyst through a Transmaxillary Approach: Case Report

A patient with an intraorbital hydatid cyst was treated successfully through a transmaxillary approach. Numerous procedures to remove intraorbital hydatid cysts are discussed.

Primary intradural extramedullary hydatid cyst

Spinal hydatid cysts account for 1% of all cases of hydatid disease; primary intradural hydatid cysts are uncommon. We present a case of pathologically confirmed intradural spinal cyst hydatid in an otherwise healthy patient who showed no other evidence of systemic hydatid cyst disease. The patient presented with back pain, paraparesis, and weakness. An intradural extramedullary cystic lesion was identified with magnetic resonance imaging and was shown to be a hydatid cyst by histopathologic examination after surgical removal. To our knowledge, this is the 25th case of hydatid cyst at an intradural extramedullary location reported in the literature.

Possible spontaneous "birth" of a hydatid cyst into the lateral ventricle

INTRODUCTION

Intraventricular hydatid cyst is an extremely rare entity. We report a solitary hydatid cyst in a lateral ventricle.

CASE REPORT

A 7-year-old girl had a free floating intraventricular cyst, diagnosed by computerized tomography examination inside the enlarged left lateral ventricle of an associated Dandy Walker malformation. The patient underwent surgery and the cyst was removed.

CONCLUSION

To our knowledge, this is the first case report in which the natural developmental phases of an intraventricular hydatid cyst have been observed.

A global perspective on spinal cord injury epidemiology

Spinal cord injury (SCI) is a devastating condition often affecting young and healthy individuals around the world. This debilitating condition not only creates enormous physical and emotional cost to individuals but also is a significant financial burden to society at large. This review was undertaken to understand the global impact of SCI on society. We also attempted to summarize the worldwide demographics and preventative strategies for SCI in varying economic and climatic environments and to evaluate how cultural and economic differences affect the etiology of SCI. A PUBMED database search was performed in order to identify clinical epidemiological studies of SCI within the last decade. In addition, World Bank and World Health Organization websites were used to obtain demographics, economics, and health statistics of countries of interest. A total of 20 manuscripts were selected from 17 countries. We found that SCI varies in etiology, male-to-female ratios, age distributions, and complications in different countries. Nations with similar economies tend to have similar features and incidences in all the above categories. However, diverse methods of classifying SCI were found, making comparisons difficult. Based upon these findings, it is clear that the categorization and evaluation of SCI must be standardized. The authors suggest improved methods of reporting in the areas of etiology, neurological classification, and incidence of SCI so that, in the future, more useful global comprehensive studies and comparisons can be undertaken. Unified injury prevention programs should be implemented through methods involving the Internet and international organizations, targeting the different etiologies of SCI found in different countries.

Recurrent spinal hydatidosis in North America

Spinal hydatidosis is an uncommon manifestation of the parasite Echinococcus, affecting fewer than 1% of patients with hydatid disease. The authors report on a 34-year-old Turkish woman who presented with recurrent primary spinal hydatid disease. The patient originally presented with progressive numbness and paraparesis that was reversed after T5–6 laminectomy and cyst removal. Pathological findings indicated parasitic infection and she underwent treatment for cysticercosis. Nevertheless, she returned 4 years later with back pain, numbness, and monoparesis. Neuroimaging studies revealed spinal cord compression with multiple cysts that were again resected. Pathological findings were consistent with Echinococcus.

Although this disease is uncommon, particularly in North America, the authors conclude that spinal hydatidosis should be considered in the differential diagnosis of any patient who has lived or traveled within endemic areas and who presents with spine lesions and cord compression. The authors review the literature pertaining to the epidemiological features, presentation, diagnosis, neuroimaging characteristics, recommended treatments, and overall prognosis of spinal hydatidosis.

