Telogen effluvium in daily practice: Patient characteristics, laboratory parameters, and treatment modalities of 3028 patients with telogen effluvium

BACKGROUND

Telogen effluvium (TE) is a common form of non-scarring alopecia, characterized by excessive shedding of telogen club hairs.

OBJECTIVES

The aim of the present study was to investigate patient characteristics, laboratory parameters, and treatment strategies in TE.

METHODS

Electronic records of 3028 patients were retrospectively analyzed. Demographic and clinical data, as well as serum parameters screening for iron, vitamin B12, vitamin D, folate and zinc deficiencies, thyroid function, and ANA titers, were evaluated.

RESULTS

In the study group, the most frequently performed test type was serum ferritin level (82.3%), followed by complete blood count (81%), both of which revealed that 6.2% of the patients had iron deficiency anemia. 4.6% of the patients had thyroid dysfunction. In screened patients, vitamin and mineral deficiencies were as follows: vitamin D (72.2%), vitamin B12 (30.7%), folate (4.4%), and zinc (2.1%). Women were more likely to be prescribed vitamin D replacement therapy. Iron replacement was the most frequently ordered treatment, comprising 37.5% of total prescriptions.

CONCLUSION

To the best of our knowledge, this is the most comprehensive retrospective study having the largest number of patients with TE. Our results will not only help to augment knowledge about TE, but also provide a diagnostic algorithm for the laboratory and clinical workup of patients with TE.

Thiol/disulfide homeostasis: A prognostic biomarker for patients with advanced non-small cell lung cancer?

BACKGROUND

The aim of this study was to investigate oxidative stress and thiol/disulfide status with a novel automated homeostasis assay in advanced non-small cell lung cancer (NSCLC).

METHODS

Thirty-five patients with advanced NSCLC, who had been newly diagnosed and previously untreated, and 35 healthy subjects were chosen for the study. We measured plasma total thiol (-SH+-S-S-), native thiol (thiol) (-SH), and disulfide (-S-S-) levels in the patients with NSCLC and the healthy subjects. The thiol/disulfide (-SH/-S-S-) ratio was also calculated.

RESULTS

Statistically significant differences between the patient group and the control group were detected for the thiol/disulfide parameters. The mean native thiol, total thiol, and disulfide levels were significantly lower in the group with advanced stage NSCLC. The cut-off value was 313 and 13.8 for native thiol and disulfide, respectively. Median overall survival (OS) was significantly shorter in patients with low native thiol and disulfide levels according to the cut-off value (respectively, P = 0.001; P = 0.006). Native thiol, total thiol, and disulfide levels were correlated with Karnofsky performance status (KPS), OS, and age. Additionally, hierarchical regression analyses showed gender, KPS, lung metastases, and plasma native thiol levels were the determinants of OS in the final model.

CONCLUSION

These results suggest that in advanced stage NSCLC, the native thiol, total thiol, and disulfide levels decrease, while the native thiol/disulfide ratio does not change. Low levels of thiol/disulfide parameters are related to tumor aggressiveness and may predict a poor outcome for patients with NSCLC.

Effect of melatonin on cerebral vasospasm following experimental subarachnoid hemorrhage

OBJECT

The current study was undertaken to determine whether melatonin therapy reverses vasospasm and prevents apoptosis by inhibiting lipid peroxidation in an experimental subarachnoid hemorrhage (SAH) model.

MATERIALS AND METHODS

The rabbits were divided into four groups as follows: Group 1, SAH + melatonin (5 mg/kg/i.p. BID) simultaneously with SAH (n = 6); Group 2, SAH + melatonin (5 mg/kg/i.p. BID) treated 2 hours after SAH (n = 6); Group 3, control group (n = 4); Group 4, SAH only (n = 6). Light microscopic examinations of the basilar arteries were performed to demonstrate the pathophysiological changes of the arterial wall with hematoxylin- eosin. Apoptosis: Immunohistology using the ApopTag Peroxidase In Situ Apoptosis Detection Kit was used to demonstrate apoptosis in a cross section of basilary arteries. Apoptotic index was calculated as the number of the immunoreactive nuclei per total number of endothelial cells, and expressed as a percentage.

RESULTS

The results of measurements of diameters of the vessels between groups were significantly different (p = 0.028). While basilar arteries of the SAH only group showed 57% constriction, Groups 1 and 2 were calculated as 33 and 26% constriction, respectively, compared with the control group (p < 0.05). And also Groups 1 and 2 showed significant protection of apoptosis compared with Group 4. The difference between the four groups was tested by Kruskal-Wallis test and the significance between the two groups was tested by Mann- Whitney U-test.

CONCLUSION

Melatonin with its strong antioxidant effect can prevent SAH-induced vasospasm and apoptosis of endothelial cells of vessels.

Primary primitive neuroectodermal tumor within the spinal epidural space: report of a case and review of the literature

Primary intraspinal primitive neuroectodermal tumors (PNETs) are rare tumors and a have poor prognosis. In reviews of the literature, it is seen that primary intraspinal PNETs may arise at all levels of the spine and may be intramedullary, intradural-extramedullary, or epidural. Spinal epidural location of PNET is extremely rare and out of 22 cases of primary spinal PNETs reported to date, only two were epidural. Tumors within the epidural space of the spinal canal are most often metastatic neoplasms from different primary sites. Here we report a case of primary extradural PNET located in the thoracic spine in a 16-year-old boy and review the relevant literature.

Analysis and prevalence of inflammatory cells in subtypes of lumbar disc herniations under cyclooxygenase-2 inhibitor therapy

OBJECTIVE

The aim of the present study was to analyse inflammatory cells in lumbar disc tissue under cyclooxygenase-2 (COX-2) inhibitor therapy, to detect their prevalence in different subtypes of lumbar disc herniations and to assess the influence of inflammatory reactions in herniated disc tissue on postoperative outcome.

METHODS

In this prospective study, intervertebral disc specimens were obtained from 50 patients. All the patients were given COX-2 inhibitor therapy (Rofecoxib) 25 mg/day for 10 days before surgery. The herniated disc specimens were routinely fixed in a 10% buffered formaline solution and paraffin-embedded; 5 microm thin sections were stained with monoclonal antibodies CD-68 for macrophages, CD-45 RO for T cells and CD-20 for B cells. The specimens were microscopically examined and classified by two independent examiners in a blinded manner.

