Brain stem abscesses in childhood

BACKGROUND

Solitary brain stem abscess is a rare condition with high mortality and morbidity. These lesions were considered to be invariably fatal before 1974 when advanced diagnostic tools were not available. Recently, the diagnosis and prognosis of brain stem abscesses have been modified by the introduction of modern radiological tools, and several patients with a favorable outcome have been reported since then. Because the pons is the most common site of the abscesses, involvement of the sixth and seventh nerves is frequent. The midbrain is the second most likely location, and medullary abscesses are distinctly rare. Treatment of a brain stem abscess includes medical therapy alone, open microsurgical intervention, or stereotactic aspiration.

CASE REPORT

We report a case of a 7-year-old girl with a solitary brain stem abscess. Her neurological examination revealed involvement of the cranial nerves and pyramidal tracts. Microsurgical exposure and aspiration of the abscess resulted in rapid improvement in her neurological condition and radiological resolution of the lesion. We discuss this uncommon case to draw attention to the importance of early diagnosis and adequate treatment, and we review the relevant literature.

Relationships between epidural fibrosis, pain, disability, and psychological factors after lumbar disc surgery

Failed back surgery syndrome (FBSS) is an important complication of lumbar disc surgery. Epidural fibrosis is one of the major causes of FBSS. However, most patients with epidural fibrosis do not develop symptomatic complaints from scarring. The purpose of this prospective study was to evaluate the relationships among the severity of epidural fibrosis, psychological factors, back pain and disability after lumbar disc surgery. Twenty-nine surgically managed patients (13 women, 16 men) were included in this study. In all patients, the presence and severity of epidural fibrosis was determined with contrast-enhanced magnetic resonance imaging (MRI). A pain visual analog scale (VAS) and Oswestry Disability Questionnaire (ODQ) were completed before and after surgery. Subjects were grouped by their type of herniation (protrusion, free fragment), MRI findings and results of the mini form of the Minnesota Multiphasic Personality Inventory (MMPI), and the groups were compared for their VAS and ODQ scores. Our results disclosed that neither the postoperative VAS scores nor the postoperative ODQ scores differed significantly among the epidural fibrosis severity groups. Moreover, postoperative VAS scores were positively correlated with the scores of the mini MMPI. These findings indicate that epidural fibrosis may be considered as a radiological entity independent of patients' complaints. Furthermore, the mini MMPI should be included in the assessment and planning of the reoperations in FBSS patients, because of the importance of psychological factors in postoperative pain and disability.

Lipid peroxidation and glutathione levels after cortical injection of ferric chloride in rats: effect of trimetazidine and deferoxamine

Intracortical injection of iron salts causes seizures. Oxidation of lipids in neural membranes by reactive oxygen species is involved in the mechanism responsible for iron-induced seizures as a model of posttraumatic epilepsy. In this study, we examined the effect of trimetazidine (TMZ) and deferoxamine (DFO) on lipid peroxidation after cortical injection of 5 microliters of an aqueous solution containing 100 mM of ferric chloride (FeCl3) in rats. Animals were divided into four groups (n = 7 each) and treated as follows: group 1, saline injection into the cortex (control group); group 2, iron injection into the cortex (injury group); group 3, iron injection into the cortex plus TMZ; group 4, iron injection into the cortex plus DFO. The animals were killed 3 h after injections, and the levels of malondialdehyde (MDA), a lipid peroxidation product, and reduced glutathione (GSH) were measured. A significant elevation of MDA was observed in group 2 (P < 0.05). MDA levels were found to be lower in both the TMZ-treated (P < 0.05) and DFO-treated (P < 0.05) groups than in the injury group. Tissue GSH levels were significantly decreased in group 2 (P < 0.05). GSH levels were increased in the TMZ-treated (P < 0.05) and DFO-treated (P < 0.05) groups compared to the injury group. The results of our study suggest that lipid peroxidation is a critical event in iron-induced epilepsy and that treatment with TMZ and DFO is effective in preventing the formation of free radicals and reducing lipoperoxides in brain tissue.