Schockraummanagement bei Verletzungen der Wirbels�ule im Rahmen eines Polytraumas

Injuries to the spine are often part of life-threatening multiple trauma. In this review diagnostics and emergency room management were investigated in order to formulate effective recommendations for the emergency strategy. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The patient's history and clinical symptoms have low rates for specificity and positive predictive value, whereas their negative predictive value and sensitivity are high between 90 and 100%, respectively. CT imaging reaches higher rates for sensitivity, specificity, and positive and negative predictive values in comparison to conventional radiographic series. The patient's history should be asked and clinical investigation should be done in any case. Imaging diagnostics preferably as multislice spiral CT should be performed after stabilization of the patient's general condition and before admission to the intensive care unit.

Neuroprotective Effects of Recombinant Thrombomodulin in Controlled Contusion Spinal Cord Injury Implicates Thrombin Signaling

Although the central nervous system (CNS) of mammals has had poor prospects for regeneration, recent studies suggest this might improve from blocking "secondary cell loss" or apoptosis. In this regard, intravenous activated protein C (aPC) improved neurologic outcomes in a rat compression spinal cord injury (SCI) model. Protein C activation occurs when the serine protease thrombin binds to the cell surface proteoglycan thrombomodulin (TM) forming a complex that halts coagulation. In culture, rTM blocks thrombin's activation of protease-activated receptors (PARs), that mediate thrombin killing of neurons and glial reactivity. Both PAR1 and prothrombin are rapidly upregulated after contusion SCI in rats, prior to peak apoptosis. We now report neuroprotective effects of intraperitoneal soluble recombinant human rTM on open-field locomotor rating scale (BBB) and spinal cord lesion volume when given 1 h after SCI. BBB scores from four separate experiments showed a 7.6 +/- 1.4 absolute score increase (p < 0.05) at 3 days, that lasted throughout the time course. Histological sections at 14 days were even more dramatic where a twofold reduction in lesion volume was quantified in rTM-treated rats. Thionin staining revealed significant preservation of motor neuronal profiles both at, and two segments below, the lesion epicenter. Activated caspase-3 immunocytochemistry indicated apoptosis was quite prominent in motor neurons in vehicle (saline) controls, but was dramatically reduced by rTM. Microglia, increased and activated after injury, were reduced with rTM treatment. Taken together, these and previous results support a prominent role for coagulation-inflammation signaling cascades in the subacute changes following SCI. They identify a neuroprotective role for rTM by its inhibition of thrombin generation and blockade of PAR activation.

Femoral head blood flow reduction and hypercoagulability under 24 h megadose steroid treatment in pigs

The pathogenesis of corticosteroid-induced femoral head necrosis is assumed to be ischemia. The purpose of this study was to investigate the perfusion pattern of the femoral head and plasma coagulability during 24 h corticosteroid megadose treatment, as recommended by the National Acute Spinal Cord Injury Studies (NASCIS), in the awake big animal model. Blindedly, 9 animals underwent megadose methylprednisolone infusion (30 mg/kg intravenously as an initial bolus, followed by 5.4 mg/kg/h for further 23 h) while 9 animals served as placebo treated controls. Regional blood flow of the systematically subdivided femoral head, proximal femur, acetabulum, and soft tissue hip regions was investigated by the microsphere technique at steady state (phase 1), after the initial bolus infusion (phase 2), and after the completed treatment (phase 3). Plasma coagulability was examined in phases 1 and 3. Blood flow of the femoral head epiphysis and metaphyseal cancellous bone was unchanged after one hour of steroid infusion, but decreased after the completed treatment at 24 h in the experimental group. Femoral head blood flow reduction was global without a tendency to more pronounced blood flow decrease in any subregion. Plasma fibrinogen was significantly higher after 24 h of steroid infusion than in the placebo control group. 24 h high dose methylprednisolone treatment causes femoral head blood flow reduction and hypercoagulability of plasma in the normal awake immature pig. These findings may be pathogenetic factors in the early stage of steroid-induced osteonecrosis.