RESULTS

CD-68 macrophages were evident in herniated lumbar disc tissue in 40% of the cases, but abundant inflammation was observed in only 18% of the cases. Macrophages were significantly common in sequesters with a prevalence of 80%, and no macrophages were observed in the protrusions. We obtained the best outcome scores in the patients with a sequestrated lumbar disc herniation.

CONCLUSION

Although most of the specimens from all the patients showed no significant inflammatory reaction, maybe due to COX-2 inhibitor therapy, they all needed surgery with no relief of the symptoms despite conservative therapy. Nerve root compression still seems to be the leading pathomechanism.

Five-year follow-up results for patients diagnosed with anaplastic astrocytoma and effectiveness of concomitant therapy with temozolomide for recurrent anaplastic astrocytoma

Background:

Anaplastic astrocytoma (AA; WHO grade-III) patients determination of prognostic factors helps generating multimodal therapy protocols. For this purpose, in the Baskent University, Adana Medical Research Center, specific characteristics of AA patients who have surgery were retrospectively investigated and factors which affect prognosis has been determined.

Patients and Methods:

Between January 2005 and 2009, 20 patients who have AA have been evaluated retrospectively. Totally, 20 patients had 31 operations. Sixteen patients had only adjuvant radiation therapy (RT). In the postoperative period, 8 patients received adjuvant RT. Nine of 10 patients with tumor recurrence received concomitant therapy with temozolomide (ConcT with TMZ) protocol. No adjuvant therapy protocol could be applied in three patients with poor general condition in the postoperative period.

Results:

Median survival for patients died was 16±17 months; one year survival was 75% and five year survival 25%. After univariate analysis, preoperative Karnofsky performance score (KPS) was ≥80 (P=0.005577^*), postoperative KPS was ≥80 (P=0.003825^*), type of tumor resection (P=0.001751^*), multiple operations (P=0.006233^*), and ConcT with TMZ protocol (P=0,005766^*) were all positive prognostic factors which extend the survival.

Conclusions:

The results of the multivariate analysis did not put forward an independent prognostic factor acting on the survival period (P>0.05).

The predictive value of the clinical features of malignancy in cases of preoperative follicular thyroid neoplasia

AIM

It is generally impossible to make a distinction between benign and malign with a cytopathological examination using a fine needle aspiration biopsy (FNAB) in follicular lesions of the thyroid gland. This is the reason why lesions are frequently reported as follicular neoplasia (FN). Our study aims to examine the predictive value of carcinoma detection of different clinical features in cases with determined FN with FNAB.

METHODS

Clinical and histopathological data of a total of 116 patients (26 male, 90 female) subjected to surgery because of thyroid gland pathology with FN between March 1997 and December 2011 were retrospectively examined in two different centers.

RESULTS

Results of the histopathological examinations were reported as: carcinoma in 33 (28.4%) cases (18 [54.5%] cases with papillary thyroid cancer, 11 [33.3%] cases with follicular thyroid cancer and 4 [12.1%] cases with papillary thyroid cancer follicular variant), as follicular adenoma (FA) in 32 (27.6%) patients and as a benign colloidal nodule in 51 (43.9%) patients. No statistical significance was determined between advanced age, male sex, solid single nodule, increased nodule diameter, hypoactive nodule existence and malignancy (P>0.05).

CONCLUSION

Malignancy was found in 28.4% cases with FN detected as a result of FNAB in our study series, a ratio which is significantly higher than that reported in the literature. We think that the characteristics of the patient and the tumor are not effective in diagnosing cancer. In the case of the existence of bilateral thyroid pathology, the surgical therapy option should be bilateral total thyroidectomy due to such a high ratio of cancer occurrence.

Antithrombin III and enoxaparin treatment inhibit contusion-triggered cell death, inflammation, hemorrhage and apoptosis after severe traumatic brain injury in rats

AIM

In this study, we aimed to show the neuroprotective effects of AT III and Enoxaparin after severe traumatic brain injury.

MATERIAL AND METHODS

The animals were divided into four groups as Group 1; control group, Group 2; trauma group, Group 3; AT III group and Group 4; Enoxaparin group. Severe trauma was performed by the weight dropping technique. These animals were killed 48 hours after injury. Histopathological and immunohistochemical analysis were performed. Specimens were graded for cell death, inflammation, hemorrhage and apoptosis.

RESULTS

The control group showed normal ultrastructure of brain tissue. Trauma produced obvious damage. 8 rats (80%) in the trauma group demonstrated minimal inflammation and grade 5 cell death. Trauma increased hemorrhage and apoptosis scores to statistically significant levels (p < 0.001). Enoxaparin was found to reduce neuronal cell death but not as effectively as AT III. A statistically significant difference was observed between the AT III and Enoxaparin group according to inflammation grades. Significant antiapoptotic properties of AT III were observed while hemorrhage was more common in the Enoxaparin group.

CONCLUSION

Anticoagulants such as AT III and enoxaparin are promising drugs in the treatment of traumatic brain injuries.

Effectiveness of temozolomide treatment used at the same time with radiotherapy and adjuvant temozolomide; concomitant therapy of glioblastoma multiforme: multivariate analysis and other prognostic factors

AIM

Prognostic factors which affect treatment results of glioblastoma multiforme (GBM; WHO Grade IV) patients has been investigated in many researches. For these patients determination of prognostic factors helps generating multimodal therapy protocols. For this purpose, in the Baskent University Medical School, Neurosurgery Clinic, Adana Medical Research Center, specific characteristics of GBM patients who have surgery retrospectively investigated and factors which affect prognosis has been determined.

METHODS

Between January 2005 and January 2009, 59 patients (25 female, 34 male) who have GBM have been evaluated retrospectively. Mean follow-up period was 27.4 (+/-17.3) months. Headache (66.1%) was the most seen symptom. Time of diagnosis was 1-2 months for most of the patients (54.2%). Fifty-nine patients had 67 operations totally. Preoperative Karnofski Performance Scale (KPS) was >or=70 for 43 operations, <or=70 for 24 operations. Frontal lobe was the most involved part of the tumor,and biggest tumor has the diameter of 4.8 (+/-1.42) cm. Forty gross total resection, 26 subtotal resection and 1 lobectomy were performed. Postoperatively for 41 operations KPS>or=70, for 26 operations KPS<or=70. After surgery 44 patients had radiation therapy (RT). Eighteen patients had only adjuvant RT, 26 patients had temozolomide (TMZ) treatment used at the same time with RT combination therapy (CombT with TMZ) and 6 cures adjuvant TMZ concomitant therapy (ConcT with TMZ). Median survival and prognostic factors of 42 GBM patients was calculated with multivariable and univariable analysis.