Whipple's disease confined to the central nervous system: case report and review of the literature

Whipple's disease confined exclusively to the CNS without systemic involvement appears to be very rare, with only 8 cases reported in the literature. We present here a further case of primary cerebral Whipple's disease in which the neurological symptoms were seen in the absence of systemic involvement and emphasize the importance of diagnosing this treatable disease.

Neuroprotective effect of magnesium on lipid peroxidation and axonal function after experimental spinal cord injury

STUDY DESIGN

An experimental study examining the neuroprotective effect of magnesium on axonal function and lipid peroxidation in a rat model of acute traumatic spinal cord injury.

OBJECTIVE

To determine the effectiveness of postinjury treatment with magnesium on evoked potentials and lipid peroxidation after spinal cord injury (SCI).

SETTING

Pamukkale University, Denizli, Turkey.

METHODS

Spinal cord injury occurred in 30 rats with an aneurysm clip at T9 and the rats were randomly assigned to undergo subcutaneous administration of one of the following at 1 h after injury: (1) Physiological saline (n = 10); (2) MgSO4, 300 mg/kg (n = 10) and (3) MgSO4, 600 mg/kg (n = 10). Spinal somatosensory evoked potentials (SSEPs) were recorded before injury, 30 min after injury and 3 h after injections. Rats were killed 24 h after the injury, and malondialdehyde (MDA) levels were measured.

RESULTS

Following SCI, there were significant decreases in the amplitudes of P1 and N1 (P<0.001) and only high-dose magnesium improved the SSEPs (P<0.01). On the other hand, there was significant difference in lipid peroxide content between high-dose magnesium treated group and both of saline treated and low-dose magnesium treated groups (P<0.01).

CONCLUSION

These results suggest that magnesium has a dose-dependent neuroprotective effect on SSEPs and lipid peroxidation after experimental spinal cord injury.

Spinal cord compression secondary to extramedullary hematopoiesis in thalassemia intermedia

Extramedullary hematopoiesis associated with thalassemia causing spinal cord compression is an extremely rare event in the course of the disease. Documentation with an imaging technique, such as MRI, is mandatory. A patient with thalassemia intermedia, who developed paraparesis in spite of transfusion, underwent surgical decompression. Rapid neurological improvement was observed postoperatively and this neurological condition was protected with adequate hemoglobin level. Management of these patients remains controversial. Various modes of therapy such as surgical decompression, radiotherapy, and transfusion are discussed and the related literature is reviewed.

The treatment of cerebral oligodendrogliomas with particular reference to features indicating malignancy: report of seventy-seven cases

Oligodendrogliomas are relatively rare tumors that arise from the oligodendrocyte or its precursors. The role of postoperative radiotherapy (RT) in these tumors still remains unclear. Data concerning a study on 77 histologically verified cases of oligodendrogliomas of the brain among a total number of 1884 cases of an intracranial glioma treated at the Hacettepe Medical Centre between 1964 and 1991 were reviewed and analyzed (6.5%). One patient died in the early postoperative period and 8 patients in pediatric age group with an aggressive from of the tumor died within 6 months of treatment. The results suggest that oligodendrogliomas which arise in childhood primarily in the intraventricular region should be considered potentially more malignant than other lesions of this type. Because of this, we believe that postoperative radiotherapy is necessary to prevent the recurrences.

Spinal extradural compression caused by granuloma of brucellosis

A rare case of extradural brucellosis granuloma in the thoracic region is presented. In spite of medical treatment, total paraplegia with sphincter disturbance developed. Delayed neurosurgical intervention resulted in significant clinical recovery. Magnetic resonance imaging was useful in obtaining detailed information and to decide on surgery.