Screening anti-inflammatory compounds in injured spinal cord with microarrays: a comparison of bioinformatics analysis approaches

Inflammatory responses contribute to secondary tissue damage following spinal cord injury (SCI). A potent anti-inflammatory glucocorticoid, methylprednisolone (MP), is the only currently accepted therapy for acute SCI but its efficacy has been questioned. To search for additional anti-inflammatory compounds, we combined microarray analysis with an explanted spinal cord slice culture injury model. We compared gene expression profiles after treatment with MP, acetaminophen, indomethacin, NS398, and combined cytokine inhibitors (IL-1ra and soluble TNFR). Multiple gene filtering methods and statistical clustering analyses were applied to the multi-dimensional data set and results were compared. Our analysis showed a consistent and unique gene expression profile associated with NS398, the selective cyclooxygenase-2 (COX-2) inhibitor, in which the overall effect of these upregulated genes could be interpreted as neuroprotective. In vivo testing demonstrated that NS398 reduced lesion volumes, unlike MP or acetaminophen, consistent with a predicted physiological effect in spinal cord. Combining explanted spinal cultures, microarrays, and flexible clustering algorithms allows us to accelerate selection of compounds for in vivo testing.

Primary hydatid disease of sacrum affecting the sacroiliac joint: a case report

STUDY DESIGN

A case report of hydatid disease of the spine.

OBJECTIVE

To describe an unusual case of hydatid disease of the sacrum affecting the sacroiliac joint and to discuss imaging, differential diagnosis, and treatment.

SUMMARY OF BACKGROUND DATA

Hydatidosis or echinococcosis affecting the spine is rare and has a characteristic geographic distribution. Signs of sacroiliac joint involvement and accompanying neurologic deficits cause difficulties in differential diagnosis of this rare condition.

METHODS

A case of 38-year-old female patient with low back pain and sciatica was presented.

RESULTS

Plain radiographs, computed tomography, and magnetic resonance imaging scans revealed destructive expansive lesion located on the right sacrum and extended through the right sacroiliac joint. Surgical enucleation of the cysts was performed together with mebendazole treatment and histopathologic examination confirmed hydatidosis.

CONCLUSION

This unusual disease should be kept in mind in the differential diagnosis of sacroiliac pain and sciatica, especially in endemic areas.

A large cerebral hydatid cyst associated with liver cyst

Hydatid disease in childhood is a serious health problem in Turkey and other places where the parasite is endemic. An 8-year-old girl from a rural area was admitted with headache, recurrent abdominal pain, abdominal distension and hypo-aesthesia and paresis of the right arm. Computerised tomography (CT) scans demonstrated a large intracranial hydatid cyst. A hydatid cyst was detected in the liver also. Her mother had been treated previously for disseminated hydatid disease. The cerebral cyst was removed but only subtotal excision of the hepatic cyst was possible. She was treated with albendazole, has fully recovered and, after 12 months of follow-up, there is no sign of recurrence.

Treatment with the neurosteroid dehydroepiandrosterone promotes recovery of motor behavior after moderate contusive spinal cord injury in the mouse

The neurosteroid dehydroepiandrosterone (DHEA) has neuroprotective properties after ischemic and excitatory insults to the brain. In the developing embryo, it is produced in discrete regions of the central nervous system (CNS), where it specifically promotes axonal growth of differentiated neurons. To test if DHEA could be beneficial after spinal cord injury (SCI), we used a model of moderate contusive SCI developed and characterized in the mouse. Immediately after surgery, we applied treatment with DHEA or with vehicle only and compared treatment groups (n = 12 in each group) over a 42-day period. Locomotor recovery was assessed in an open field using a standardized 21-point scale, according to gait analysis on paw print recordings and using foot fault analyses on an inclined ladder beam. The DHEA-treated group showed improved function compared to vehicle-treated animals in these tests. More strikingly, DHEA enhanced recovery of left-right coordination and fine motor control. In an attempt to correlate functional recovery with spinal cord neuropathology in the different experimental groups, we studied the area of spared white matter at the epicenter and reactive gliosis/scar formation 42 days post-injury (DPI). DHEA significantly increased the area of white matter spared at the epicenter and reduced the area of reactive gliosis surrounding the lesion. These data demonstrate the effectiveness of DHEA in promoting functional recovery in the adult murine injured spinal cord.

