Recurrence and Mortality Rate in a 42 Patient Cohort of Giant Meningiomas

BACKGROUND

Giant meningiomas may show special features in terms of biological behavior and management. We aimed to research recurrence and mortality of giant meningiomas.

METHODS

Medical files of patients with meningioma with at least 1 dimension of ≥5 cm in any plane in radiological investigations between December 2012 and January 2022 were retrospectively reviewed. Tumor dimensions were measured on magnetic resonance images except 1. All patients except two underwent clinical follow-up at a mean of 27.19 ± 29.87 (range, 4-112) months.

RESULTS

There were 42 patients, 26 (61.9%) women and 16 (38.1%) men who ranged in age from 31 to 85 (mean, 60.31 ± 14.86) years. Headache (57.1%) was the most common symptom. The mean tumor size was 70.14 ± 19.03 (range, 50-152) mm. Tumors were most located at the frontal convexity (40.5%). Simpson grade I resection was achieved in 19% of the cases. The tumors were World Health Organization grade 1 in 74% and grade 2 in 26% of the cases. Major complications developed in 26.1% of the patients. Recurrence happened in 5 (11.9%) cases. The number of World Health Organization grade 2 tumors (P = 0.013; P < 0.05) and tumor size (P = 0.006; P < 0.01) were significantly higher in the recurrent cases. Mortality was % 11.9 and statistically significantly higher in the recurrence group (P = 0.025; P < 0.05).

CONCLUSIONS

Giant intracranial meningiomas are challenging because of surgical experience, tumor size, peritumoral edema, blood supply, anatomical changes, and limited visibility. They have a high risk of recurrence and mortality.

Surgical Management Thoracolumbar Fractures in Patients with Ankylosing Spondylitis: Technical Note with Case Series

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. Complications such as traumatic spinal fractures are mostly caused by hyperextension and are unstable. We report the cases of 5 patients with AS surgically treated for thoracolumbar fractures.

METHODS AND RESULTS

We shared our experience of posterior stabilization surgery performed for the treatment of thoracolumbar fractures after traumas such as fall-accident in patients with AS. Patients were all men, and their ages were between 52 and 77 years. The first 3 patients woke up with neurologic deficits and were managed surgically under general anesthesia. We managed the last 2 patients with unilateral short-level stabilization under local anesthesia followed by bilateral long-level stabilization under general anesthesia. No neurologic deterioration was found in the postoperative examination of these 2 patients. We assume that the reason for neurologic deterioration after general anesthesia is the relaxation of muscles. All 3 columns of the spine are affected in patients with AS and the stability is provided by the tone of the muscles around the spine.

CONCLUSIONS

To prevent postoperative neurologic complications after the surgical treatment of traumatic hyperextension thoracic and lumbar fractures in patients with AS, we recommend securing the fracture level with unilateral short-level stabilization under local anesthesia and then completing the operation with general anesthesia.

Risk Factors for Intracranial Aneurysm Rupture: A Clinical Case Series and Systematic Review of the Literature

AIM

To evaluate the patients who underwent surgery for an anterior communicating artery (AcomA) aneurysm at our institution. We analyzed our case series and systematically reviewed the literature to identify factors that could predict the rupture of an intracranial aneurysm in patients with AcomA aneurysms or any intracranial aneurysm.

MATERIAL AND METHODS

We conducted a cross-sectional analysis of prospectively collected data from patients who underwent surgery for AcomA aneurysms at a single institution between January 2014 and May 2023. Predictors for the rupture of intracranial aneurysm were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Pubmed and MEDLINE databases.

RESULTS

Younger age (odds ratio (OR): 0.957, 95% confidence interval (CI): 0.920-0.995, p = 0.028), presence of a daughter sac (OR: 3.209, 95% CI: 1.095-9.408, p = 0.034), and ever-smoking (OR: 0.357, 95% CI: 0.137-0.930, p = 0.035) were significant predictors of increased risk of rupture in patients with AcomA aneurysms. Several aneurysm- and patient-related risk factors for rupture of intracranial aneurysms were retrieved via the literature analysis.