RESULTS

Median survival was 8 (+/-1.5) months for patients who died. One year survival was 83.3% and two-year survival 16.7%. After treatment, relapse occurred in 12 patient at the site of the tumor and these patients had been reoperated. After univariate statistical analysis preoperative KPS was >or=70 (P=0.0000) , postoperative KPS 2 was >or=70 (P=0.0000), type of tumor resection (P=0.00002), multiple operations (P=0.001), adjuvant RT (P=0.0000) and ConcT with adjuvant TMZ (P=0.0000) were all positive prognostic factors which extend the survival. After multivariate analysis, post operative KPS was >or=70 (P=0.003; OR:0.89; % 95 CI:0.83-0.96), type of resection (P=0.055; OR:0.37; % 95 CI:0.13-0.12) and multiple operations (P=0.042; OR:2.65; % 95 CI:1.03-6.82) were independent prognostic factors.

CONCLUSION

When independent prognostic factors were examined ,median survival found out 7.8 months longer fort he patients whose postoperative KPS were >or=70, 5.7 months longer for the patients who had radical resection, 6.6 months longer for the patients who had multiple operations. Although patients who had ConcT with adjuvant TMZ had 1.7 months longer survival compared to patients who had only adjuvant RT, it was not determined as an independent prognostic factor.

Spontaneous primary intraventricular hemorrhage in adults: clinical data, etiology and outcome

AIM

Primary intraventricular hemorrhage (PIVH), bleeding in the ventricular system without a recognizable parenchymal component, is a rare neurological disorder. The purpose of this study was to identify clinical features, risk factors, etiology and outcome of patients with PIVH.

MATERIAL AND METHODS

We retrospectively reviewed the clinical data, complementary examinations, outcome and computed tomography (CT) IVH score of 24 patients in our hospital from 2004 to 2008. We identified 24 patients with the inclusion criteria of non-traumatic PIVH. Their mean age was 60.6+/-17.4 years (range 38-79). Fourteen patients were male and 10 were female.

RESULTS

The major symptoms included headache (n=24), loss of consciousness (n=6), confusion and disorientation (n=14), nausea/vomiting (n=10). Angiography revealed vascular malformations in five patients (21%). Other possible causative factors were hypertension in 12 patients (50%) and clotting disorder in one. The aetiology remained unknown in six patients. Most PIVH patients had associated hydrocephalus (58%) and 37% of the patients required ventricular drainage. In-hospital mortality was high (41%) and a FOUR score <or=10, GCS <or=8 and early hydrocephalus were independent predictors of mortality.

CONCLUSION

Hypertension is the most common associated risk factor for PIVH followed by vascular malformation. Spontaneous resorption and rebleeding may be seen. The neurological status of the patients and an early developing hydrocephalus are the most important risk factors.

Paraparesis following straining accompanied by spontaneous thoracolumbar spinal epidural hematoma: a case report

Spontaneous spinal epidural hematoma (SSEH) is a rare disease that requires emergency surgical intervention because it can cause serious and permanent neurological damage. Its etiology is related to coagulopathy, vascular malformation, hypertension, neoplasms, infections and idiopathic causes. It is frequently observed in the cervicothoracic and thoracolumbar regions. Inadequate spinal vascularization of the thoracolumbar junction increases the risk of spinal infarcts in lesions in this region. Therefore, prompt and effective surgical intervention is critical in patients with a thoracolumbar SSEH. We conclude that prognosis would be better than it is if patients with complete neurological damage were to undergo spinal decompression within the first 36 hours, and patients with incomplete neurological damage were operated on in the first 48 hours. We report a 71-year-old female patient with a history of aspirin use who developed paraparesis accompanied by SSEH following straining, and emphasize the importance of early surgical treatment.

Posterior epidural mass: can a posteriorly migrated lumbar disc fragment mimic tumour, haematoma or abscess?

A 60-year-old woman complained of low back pain radiating to both buttocks and to the anterior aspect of the left thigh. MRI showed a left posterolateral epidural mass at the L1-L2 level. An epidural abscess was suspected, but the biochemistry was normal. Excision yielded complete relief of symptoms. Pathological examination demonstrated that the specimen was a migrated disc fragment. The authors found 29 other cases of disc migration to the posterior epidural space; two of these were at the thoracic level. Eleven of the 27 lumbar cases (40%) were complicated with Cauda Equina Syndrome (CES). MRI is the method of choice to make the diagnosis. The differential diagnosis includes tumour, haematoma and abscess.

Parkinsonian syndrome associated with subacute subdural haematoma and its effective surgical treatment: a case report

There have been several reports of parkinsonian syndrome arising from a mass effect from subdural haematomas. In this study, we present a case of parkinsonian syndrome caused by a subacute subdural haematoma. Evacuation of the haematoma resulted in the disappearance of parkinsonian symptoms in this case. Parkinsonism is not common complication of subdural haematoma; surgical treatment of those cases is associated with favourable outcome, without the need for antiparkinsonian medication.

Therapeutic Difficulty in a Case of Supratentorial Primitive Neuroectodermal Tumor Diagnosed during Pregnancy

We report a supratentorial primitive neuroectodermal tumor (sPNET) in 17-year-old primipara in the second trimester her pregnancy. Magnetic resonance imaging revealed a left frontoparietal mass with solid and cystic component. Gross-total resection was achieved via a left frontoparietal craniotomy. It was decided to suspend the radiotherapy and chemotherapy until the 30 weeks of gestation. But, a sudden uncal herniation was developed due to the reccurrence of the tumor and bleeding into the tumor at the 25 weeks of gestation and the patient died after urgent decompressive surgery. sPNETs is an extremely rare brain tumor in pregnancy and only two cases were reported in the literature to date. There is no universally agreed treatment protocol for sPNETs during pregnancy and a multidisciplinary approach is required in treatment. In the present study, the clinical, histopathological features and therapeutical difficulties of sPNETs diagnosed during pregnancy was discussed with the literature review.