Molecular approaches to spinal cord repair

Axon growth inhibitors associated with myelin and the glial scar contribute to the failure of axon regeneration in the injured adult mammalian central nervous system (CNS). A number of these inhibitors, their receptors, and signaling pathways have been identified. These inhibitors can now be neutralized by a variety of approaches that point to the possibility of developing new therapeutic strategies to stimulate regeneration after spinal cord injury.

Early induction of secondary injury factors causing activation of calpain and mitochondria-mediated neuronal apoptosis following spinal cord injury in rats

To investigate a potential relationship between calpain and mitochondrial damage in spinal cord injury (SCI), a 40 gram-centimeter force (g-cm) injury was induced in rats by a weight-drop method and allowed to progress for 4 hr. One-centimeter segments of spinal cord tissue representing the adjacent rostral, lesion, and adjacent caudal areas were then removed for various analyses. Calcium green 2-AM staining of the lesion and penumbra sections showed an increase in intracellular free calcium (Ca(2+)) levels following injury, compared with corresponding tissue sections from sham-operated (control) animals. Western blot analysis showed increased calpain expression and activity in the lesion and penumbra segments following SCI. Double-immunofluorescent labeling indicated that increased calpain expression occurred in neurons in injured segments. Western blot analysis also showed an increased Bax:Bcl-2 ratio, indicating the induction of the mitochondria-mediated cell death pathway in the lesion and penumbra. The morphology of mitochondria was altered in lesion and penumbra following SCI: mostly hydropic change (swelling) in the lesion, with the penumbra shrunken or normal. At 4 hr after induction of injury, a substantial amount of cytochrome c had been released into the cytoplasm, suggesting a trigger for apoptosis through caspase 3 activation. Neuronal death after 4 hr of injury was detected by a combined TUNEL and double-immunofluoresence assay in the lesion and penumbra sections of injured cord, compared with sham controls. These results suggest that an early induction of secondary factors is involved in the pathogenesis of SCI. The increased Ca(2+) levels could activate calpain and mediate mitochondrial damage leading to neuronal death in lesion and penumbra following injury. Thus, secondary injury processes mediating cell death are induced as early as 4 hr after the injury, and calpain and caspase inhibitors may provide neuroprotection.

Hydatid disease of the spine in South African children

We present three patients with neurologic complications of the spine from hydatid disease. The first was a 6-year-old girl with lower limb paralysis evolving over 2 weeks. Neuroimaging revealed a cystic mass compressing the spinal cord at the level of T8 and extending from the vertebral body. She underwent surgical decompression. Histopathologic examination confirmed hydatid disease. At 6-month follow-up, functional improvement had occurred with full ambulation. She continues on long-term albendazole therapy. Two other patients are described, one with primary spinal disease and the other with cerebral disease and secondary seeding to the spine. Spinal hydatid disease is a rarity, even more so in children. Although secondary disease, primarily affecting bone, carries a poorer long-term outlook, the first patient made a dramatic recovery and has raised therapeutic dilemmas as to the total duration of continuing albendazole therapy. The literature documents some 37 reports, mostly in adults. Considering the frequency of hydatid disease in South Africa, the incidence in our population could be under-recorded. Unless the clinician includes spinal hydatid disease, in endemic areas, as part of the differential list for paralysis and considers performing neuroimaging, this potentially treatable diagnosis will be missed.