CONCLUSION

Younger age, ever-smoking, and presence of a daughter sac increased the risk of AcomA aneurysm rupture. A systematic literature review revealed several more aneurysm- and patient-related risk factors for rupture of the intracranial aneurysms. Our results could aid neurosurgeons during their decision-making process when treating patients with unruptured intracranial aneurysms.

Cingulate sulcus morphology and paracingulate sulcus variations: Anatomical and radiological studies

The sulci and gyri found across the cerebrum differ in morphology between individuals. The cingulate sulcus is an important landmark for deciding the surgical approach for neighboring pathological lesions. Identifying the anatomical variations of anterior cingulate cortex morphology would help to determine the safe-entry route through neighboring lesions. In this study, magnetic resonance imaging data acquired from 149 healthy volunteers were investigated retrospectively for anatomical variations of the paracingulate sulcus. Also, human cadaveric brain hemispheres were investigated for cingulate and paracingulate sulcus anatomy. All participants had cingulate sulci in both hemispheres (n = 149, 100%). Three types of paracingulate sulcus patterns were identified: "prominent," "present," and "absent." Hemispheric comparisons indicated that the paracingulate sulcus is commonly "prominent" in the left hemisphere (n = 48, 32.21%) and more commonly "absent" in the right hemisphere (n = 73, 48.99%). Ten (6.71%) people had a prominent paracingulate sulcus in both the right and left hemispheres. Seven (4.70%) of them were male, and 3 (2.01%) of them were female. Paracingulate sulci were present in both hemispheres in 19 people (12.75%), of which 9 (6.04%) were male and 10 (6.71%) were female. There were 35 (23.49%) participants without paracingulate sulci in both hemispheres. Eleven (7.38%) were male and 24 (16.11%) were female. There were 73 (48.99%) participants without right paracingulate sulcus and 57 (38.26%) participants without left paracingulate sulcus (p = 0.019). In the examinations of the cadaver hemispheres, the paracingulate sulcus was present and prominent in 25%, and the intralimbic sulcus was present in 15%. It has been observed that the paracingulate sulcus is more prominent in the normal male brain compared to females. In females, there were more participants without paracingulate sulcus. This study shows that there are both hemispheric and sex differences in the anatomy of the paracingulate sulcus. Understanding the cingulate sulcus anatomy and considering the variations in the anterior cingulate cortex morphology during surgery will help surgeons to orient this elegant and complex area.

Glioblastoma Shortly after a Normal Conventional Brain Magnetic Resonance Imaging: A Report of Two Cases and Review of the Literature

Glioblastoma (GB) is the most common malignant tumor of the brain. Most of these tumors are primary or de novo GBs that manifest rapidly with initial presentations such as headache, new-onset epileptic seizure, focal neurological deficits, and altered mental status. The typical radiological features of GB include strong contrast enhancement, central necrosis, and edema with mass effect. Herein, we describe two cases of primary GB – two women aged 60 and 51 years who were diagnosed with GB 3.5 and 4 months, respectively, after their initial admission. These patients presented with right-sided headaches, and their neurological examination was within the normal limits. Their initial radiological investigations revealed no suspicious lesions, either on T1-weighted or T2-weighted magnetic resonance (MR) images. The 60-year-old patient was readmitted with persistent headache, and her T1-weighted MR images revealed a well-demarcated mass lesion in the right temporal lobe with strong contrast enhancement. Moreover, the T2-weighted MR images revealed closed sulci and swollen midline structures because of edema. The 51-year-old patient was readmitted with persistent headache, and her MR image revealed a mass lesion with heterogeneous contrast enhancement and necrosis on T1-weighted images and hyperintense areas with severe edema on T2-weighted images. The patients underwent craniotomy and gross total tumor resection. Notably, in both cases, the lesions were pathologically diagnosed as GB. Therefore, it should be borne in mind that only persistent headache could be a sentinel sign of GB before it becomes radiologically visible, thereby emphasizing the need for follow-up imaging studies at short intervals.