An unusual cause of low back pain: paravertebral muscle metastases of lung cancer

Paravertebral muscle metastasis is an extremely rare cause of low back pain. Lipomas, haemangiomas, hibernomas and liposarcomas should be considered first in the aetiology of paravertebral muscle masses. Schwannoma, neurofibroma, ganglioneuroma and paraganglioneuromas that show contiguous spread should also be included in the differential diagnosis. Haematogenous metastases are most frequently caused by lung cancers. Lung cancers typically metastasize to liver, brain, bone, kidney, and adrenal glands. They rarely metastasize to skeletal muscles due to metabolism, high tissue pressure and blood flow of muscles. Our case was a 48-year-old male who had been smoking 40 cigarettes per day and presented to our clinic with low back pain and a mass in the lower back region. The mass in his lower back region was excised and histopathological examination confirmed metastasis of a neuroendocrine tumour. Further examinations revealed the lung as the primary source of the metastasis.

A non-bleeding complex intracerebral giant aneurysm case: case report

An intracranial aneurysm with a diameter larger than 25 mm is considered a giant aneurysm (GA), and represent about 3-5% of all aneurysms. They are divided into two forms, specifically saccular and fusiform. Fusiform aneurysms are rare, making up only 1% of all intracranial aneurysms. They frequently involve the internal carotid artery (ICA) or the basilar or vertebral arteries, and rarely bleed. Treatment of huge aneurysms that have not bled is still controversial. Unlike the saccular huge aneurysms that lead to death of 80% of the patients few years after diagnosis, fusiform huge aneurysms, particularly those presenting with mass effect, have a better prognosis. In this manuscript, we discuss the infrequently seen intracranial fusiform giant aneurysms in light of the pertinent literature.

The role of standing flexion-extension radiographs for spondylolisthesis following single level disk surgery

OBJECTIVES

Spondylolisthesis is the forward displacement of a lumbar vertebra relative to the adjacent vertebra, occurs as result degeneration or surgery and is a special type of lumbar instability. There is no consensus about which radiologic modality or findings truly reflect the lumbar instability and the exact incidence after single level disk surgery is unknown.

METHODS

In this prospective study, we have included 90 patients who were operated by the same surgeon with single level disk herniation. We aimed at evaluating the post-operative lumbar spondylolisthesis, with flexion and extension lateral radiographs in addition to standard magnetic resonance imaging (MRI).

RESULTS

We have seen spondylolisthesis in six of 90 cases with standing lateral flexion-extension radiographs, which were undefinable with MRI. Pain intensity and functional-economic rating scale (Prolo scale) were unremarkable.

DISCUSSION

We have concluded that standing flexion-extension radiographs should be routinely combined in patients with failed back surgery syndrome and even if lumbar instability is clinically suspected, especially when conventional MR examination is normal. When the MR examination showed spondylolisthesis, standing flexion-extension radiographs could not give additional information.

Endovascular treatment of primary infectious aneurysm in childhood: a case report

Infectious aneurysms constitute 4% of all intracranial aneurysms. The microorganisms responsible are most commonly streptococcus viridans, staphylococcus aureus and combined bacterial infections. Nonetheless, cases with no reproduction in their cultures are rather frequent. A 6-year-old patient admitted with complaints of sudden headache, nausea, vomiting and high temperature. Intracerebral hematoma and saccular aneurysm located at the distal posterior cerebral artery were diagnosed as a result of the laboratory investigations and neuroradiological examinations. Infectious aneurysm was considered due to the clinical findings, morphology and location of the aneurysm. Although the causative microorganism was detected in blood culture, no focus could be detected. The aneurysm was hindered by endovascular intervention. In this manuscript, we discuss the infrequently seen childhood infectious aneurysm in the light of the pertinent literature.

A rare case of massive NF1 with invasion of entire spinal axis by neurofibromas: case report

Neurofibromatosis type-1 (NF1) is a type of phakomatosis inherited in an autosomal dominant fashion. Also called 'von Recklinghausen disease' or 'peripheral neurofibromatosis', it comprises 90% of all neurofibromatosis (NF) cases. It is characterized by multiple peripheral nerve sheath tumors of benign character called neurofibromas. Surgical intervention is indicated when myelopathy and motor losses develop in the case of paraspinal neurofibromas, which are frequently localized to the cervical and lumbar regions. The level of surgical intervention required should be carefully considered and should take into account neurophysiological tests of paraspinal neurofibroma cases that allow estimation of the risk that the neurofibromas will invade the complete spinal axis. The best results are obtained with patients showing minimal neurological deficits during the pre-operative period. Little improvement may be expected from the patients who develop complete transection syndrome during the postoperative period. In the present paper, we discuss an NF1 case in which paraspinal neurofibromas were observed along the complete spinal axis of a 32-year-old male patient who arrived at the clinic reporting increasingly intense pins and needles and weakness. We discuss the patient's diagnosis, treatment, and prognosis, and relate this case to the literature.

CT and MRI findings in calvarial non-infectious lesions

Differential diagnosis of the calvarial lesions is important in order to decide whether biopsy, surgical intervention, or follow-up is required for further management. In this pictorial essay on calvarial lesions, lytic or sclerotic patterns, contours of the lesions, calcifications, soft tissue components, inner and outer table localizations were evaluated with computed tomography (CT). On magnetic resonance imaging (MRI) signal characteristics and contrast enhancement of the lesion, relation to brain parenchyma and soft tissue were evaluated. CT scan is considered to be the best examination to characterize bone alterations whereas MRI depicts bone marrow abnormalities and invasion of adjacent tissues.

The effect of mexiletine on the level of lipid peroxidation and apoptosis of endothelium following experimental subarachnoid hemorrhage

OBJECTIVE

The role of apoptosis in etiopathogenesis of vasospasm is not clearly understood yet. It is widely accepted that protection of the endothelial cells from the process of apoptosis could have beneficial effects on cerebral vasospasm after subarachnoid hemorrhage (SAH). Mexiletine blocks sodium and calcium channels and activates ATP-sensitive K(+) channels. Moreover, mexiletine is known to have potent antioxidant effects through inhibiting free-radical production.