A clinician's view of spinal cord injury

The primary cause of spinal cord injury (SCI) is automobile collisions, followed by violence, falls, and injuries in sporting events. The patient is most frequently a young male. Regardless of cause and age, SCI is a potentially catastrophic injury. The unique anatomical relationship of the spinal cord, being enclosed in the dural sac within the bony vertebral column, make it venerable to a wide range of traumatic insults. SCI is classified as complete or incomplete with several subclasses arranged under each of these respective headings. The probability of recovery to a functional state is usually better for patients with incomplete injuries. Treatment for SCI involves initially immobilizing the injured vertebral column, medications to prevent secondary injury, and potential surgery to release pressure on the spinal cord and restore stability to the vertebral column. Postsurgical care is directed toward prevention and treatment of secondary complications of SCI such as respiratory failure, deep venous thrombosis, and decubitus ulcers. Advances in these areas are providing patients with a greater probability of recovery, a longer life, and a better quality of life. Research in the clinical and basic sciences is opening new avenues of hope for the spinal cord injury patient.

Restoring function after spinal cord injury

BACKGROUND

By affecting young people during the most productive period of their lives, spinal cord injury is a devastating problem for modern society. A decade ago, treating SCI seemed frustrating and hopeless because of the tremendous morbidity and mortality, life-shattering impact, and limited therapeutic options associated with the condition. Today, however, an understanding of the underlying pathophysiological mechanisms, the development of neuroprotective interventions, and progress toward regenerative interventions are increasing hope for functional restoration.

REVIEW SUMMARY

This study addresses the present understanding of SCI, including the etiology, pathophysiology, treatment, and scientific advances. The discussion of treatment options includes a critical review of high-dose methylprednisolone and GM-1 ganglioside therapy. The concept that limited rebuilding can provide a disproportionate improvement in quality of life is emphasized throughout.

CONCLUSIONS

New surgical procedures, pharmacologic treatments, and functional neuromuscular stimulation methods have evolved over the last decades that can improve functional outcomes after spinal cord injury, but limiting secondary injury remains the primary goal. Tissue replacement strategies, including the use of embryonic stem cells, become an important tool and can restore function in animal models. Controlled clinical trials are now required to confirm these observations. The ultimate goal is to harness the body's own potential to replace lost central nervous system cells by activation of endogenous progenitor cell repair mechanisms.

Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia

STUDY DESIGN

Retrospective review of 412 patients with traumatic, incomplete, cervical spinal cord injuries, and an average follow-up period of 2 years.

OBJECTIVES

To determine what patient characteristics, injury variables, and management strategies are associated with improved neurologic outcomes. In particular, the effects of intravenous steroids (NASCIS II protocol), early definitive surgery (<24 hours after injury), early anterior decompression for burst fractures or disc herniations (<24 hours after injury), and surgical decompression for stenosis without fracture were assessed.

SUMMARY OF BACKGROUND DATA

Controversy surrounds the pharmacologic and surgical management of patients with spinal cord injuries.

METHODS

Neurologic data were collected retrospectively and classified using American Spinal Injury Association guidelines. This information was recorded at the time of injury, on admission to rehabilitation, on discharge from rehabilitation, and at 1, 2, and final year of follow-up evaluation. Outcome measures included change in motor score, change in sensory score, final motor score, and final sensory score. The SPSS v10.0.7 statistical software package was used for data analysis.

RESULTS

Neurologic recovery was not related to the following factors: gender, race, type of fracture, or mechanism of injury. Neurologic recovery also was not related to the following interventions: high-dose methylprednisolone administration, early definitive surgery, early anterior decompression for burst fractures or disc herniations, or decompression of stenotic canals without fracture. Improved neurologic outcomes were, however, noted in younger patients ( = 0.002), and those with either a central cord or Brown-Sequard syndrome ( = 0.019).

CONCLUSIONS

The most important prognostic variable relating to neurologic recovery in a patient with a spinal cord injury is the completeness of the lesion. When an incomplete cervical spinal cord lesion exists, younger patients and those with either a central cord or Brown-Sequard syndrome have a more favorable prognosis for recovery. In this study, no evidence was found to support high-dose steroid administration, routine early surgical intervention, or surgical decompression in stenotic patients without fracture.