A Brief Look from the Neurosurgical Perspective into the Philosophy of Science

Philosophy meaning "love of wisdom" is a research product of people who think, produce ideas, and transfer these ideas to each other. The philosophy of science questions the concept of "scientific knowledge" and analyzes the procedures and observations for a logical explanation of facts from a scientific perspective that is important for natural sciences in general and neurosurgery in particular. Observation, experimentation/measuring, and scientific explanations are examples of the methods of the philosophy of science. Besides the theories, facts, and logical/strong evidences, there are numerous concepts of the philosophy of science in neurosurgery that are difficult to understand in practice. For example, do "numbness," "pain," and "visual analog score" mean the same to the patient and the doctor? Can mechanical low back pain and instability be a real subject of the philosophy of science in the same phenomenon; how can a concept of movement-"instability" explain the cause of a concept of sensation-"pain"? Can concepts from entirely different categories like "dynamic stabilization" occur in the same scientific explanation? There are also some problematic terms that remain unsolved such as "observable" and "unobservable," which gradually increase with technological advances in neuroscience. In conclusion, these types of subjects not only affect the basis of our "scientific knowledge" but also the relationships with our patients and colleagues; it is essential to "understand" and be "understandable." We should bring "scientific perspectives" to these issues by using critical, analytical, and integrative features of philosophy.

Cisterns as Vital Structures: Byzantine Cisterns and Subarachnoid Cisterns

Water is essential for life. It is needed not only to survive but also to sustain daily life activities. The maintenance of daily life activities related to hygiene as well as prevention of epidemic diseases and accidents involving fire was as important in the past as today. Powerful empires built many open-air and covered cisterns for water reservation and constructed aqueducts to bring water from hinterland to these cisterns. The first prototypes of cisterns were constructed in the Neolithic age. Byzantine cisterns such as the Basilica Cistern and Aqueduct of Valens are excellent examples that are remnants from the past to present. Similar to these social measures for water preservation, biological structures exhibit their own measures. In the human body, subarachnoid cisterns of central nervous system are the best-known cisterns, despite the presence of the cisterna chyli and Golgi body. The central nervous system produces and stores water in the form of cerebrospinal fluid in the subarachnoid cisterns for mechanical and immunological protection of the anatomical structures and for autoregulation of cerebral blood flow every day. Any condition that may adversely affect the cisterns, public or subarachnoid, may cause serious and irreversible damage to life. Hence, we should appreciate the importance of water for life; moreover, ?if there is water there is life? is not a great prophecy.

An Unusual Schwannoma in the Proximal Forearm: A Case Report

Schwannomas are common, well-encapsulated benign tumors of the peripheral nerves. They rarely emerge from the median nerve in the forearm. Here we report a case of an unusual schwannoma measuring 3 × 4 × 3 cm originating from the median nerve in the proximal forearm of a 49-year-old man. The mass was painless, but Tinel’s sign was positive. Ultrasonography showed a solid, hypoechoic mass with central cystic areas in the flexor muscle group in the left forearm. Magnetic resonance imaging with contrast enhancement in T1 sequences revealed that it originated from the median nerve. Surgical resection was performed by separating the nerve fibers from the tumor without any complications. Histological examination confirmed it as a schwannoma.