METHODS

Twenty-one rabbits were allocated into three groups randomly. Group I was sham operated group (n=7). SAH occurred but no medication was given to the Group II rabbits (SAH only group) (n=7). Mexiletine (50 mg/kg, b.i.d., i.p.) was administered just before SAH and continued until 48 hours following SAH to the Group III rabbits (Mexiletine treated group) (n=7). The ApopTag peroxidase in situ apoptosis detection kit (Serologicals Corporation, former Intergen) was used to demonstrate apoptosis in a cross section of basillary arteries. Thiobarbituric acid reactive material was used to determine the lipid peroxidation levels.

RESULTS

There was a statistically significant difference between lipid peroxidation product levels of the control and SAH only groups (p<0.05). The level of lipid peroxidation production in Mexiletine treated group was significantly lower compared with SAH only group (p<0.05) but not significantly higher than the control group (p>0.05).

DISCUSSION

In the present study we investigated the antioxidant action of mexiletine on apoptosis of endothelium following a rabbit SAH model. This experimental study directly suggested that lipid peroxidation is an important step in development of apoptosis in endothelial cells and prevention of structural integrity of endothelial cell should play a beneficial role in attenuation of cerebral vasospasm. Mexiletine treatment prevented the increase in lipid peroxidation and cerebral vasospasm. Examination of endothelial cells by staining specific for apoptosis demonstrated significant protection of cell integrity in the treated group.

Silent pituitary macroadenoma co-secreting growth hormone and thyroid stimulating hormone

Silent pituitary adenomas are a group of tumors showing heterogenous morphological features with no hormonal function observed clinically. To date no explanation has been provided as to why these tumors remain "silent". We report a case of a silent macroadenoma with both growth hormone (GH) and thyroid stimulating hormone (TSH) staining and secretion but with no clinical manifestations, in particular, the absence of features of acromegaly or hyperthyroidism. The relevant literature is reviewed.

Primary Amyloidoma of the Thoracic Spine

Amyloidoma is a nodular mass of amyloid with no evidence of generalized amyloidosis. Primary amyloidoma of the spine is very rare and has a predilection for the thoracic region. The tumor-like appearance and behavior make it difficult to diagnose on imaging studies. Despite its rarity and nonspecific radiologic findings, primary spinal amyloidoma should be included in the differential diagnosis of an osteolytic and calcified mass of the spine. We report the case of a 38-year-old woman with amyloidoma involving the thoracic spine and describe the main characteristics of this condition.

Atypical traumatic craniocervical junction focal spinal subdural hematoma

Spinal subdural hematoma (SSDH) is a rare entity and post-traumatic cervical SSDH is very rare. Review of the literature revealed 8 reported cases of traumatic SSDH and only 2 were cervical. The exact mechanism and pathogenesis of SSDHs are unclear. There are still controversies about the source of bleeding and mechanisms of formation of a hematoma. Here we report a case of a unique traumatic craniocervical junction focal subdural hematoma in an 8-year-old boy and discuss the possible mechanisms of SSDHs in trauma cases.

Management of fronto-orbital sphenoidal and facial osteosarcoma: a case with uncommon localization

Osteogenic sarcomas of the head and neck are rarely seen; approximately 6% to 13% these tumors occur in the head and neck, and less than 2% occur in the cranium. Not only eradication of the tumor but reconstruction to achieve satisfactory esthetic and functional results are the main issues regarding these tumors. In this report, a case of osteogenic sarcoma that invaded the infratemporal area, fronto-orbital region, and sphenoid wing is presented. The surgical results of eradication and reconstruction are also presented.

Fronto-orbital leptomeningeal cyst manifested with exophthalmus

A 41-year-old female patient with fronto-orbital leptomeningeal cyst is presented. After decompression of the cyst, repair of bone and dura defects were achieved with autogenous bone grafts and pericranial flap. Our case was very interesting in several aspects: a head trauma at 3 years of age and manifestation of clinical symptoms (headaches and exophthalmia) after almost 4 decades that had been progressive for 6 months and a rare location (fronto-orbital region) that required a special management. A thorough history is crucial in such cases because clinical symptoms might appear after decades. An old fracture that is surrounded by thin calvarial tissue in conjunction with intracranial cystic formation should make one take a leptomeningeal cyst into consideration in differential diagnosis. Extensive dissection and adequate access osteotomies followed by repair with autologous and vascular tissues are the key factors for a successful outcome in the management of fronto-orbital pathologies.

Effects of sevoflurane and desflurane on cytokine response during tympanoplasty surgery

BACKGROUND

This study was devised to compare the effects of sevoflurane and desflurane anaesthesia on the cytokine response.

METHODS

Sixty ASA I-II patients, scheduled for tympanoplasty, were randomly allocated to be anaesthetized with either sevoflurane or desflurane at maintenance inspiratory concentrations of 1-1.5 MAC of either agent. Blood samples were taken for plasma tumour necrosis factor alpha (TNFalpha), interleukin 1beta and interleukin-6 assay before induction of anaesthesia, before surgery, and at the end of surgery. Alveolar cells were obtained after induction of anaesthesia and at the end of surgery.

RESULTS

Plasma TNFalpha was greater with desflurane than sevoflurane both before surgery (45.1 +/- 3.5 pg ml(-1) for desflurane vs. 23.2 +/- 2.5 pg ml(-1) for sevoflurane, P < 0.01) and (62.0 +/- 5.3 pg ml(-1) vs. 35.5 +/- 4.6 pg ml(-1), P < 0.001). Interleukin 1beta was similarly greater with desflurane than sevoflurane before (39.3 +/- 4.0 pg ml(-1) vs. 17.4 +/- 3.0 pg ml(-1); P < 0.01) and after surgery (46.0 +/- 3.4 pg ml(-1) vs. 23.3 +/- 3.2 pg ml(-1), P < 0.001). There were similar results for interleukin 6 before (42.3 +/- 3.5 pg mls(-1). 29.0 +/- 2.6 pg ml(-1), P < 0.001) and after surgery (86.0 +/- 4.5 pg ml(-1) vs. 45.9 +/- 6.3 pg ml(-1), P < 0.001). Alveolar cell TNFalpha concentrations after surgery were also greater with desflurane than sevoflurane (96.3 +/- 12.4 pg ml(-1) vs. 64.8 +/- 10.1 pg ml(-1), P < 0.001), as were interleukin 1beta (75.4 +/- 6.2 pg ml(-1) vs. 32.0 +/- 8.3 pg ml(-1), P < 0.001) and interleukin 6 concentrations (540.1 +/- 65.3 pg ml(-1) vs. 363.6 +/- 29.2 pg ml(-1), P < 0.001).