Spinal cord injury

Pediatric spinal cord injury is a relatively uncommon problem, responsible for approximately 5% of all spinal cord injuries. Anatomic and behavioral differences between adults and children lead to variation in injury type and severity. Young children are more prone to high cervical injuries, with nearly 80% of injuries in children < 2 yrs old affecting this area. As the child approaches 8-10 yrs of age, the spinal anatomy and therefore injury pattern more closely approximates adult injuries. Although the prevalence of spine injuries is lower in children, clearing the spine becomes more complex due to radiographic differences and the inability to "clinically" clear the cervical spine in young children. In this article, the types of injuries seen in children are discussed, with an emphasis on acute management and clearance of the cervical spine. Treatment options and long-term issues are also discussed.

Parasitic worms of the central nervous system: an Australian perspective

The diagnosis and management of parasitic diseases of the central nervous system (CNS) is difficult, even for infectious diseases physicians and neurologists. Furthermore, few overviews of the spectrum of causative helminths and clinical syndromes have been published. In the present study, we review the seven most common parasitic diseases of the CNS: (i) cysticercosis, (ii) neuroschistosomiasis, (iii) paragonimiasis, (iv) angiostrongyliasis, (v) hydatid disease, (vi) sparganosis and (vii) gnathostomiasis. Major syndromes of parasitic disease of the CNS and their differential causes are discussed, including: (i) cystic lesions, (ii) enhancing granulomas (with and without creeping subcutaneous eruptions), (iii) eosinophilic meningoencephalitis and (iv) spinal cord disease. Specific risk factors that predispose to these infections are also discussed and particular attention is drawn to the situation in Australia.

Prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with acute thoracolumbar disk extrusions: 112 cases

OBJECTIVES

To determine prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with intact pain sensation and acute Hansen type-1 disk extrusions.

STUDY DESIGN

Retrospective clinical study.

ANIMALS

One-hundred twelve dogs with Hansen type-I disk extrusions that had decompressive hemilaminectomy or dorsal laminectomy.

METHODS

All dogs had thoracolumbar disk extrusion and were nonambulatory with intact pain sensation at admission. Variables considered included age, weight, voluntary motor function at time of anesthetic induction, glucocorticoid use, times from onset of nonambulatory status to admission and surgical decompression, time in hospital to surgical decompression, anesthetic time, surgical time, number of contrast injections required to perform a diagnostic myelogram, postoperative pain sensation, and postoperative voluntary motor function. Time to ambulation was defined as the number of days from surgical decompression until the dog was able to stand and take a series of steps without assistance.

RESULTS

One-hundred seven dogs (96%) were able to ambulate within 3 months. The mean time to ambulation was 12.9 days and was significantly shorter if dogs had postoperative voluntary motor function (7.9 days v 16.4 days, P <.0001). No other variable had a significant association with time to ambulation.

CONCLUSIONS

Few perioperative variables have prognostic value for return to ambulation. Nonambulatory dogs with intact pain sensation and Hansen type-1 disk extrusions in the thoracolumbar spine that are treated with surgical decompression have a favorable prognosis.

CLINICAL RELEVANCE

The presence of postoperative voluntary motor function is a favorable prognostic indicator for early return to ambulation.

Methylprednisolone and interleukin-10 reduce gray matter damage in the contused Fischer rat thoracic spinal cord but do not improve functional outcome

The effects of two antiinflammatory and neuroprotective agents, methylprednisolone (MP) and interleukin-10 (IL-10), singly and in combination on tissue damage, axonal preservation and functional recovery were studied in the contused adult Fischer rat thoracic spinal cord 12 weeks after injury. MP (30 mg/kg at 5 min, and 2 and 4 h after injury) was administered intravenously and IL-10 (15 or 30 microg/kg at 30 min after injury), intraperitoneally. MP, IL-10, or the combination significantly reduced the volume of damaged tissue (including cavities) compared to control animals. The loss of spinal tissue (cavities) was reduced after treatment with MP alone or combined with IL-10, but not with IL-10 alone. The reduction in tissue damage was confined to spinal gray matter; at the level of the lesion epicenter, the thickness of the lateral white matter columns was similar in all groups. Retrograde tracing using fast blue revealed that the number of spared propriospinal and supraspinal projections was similar in all groups at 12 weeks after the contusion. The open-field BBB-test showed no significant difference in hindlimb locomotion between groups. Our results demonstrate that all tested antiinflammatory treatments significantly increase the volume of spared spinal gray matter 3 months after a moderate contusion of the Fischer rat thoracic spinal cord, but none of the treatments improved axonal preservation or functional recovery.