Intramedullary spinal tuberculoma presenting as a conus tumor: a case report and review of the literature

Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. Although tuberculosis is unusual in the west, it is still prevalent in Asia and Africa. We report a case in which the diagnosis was made histologically without evidence of symptoms of systemic tuberculosis. The lesion, located in the conus medullaris, mimicked a conus tumor. The patient was a 20-year-old man who presented with a history of progressive leg weakness, urinary urgency, and impotence. There was no history of, or recent contact with, tuberculosis. A diagnosis of an intramedullary tumor in the conus medullaris was made by MRI. The patient underwent a T11-L1 laminectomy and total resection of the lesion with microsurgical technique. Histologic examination revealed a granulomatous lesion containing Langhans' giant cells, inflammatory cells, and caseating necrosis. Antituberculous medication was instituted as soon as the diagnosis was made. Neurologic symptoms and signs slowly improved postoperatively. A combination of microsurgical resection and antituberculous chemotherapy should be the choice of treatment for intramedullary tuberculomas.

Intraradicular lumbar disc herniation: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Intradural or intraradicular herniation of a lumbar disc is a rare complication of disc disease. The mechanism of the tearing of the dura mater by a herniated disc is not known with certainty. Only six cases of intraradicular disc herniation have been reported. By reporting the seventh case of this rare neurosurgical entity, we emphasize its importance and review the literature on intraradicular disc herniation.

CLINICAL PRESENTATION

A 41-year-old man was admitted with a 3-year history of low back pain and sciatica. A neurological examination revealed motor weakness during plantar flexion, positive Lasègue's sign, sensory deficit on the S1 dermatoma, and loss of Achilles reflex. Magnetic resonance imaging revealed disc protrusion at the L5-S1 level. Therefore, we decided to operate on the patient having made a diagnosis of lumbar disc disease.

INTERVENTION

The patient underwent a standard hemilaminotomy and foraminotomy for a removal of the L5-S1 disc. There was no disc protrusion or extruded fragment. The left S1 nerve root was observed to be swollen and immobile. A longitudinal incision was made on the radicular sheet of the S1 root, and a free disc fragment, approximately 2 x 1 x 1 cm, was extirpated in one piece.

CONCLUSION

The patient was immediately relieved of pain and was discharged on the 7th day after the operation with normal muscle strength. It seems probable that in some patients with "failed back syndrome," intraradicular or intradural disc herniation is the cause of failure.

Extensive damage to the end-plates as a complication of laser discectomy. An experimental study using an animal model

To date, there have been no reports of experiments demonstrating the effects of neodymium:YAG laser (Nd:YAG laser) on the vertebral end-plates. In this study the effect of Nd:YAG laser on end-plates was examined in 32 guinea pigs which were randomly divided into two groups. The first group was the control group, the second one the Nd:YAG laser group. All animals had experimental disc degeneration at three levels. Re-exploration was performed two months after the surgical ventral disc herniation. In the second group the same procedure was performed but at the end of the re-exploration, Nd:YAG laser irradiation of the degenerated discs was done. The wounds in both groups were closed again. Two months later all animals were sacrificed for histological and biochemical analysis. The cervical spine was excised en bloc and the overlying muscles were removed. Determination of hydroxyproline was done colorimetrically in the specimens harvested from each of these groups. Light microscopy was undertaken to evaluate the extent of morphological changes. The differences observed between the two groups were statistically significant (p < 0.05). From the results of this study, there is the question whether the Nd:YAG laser is a useful instrument in neurosurgery. Therefore, it remains to be proven whether or not this is of real benefit in the treatment of patients with degenerated disc disease.

Applying critical pressure to middle cerebral artery in dogs

The purpose of our model was to provide maximum pressure level of the middle cerebral artery (MCA) without causing any histological variation like focal cerebral ischaemia. In this experimental study 9 dogs were used. A modified Spetzler occluder was applied to the MCA of the dogs to determine regional cerebral blood flow (rCBF) and somatosensory evoked potentials (SSEP). Seven animals underwent the surgical procedure with measurements of rCBF after arterial microdissection and then after applying 80% blood pressure (BP) to the MCA for 15 minutes. In rCBF a 29% average reduction was observed. The average value of rCBF at the end of 15 minutes was 63.5 +/- 6.52 ml/100g min. Simultaneous somatosensory evoked potential recordings were also obtained. When rCBF was reduced 29%, 80% BP applying to MCA did not cause complications.