CONCLUSION

Desflurane appears to cause a greater systemic and intrapulmonary pro-inflammatory response than sevoflurane during anaesthesia for ear surgery.

The relation between serum levels of osteoprotegerin and postoperative epidural fibrosis in patients who underwent surgery for lumbar disc herniation

OBJECTIVES

Epidural fibrosis (EF) is a part of the normal physiological tissue response to laminectomy and it is an important cause of failed back surgery syndrome (FBSS). Osteoprotegerin (OPG) is a soluble member of the tumor necrosis factor receptor family, and is expressed in high concentrations by a variety of tissues and cell types. The objective of this study was to evaluate the relationship between serum OPG levels, and the existence of postoperative EF in patients with lumbar disc herniation. It has been suggested that cytokines and growth factors, which play a role in the wound healing, may enhance the expression of OPG.

METHODS

Forty women who underwent surgery for lumbar disc herniation were included in this study. Postoperative MRI was performed to assess EF in all patients.

RESULTS

The serum OPG levels of subjects with postoperative EF were significantly higher than those of subjects without postoperative EF (4.72 +/- 0.27 versus 3.25 +/-0.41 pmol/l; p=0.005)

DISCUSSION

Although the role of OPG in the development of EF is poorly understood, our results suggest that elevated levels of serum OPG are associated with and may play a role in the pathogenesis of fibrotic process.

The role of closed-suction drainage in preventing epidural fibrosis and its correlation with a new grading system of epidural fibrosis on the basis of MRI

In this study we aimed to evaluate the role of closed-suction drainage on the extent of epidural fibrosis (EF) after lumbar disc surgery and to define a new grading system of epidural fibrosis in these patients, based on magnetic resonance imaging. Seventy-nine patients (34 women, 45 men) with a unilateral, single-level lumbar disc herniation were included in this study. Forty-one patients in whom closed-suction drainage was implanted were compared with 38 patients in whom the drain was not implanted. We have used a new grading system for the extent of epidural fibrosis, on the basis of follow-up magnetic resonance imaging findings. Pain intensity was evaluated by visual analog scale (VAS), and the patients' function and working ability were measured according to the Prolo functional-economic scale. We conclude that, in patients operated on for unilateral, single-level lumbar disc hernias, implantation of closed-suction drainage into the operation site results in less formation of EF radiologically and yields better clinical outcome.

Can E-selectin be a reliable marker of inflammation in lumbar disc disease?

The cause of sciatica and low back pain associating with lumbar disc herniation has not been clearly identified until now. Inflammation has been shown to occur via immunohistochemical and biochemical methods in herniated disc tissues. The important prognostic role of E-selectin has recently been substantiated by other studies in early rheumatoid arthritis (RA) and juvenile rheumatoid arthritis (JRA). The important role of adhesion molecules in the initiation and progression of the inflammatory response is well known for infectious diseases and autoimmune disorders. In our study, we aimed to show the role of E-selectin as an inflammatory marker and the correlation of inflammation with straight-leg raise (SLR) test findings and subtype of disc herniation. We found that the cases with positive SLR test had higher rates of immunostaining with E-selectin. This led us to think that E-selectin might play an important role in the activity status of the disease, meaning patients with more limited movement capacity might benefit from E-selectin antagonist therapy. Among the many studies performed to identify the relationship between the inflammation markers and activity of lumbar disc herniation, this is the first investigation held with E-selectin.

Giant cell tumour of the sixth cervical vertebrae with close relationship to the vertebral artery

Giant cell tumours of the vertebral column are rare and cervical vertebrae involvement is even less common. As these lesions may be closely related to the vertebral artery, therapeutic decision-making may be complex. Reviewing the literature, we found that there was no consensus on treatment or outcome assessment for these rare and difficult lesions. We present a case of a giant cell tumour of the sixth cervical vertebrae involving the posterior elements, neural foramina and transverse foramina and closely related to the vertebral artery. Radiological evaluation and therapeutic solutions are also discussed.

Unusual case of skull metastasis secondary to pancreatic adenocarcinoma

Skull metastasis must be kept in mind when considering the differential diagnosis of a skull tumor. Skull metastases cause local swelling that is usually painless, and rarely they lead to neurologic dysfunction. Despite the fact that hematogenous skull metastases can be caused by nearly all types of tumors (lung, prostate, thyroid carcinoma, malignant melanoma), breast cancer is associated with the highest rate of metastatic skull lesions. We report an extremely rare case of skull metastasis from a pancreatic adenocarcinoma, in a 65-year-old woman, presented with painless frontoparietal scalp swelling which developed within three months. To the best of our knowledge, this is the second case involving the skull secondary to a pancreatic adenocarcinoma, and the first case when skull metastasis was the first evidence of a pancreatic adenocarcinoma.

Lumbar meningeal hamartoma and epidermoid cyst associated with spinal dysraphism in an elderly patient

Meningeal hamartoma associated with spinal dysraphism in an elderly patient is an extremely rare clinical presentation. A 62-year-old woman who progressively developed gait disturbance and urinary retention was admitted to our hospital. Magnetic resonance imaging (MRI) revealed a large cystic mass associated with a dermal sinus at the L4-L5 level. MRI was useful in the diagnosis and determination of this lesion. However, preoperative differential diagnosis of the tumor was not possible based on neuroimaging evidence. The diagnosis of meningeal hamartoma was based on the histological and immunohistological findings of the specimen obtained from the tumor. Meningeal hamartoma associated with spinal dysraphism should be kept in mind, even in adult cases. In this article, we also discuss the radiological and pathological appearance of this rare clinical entity.

Hemispheric cerebrovascular venous thrombosis due to closed head injury

CASE REPORT

We present the case of an 8-month-old infant who was admitted to our Neurosurgery Department with venous infarction related to sagittal sinus thrombosis. The infarction was radiologically detected 5 days after the baby had undergone surgery for acute subdural hematoma due to a closed head injury.