Efficacy of methylprednisolone therapy for the injured rat spinal cord

Currently the synthetic glucocorticosteroid methylprednisolone sodium succinate (MPSS) is the standard therapy after acute spinal cord injury (SCI) in humans based on reported neurological improvements. The mechanisms for its beneficial actions are not entirely clear, but experimental evidence suggests MPSS affords some degree of neuroprotection. As many studies with rat models of SCI have been unable to demonstrate improved behavioral outcome or tissue sparing after MPSS treatment, we chose to stereologically assess whether it alters lesion volume and tissue sparing over time, as well as long-term behavioral recovery. Adult rats subjected to contusion SCI with the NYU impactor were administered either MPSS or saline for 24 hr beginning 5 min post injury. Over time the lesion dimensions were extremely dynamic, such that by 6 weeks post injury the volumes were reduced to a third of those seen after the first week. MPSS marginally reduced lesion volumes across time vs. controls, but the amount of spared gray and white matter remained unaltered between the two groups. Behavioral results further showed that MPSS failed to improve recovery of hind-limb function. These findings add to the emerging scrutiny of MPSS as the standard therapy for acute SCI, as well as indicate the existence of a therapeutic window for tissue sparing restricted to the first several days after this type of SCI in rats. Equally important, our results caution the use of lesion volume dimensions or percent tissue sparing at the epicenter as indicators of therapeutic efficacy because neither reflects the actual amount of tissue sparing.

Non-surgical management of spinal cord injury

Spinal cord injury remains a devastating neurological condition with limited therapeutic opportunities. Since decompressive surgery and high-dose methylprednisolone have limited utility for most patients, spinal cord injury clearly represents a major medical challenge. Experimental evidence has suggested that secondary cellular injury processes may be a realistic target for therapeutic intervention with the goal of inhibiting the progression of detrimental changes that normally follows traumatic injury to the cord. Preventing or reducing this delayed cellular injury may alone improve neurological recovery or facilitate future regenerative approaches to the injured cord. This review summarises recent advances in the development of pharmacological agents targeting the acute phase of spinal cord injury as well as potential strategies to facilitate regeneration of the spinal cord.

Spinal hydatid disease

STUDY DESIGN

Review article on spinal involvement of hydatid disease.

OBJECTIVES

A better understanding of this rare but clinically challenging disease is intended. An overview of the epidemiology, pathogenesis, presentation and diagnosis of spinal hydatid disease is provided. Management problems and frequent pitfalls are discussed as well as current therapeutic options, results and outcome.

METHODS

Thirty-seven reports of spinal hydatid disease published between 1964 and 2000 were reviewed.

RESULTS

Most of the reported cases of spinal hydatid disease presented with spinal cord compression syndrome. Due to the relative rarity of the problem the diagnosis was frequently made during surgery. Surgical intervention by decompressive laminectomy was the most frequent first management. Reports of anterior procedures as well as spinal stabilization exist. Intraoperative prophylaxis to reduce spillage as well as pharmacotherapy were usually instituted. Results of surgery were generally reported to be poor. Progressive neurological and mechanical deterioration over the years was the most frequently reported disease course. Anecdotal reports of alternative management strategies exist.

CONCLUSION

Spinal hydatid disease should be considered in the differential diagnosis of spinal cord compression syndrome in endemic countries and sought after with imaging and serology. Treatment is based on surgical decompression. Despite therapy the disease frequently relapses with progressive destruction of the vertebral column and neurological deterioration. Retention of spinal stability is the major long term concern. Overall outcome is poor with few reports of disease-free long term survival.