Optic nerve glioma presenting as a huge intrasellar mass. Case report

We report the case of a twelve-year-old boy who presented with visual impairment and headache and was found to harbour a purely intrasellar cystic pilocytic astrocytoma originating from proximal left optic nerve. The mass was explored transcranially and decompression of the optic apparatus and subtotal resection of the cyst wall was accomplished. The patient received post-operative radiotherapy and stays symptom-free after two years. A review of the literature revealed six cases of optic pathway astrocytomas associated with cyst formation. Our case appears as the first case of an optic glioma to present as an intrasellar mass.

Status epilepticus following iohexol myelography

Iohexol, a contrast medium widely used for myelography, has rarely been reported to cause convulsive disorders. A case of status epilepticus resulting from iohexol myelography is reported and problems of treatment are discussed.

Craniosynostosis: a review of 143 surgically-treated cases

In this study, 143 cases of craniosynostosis are presented. There were 109 males and 34 females. The major complaints were skull deformity (92 patients), proptosis (38 patients) and microcephalus (32 patients). Neurological examination revealed the presence of optic atrophy in 24 patients and papilledema in 20 patients. Seventy-four patients (53%) had three or more suture closures, with the sagittal suture being the most commonly involved (20% of patients). All patients underwent surgery. Suture removal was performed in 131 patients (91.7%), suture removal plus orbital decompression in 34 (23.8%), and linear craniectomy plus wrapping in 12 (8.3%). The reoperation rate was 6.2 percent. During the follow-up period, preoperative papilledema and proptosis improved in 88.2 and 78.9 percent of patients, respectively. Skull deformity disappeared in 46.9 percent of patients, but remained unchanged in 16.6 percent.

Primary multiple spinal extradural hydatid cysts. Case report and review of the literature [corrected]

In this paper a patient with primary multiple extradural hydatid disease is described. He had no neurological deficits, although there were numerous hydatid cysts located at the thoracic 7-9 level extradurally. Nuclear magnetic resonance (NMR) was used for what would appear to be the first time for the diagnosis of spinal hydatid disease.

Extradural haematoma after continuous extradural anaesthesia

We report a case of extradural haematoma occurring after extradural anaesthesia in an anticoagulated patient. The diagnosis was confirmed by magnetic resonance imaging and the haematoma was evacuated surgically. A search of the literature revealed only five previous reports of extradural haematoma in association with extradural anaesthesia.

Primary intracranial extradural Burkitt-type lymphoma. A unique presentation with unilateral loss of vision in a child

An unusual case of primary extranodal Burkitt's-type lymphoma of the frontal base dura and adjacent bone with intradural invasion is reported in a 5-year-old child who presented with unilateral loss of vision in the left eye. Tissue diagnosis was obtained through a craniotomy and the patient received radiotherapy plus intravenous and intrathecal chemotherapy. The tumor regression and improvement in vision was well documented by means of CT and visual evoked potential studies (VEP). A review of the literature on this exceptionally rare tumor is presented.

Nonsuture closure of arterial defect by vein graft using isobutyl-2-cyanoacrylate as a tissue adhesive

Nonsuture repair of intracranial blood vessel is still a challenging issue in neurosurgery. In this experimental study isobutyl-2-cyanoacrylate was used for nonsuture repairing of carotid artery to observe its histotoxicity. Isobutyl-2-cyanoacrylate was dropped over the edge of defect on carotid artery of rat under the surgical microscope and jugular vein was placed to cover the defect. Rats were divided in 6 group according to postoperative survival period (2, 5, 7, 14, 21, 28 days respectively). The carotid arteries were patent of all rats according to angiography and autopsy specimen. Histopathological results showed that: the changes are mainly inflammatory respons +, there was no necrotic tissue at any time the healing progress and no significant differences in the vein graft. Therefore isobutyl-2-cyanoacrylate is considered helpful and safe adhesive material for the nonsuture repair of blood vessel.

Primary multiple cerebral hydatid cysts

Primary multiple cerebral hydatid cysts are extremely rare: In this paper, an 8-year-old male patient who has one primary cerebral hydatid cyst in each cerebral hemisphere is presented. CT findings and operation are discussed. The literature is reviewed and the incidence of multiple cerebral hydatid cyst is compared with the published reports.