RESULTS AND CONCLUSIONS

Cerebrovascular venous thrombosis is a rare clinical entity that has multiple causes and variable presenting symptoms. There is no consensus on overall strategy concerning surgical, radiosurgical, or medical therapy (anti-coagulation, thrombolytic, and anti-edema treatment), and exactly how, when, or in which cases these should be applied. The treatment planning should be based on clinical findings, and should be modified according to the clinical course. In this case, the clinical and radiological findings regressed with symptomatic treatment alone.

Intradural disc mimicking: a spinal tumor lesion

STUDY DESIGN

A case report of intradural disc hernia mimicking an intradural extramedullary spinal tumor lesion in radiological evaluation.

OBJECTIVE

To describe a lumbar intradural disc herniation with atypical radiological appearance and point out the role of contrast magnetic resonance imaging (MRI) of the lumbar spine.

SETTING

Turkey.

CASE REPORT

A 58-year-old man with suspected lumbar intradural mass and neurological involvement received L5 total laminectomy. L5 total laminectomy was performed, and on inspection dura was swollen and immobile. A longitudinal incision was made in the dura and an intradural-free disc fragment was removed. The patient's postoperative period was uneventful and he had full recovery in 3 months.

CONCLUSIONS

Lumbar intradural disc rupture must be considered in the differential diagnosis of mass lesions causing nerve root or cauda equina syndromes. Contrast-enhanced MRI scans are useful to differentiate a herniated disc from a disc space infection or tumor. This case demonstrates the role and the importance of contrast MRI in the diagnosis of intradural disc herniation.

Anterior cervical fusion with the PCB cage-plate system

Anterior cervical discectomy and fusion, as originally described by Robinson, is highly successful in the treatment of neural compression caused by disc material or osteophytes. Although the necessity for fusion after anterior cervical discectomy is still debated, anterior cervical fusion with interbody bone graft and anterior plate implantation is a commonly accepted procedure. In this study, preliminary results with a recently developed PCB cervical plate system (SCIENT'X, Paris, France), which combines a hollow intradiscal cage with an integrated plate, in the management of cervical disc disease are reported.

Rapidly calcifying and ossifying epidural hematoma

Conservative treatment of an epidural hematoma is not always effective in children. We describe an 8-year-old boy who had been followed up conservatively for 10 days at a local hospital due to acute epidural hematoma. A new CT revealed an expansion of the former hematoma accompanied by a thick hyperdense layer. Because the patient presented with symptoms of elevated intracranial pressure, an immediate craniotomy was performed to evacuate the hematoma. The ossified layer, which was densely adhered to the dura mater, was also completely removed. Rapid ossification and/or calcification of an epidural hematoma appearing 10 days after a head injury have not been reported previously. Possible mechanisms of rapid ossification are also discussed in relation to the present report, and the relevant literature is reviewed.

Prefabricated galeal flap based on superficial temporal and posterior auricular vessels

Scalp layers are widely used in reconstructive procedures. The authors used prefabricated galeal flaps based on the superficial temporal or postauricular vessels for ear, cheek, mandible, and cranium reconstructions in three cases. In case 1, synchronous beard and ear reconstructions were accomplished by using the temporoparietal and retroauricular flaps. In case 2, a buccomandibular defect was reconstructed by transposing the supra-auricular and retroauricular galea with prefabricated bone and skin. In case 3, an epidural hematoma in the left frontoparietal area was evacuated after a circular craniectomy. The harvested bone was not put back on the defect area but buried between the periosteal and galeal layers because of brain edema. These layers were raised as an osteogaleoperiosteal flap and transposed onto the defect area after 7 weeks. When used with a prefabrication method, scalp layers offer versatile options for repairing composite defects of the head region. A galeal flap based on the posterior auricular vessels is practical and reliable in reconstructive procedures. The authors suggest that this flap is an option in cases in which the temporoparietal fascia artery or the superficial temporal artery is not available. Prefabrication of the harvested cranial bone inside the adjacent tissues offers several advantages in that a viable bone is provided at the end of the procedure, intervention at a distant area is avoided, the graft is placed on osteogenic tissue (periosteum) that is also transposed onto the defect, and sophisticated procedures such as microsurgical techniques are not needed.

Roles of periosteum, dura, and adjacent bone on healing of cranial osteonecrosis

It has been reported that large cranial osteonecrotic areas can heal. It was hypothesized that optimal healing is possible by the synchronized contribution of the osteogenic structures (periosteum, dura, and adjacent bone) that envelop the necrotic cranium. This hypothesis was tested by preserving or isolating the contribution of these osteogenic tissues. A total of 37 4-old-month rats were included in the study. Twelve animals were killed immediately, and cranial bone samples were taken and processed for examination (from 6 animals as fresh samples [Group A] and from the rest as autoclaved samples [Group B]). Group B was created to test if the bone was completely nonviable. In Group C (n = 25), cranial bone disks 8 mm in diameter were taken from 4-month-old rats, autoclaved, and put back onto the defect area. This group was further divided into the four Subgroups C1 through C4 (n = 7 in C3; n = 6 in C1, C2, and C4). Dura mater was isolated from the overlying bone disk with a polytetrafluoroethylene sheet in Subgroups C1 and C2, whereas the bone contacted the dura in the rest. The bone samples were covered with healthy periosteum in Subgroups C1 and C3 and with skin in Subgroups C3 and C4. These animals were killed after a healing period of 12 weeks, and the relevant bone disks were obtained. Surrounding healthy bone was also harvested from the same animals after they were killed to create Group D. The data of Group A and D were compared with those of the experimental group to comment on the degree of bone healing in the latter group. Quantitative and qualitative assessment was performed by mammography, bone densitometry, computed tomography, and histological examinations to find out the density and cellular content (osteocytes and vessels) of the samples. Examination of Group B samples showed nonviable tissue with a preserved microstructure. Analysis of other samples showed that both the periosteum and, mainly, the dura play an important role in cranial bone healing. The periosteal reaction was observed to be more evident when the dura was not separated. Cellular repopulation was more evident when both structures contributed to the healing process. Newly formed bone progressed centripetally; however, adjacent bone without the support of the dura and periosteum was capable of producing limited neovascularization and bone formation.

Effects of lumbar disc surgery on bone mineral density in women with lumbar disc disease

This prospective study evaluated 60 reproductive-age and postmenopausal women with lumbar disc disease to demonstrate the short-term effects of lumbar disc surgery on bone mineral density (BMD). Lumbar BMD was measured preoperatively and 3 months postoperatively by dual-energy X-ray absorptiometry (DEXA). Surgery was performed at only one level (L3-L4) and consisted of partial hemilaminectomy, discectomy, and, if necessary, partial facetectomy. Before surgery, 50% of the patients had osteopenia, and 31.7% had osteoporosis. After surgery, BMD decreased 5.5% in L3 vertebrae (P=.07), 14% in L4 vertebrae (P=.003), and 4.6% in L1-L4 (P=.039). Six of 11 patients with normal BMD before surgery became osteopenic postoperatively; 9 of 30 women with osteopenia fulfilled criteria for osteoporosis after surgery. Reproductive-age and postmenopausal women undergoing surgery for lumbar disc disease are at risk of bone loss and should be spared an extensive procedure, which can further increase the amount of bone lost. All women for whom a surgical intervention is planned should be evaluated by DEXA preoperatively and postoperatively.

Multi-organ cavernous hemangiomas: case report

Hemangiomas are rare benign tumors of vascular origin and multiple location of these tumors in different organs is extremely unusual. We report a case with multiple hemangiomas, characterized by calvarial, hepatic and suspicious costal involvement. Organ involvement and multiplicity of the neoplasm made our case very interesting and distinct. Our search of the English literature has revealed that no similar case has ever been published.

Intravenous and local intraarterial tissue-plasminogen activator in a rabbit model of acute thromboembolic stroke: angiographic comparison

The aim of early thrombolytic therapy in acute stroke is to obtain early recanalization of occluded cerebral arteries and prevent or reduce irreversible ischemic brain damage. In this study, Seldinger technique and digital subtraction angiography were used to verify thromboembolic occlusion of the common carotid artery by an autologous 12-hour-old thrombus in 28 rabbits. Thirty minutes after embolization, 2 mg/kg of recombinant tissue-plasminogen activator (rt-PA) was delivered intravenously by way of the femoral vein in group A (n = 8) and through a local intraarterial infusion in group B (n = 8). Twelve control animals received an equivalent volume of saline intravenously (group C, n = 6) or by local intra-arterial infusion (group D, n = 6). A comparison of posttreatment angiographs of the treatment groups and the control groups was used to demonstrate reperfusion induced by thrombolytic therapy. None of the control animals showed any evidence of recanalization. Both intravenously (group A) and intra-arterially (group B) treated animals achieved 100% recanalization, although the average time to recanalization was significantly longer in group A (P = .01; 123.7 vs 82.5 min). These results suggest that local intra-arterial administration of rt-PA within 30 minutes produces more rapid reperfusion compared with the intravenous route. Further studies and additional treatments are needed to widen the therapeutic window and decrease hemorrhagic side effects.

Cerebellar hemangioblastoma in pregnancy. A case report

BACKGROUND

The incidence of symptomatic hemangioblastoma of the posterior fossa during pregnancy is extremely low. Previous reports have noted that pregnancy seems to aggravate the clinical course of intracranial tumors, but little is known about the possible reasons. Various theories have been proposed to explain the rapid neurologic deterioration of hemangioblastoma patients during pregnancy; however, the pathophysiologic behavior and histogenesis of this vascular tumor are still not well understood.

CASE

A case of cerebellar hemangioblastoma was diagnosed during pregnancy. Urgent surgery was required due to rapid development of obstructive hydrocephalus and brainstem compression.

CONCLUSION

Obstetricians and neurosurgeons should be aware of the rare clinic entity of hemangioblastoma during pregnancy. Surgery might be indicated as soon as the tumor becomes symptomatic.

Osteogaleal flaps in pediatric cranioplasty

Reconstruction of cranial defects larger than 2 to 3 cm in diameter and frontal defects of any size is indicated for mechanical protection and cosmetic reasons. The authors used osteogaleal flaps for cranioplasty in 2 pediatric patients with the aim of decreasing infection risk and maximizing bone healing. In the first patient, bone was harvested from the diploë. Children's cranial bones are thin, and in the second patient the authors used full-thickness grafts of adjacent bone, splitting this into three pieces to cover the recipient and donor sites. The postoperative period was uneventful for both children. Scintigraphic studies performed the first week after surgery revealed uptake in the flaps. Computed tomography demonstrated rapid bone healing with good contouring. The scintigraphic findings and rapid bone healing suggest that the bone component of the osteogaleal flap nourishes the graft site with blood from the galea and the periosteum. These flaps are an ideal choice for reconstruction of cranial defects because of their membranous origin, ease of harvest, applicability to any part of the calvarium, and reliable vascularity.

Correlation of the relationships of brain-tumor interfaces, magnetic resonance imaging, and angiographic findings to predict cleavage of meningiomas

OBJECT

The authors examined the relationships of brain-tumor interfaces, specific magnetic resonance (MR) imaging features, and angiographic findings in meningiomas to predict tumor cleavage and difficulty of resection.

METHODS

Magnetic resonance imaging studies, angiographic data, operative reports, clinical data, and histopathological findings were examined retrospectively in this series, which included 126 patients with intracranial meningiomas who underwent operations in which microsurgical techniques were used. The authors have identified three kinds of brain-tumor interfaces characterized by various difficulties in microsurgical dissection: smooth type, intermediate type, and invasive type. The signal intensity on T1-weighted MR images was very similar regardless of the type of brain-tumor interface (p > 0.1). However, on T2-weighted images the different interfaces seemed to correlate very precisely with the signal intensity and the amount of peritumoral edema (p < 0.01), allowing the prediction of microsurgical effort required during surgery. On angiographic studies, the pial-cortical arterial supply was seen to participate almost equally with the meningeal-dural arterial supply in vascularizing the tumor in 57.9% of patients. Meningiomas demonstrating hypervascularization on angiography, particularly those fed by the pial-cortical arteries, exhibited significantly more severe edema compared with those supplied only from meningeal arteries (p < 0.01). Indeed, a positive correlation was found between the vascular supply from pial-cortical arteries and the type of cleavage (p < 0.05).

CONCLUSIONS

In this analysis the authors proved that there is a strong correlation between the amount of peritumoral edema, hyperintensity of the tumor on T2-weighted images, cortical penetration, vascular supply from pial-cortical arteries, and cleavage of the meningioma. Therefore, the consequent difficulty of microsurgical dissection can be predicted preoperatively by analyzing MR imaging and angiographic studies.