Median Nerve Injury from the Eye of an Artist: Gladiators

Artists use their work to help us understand the universe. With their creations, we can rest our souls, find some solutions to problems, and even explore new dimensions. A 19th-century artist, Gérôme, has depicted a gesture used to ask for mercy as a benediction sign in two of his works of art dealing with gladiatorial fighting. A warrior defeated in a gladiator combat is well known to ask for mercy with the extended index finger and fist. A benediction gesture by a gladiator after combat could be due to an acute nerve injury. At the sources that inspired the artist, the mercy gesture may have evolved into the benediction sign for an unknown reason. It is probable that a warrior cannot accurately form the mercy gesture following a peripheral nerve injury during combat. While his index finger was extended, the other fingers could not flex in the strict sense of making a fist due to traumatic median nerve injury.

Traumatic Pseudoaneurysms of the Head in War Time: Report of Two Unusual Cases

Either intracranial or extracranial pseudoaneurysms due to penetrating head injuries with gunshot are very rare entities. As the pseudoaneurysms of the superficial temporal artery are represented commonly with a pulsating mass lesion beneath scalp, the intracranial pseudoaneurysms are represented with symptoms including decreased conscious level, seizure, or focal neurological deficits. Here, two patients with combat related pseudoaneurysms are reported; one was in distal cortical branch of anterior cerebral artery and one was in superficial temporal artery. Both of the cases were victims of Libyan war. One was admitted with a swelling in his scalp and a pseudoaneurysms on parietal branch of superficial temporary artery diagnosed with computed tomography; and the other was incidentally diagnosed on distal cortical branch of anterior cerebral artery during operation for removal of an intracranial bullet. Both of the aneurysms treated with surgical excision without any complication.

Case Report of an Obstructive Hydrocephalus Caused by an Unruptured Mesencephalic Arteriovenous Malformation in a Boy and a Review of Literature

Objective

Arteriovenous malformation (AVM) is the most common form of intracranial vascular malformations in adults. Intracranial pediatric AVMs are rare. AVM located in the vicinity of the brain stem in children are even more rare.

Case report

This study reports a rare case of acute obstructive hydrocephalus following aqueductal stenosis caused by an unruptured grade IV perimesencephalic arteriovenous malformation. An 11-year-old boy admitted to the hospital with progressive headache, nausea and vomiting throughout a month. A Computerized Tomography (CT) showed an obstructive hydrocephaly. A Magnetic Resonance (MR) imaging revealed a mesencephalic AVM compressing the aqueduct. The patient deteriorated in hours and an emergency ventriculoperitoneal shunting was performed. He did well in the early postoperative period. AVM examined with Digital Subtraction Angiography (DSA) in detail for maintaining the definitive treatment by means of endovascular embolization, microsurgery and stereotactic radiosurgery; but the patient was lost to follow up.

Conclusion

A Pubmed search revealed 34 cases of hydrocephalus caused by an unruptured AVM in the literature, and only four cases were less than 18 years old with unruptured AVM locating in brain stem or posterior fossa. Although focal neurologic deficit, seizure and headache are the most common symptoms, acute neurologic deterioration due to hydrocephalus may be the presenting symptom in these cases. The decrease in intracranial pressure by changing the flow of cerebrospinal fluid (CSF) via an emergency ventriculoperitoneal (VP) shunting or Endoscopic Third Ventriculostomy (ETV) can be a lifesaving procedure that gives a chance for further treatment modalities.

Evaluation of 126 Consecutive Stereotactic Procedures: Brain Biopsy, Diagnostic Yield, Accuracy, Non-Diagnostic Results, Complications and Follow-up

AIM

A retrospective analysis of 126 consecutive computed tomography (CT)-guided, frame-based stereotactic procedures in 121 patients is presented to evaluate the diagnostic yield, accuracy, complications, management of non-diagnostic cases and followup.

MATERIAL AND METHODS

The medical records of the identified patients were investigated retrospectively. Age, sex, surgical procedures, histopathological diagnosis, diagnostic yield, accuracy, complications, management of non-diagnostic cases and follow-up were analyzed in 121 consecutive patients. Stereotactic procedures were performed by the author by using Leksell's stereotactic system, and stereotactic biopsies were conducted under local anesthesia except for those patients who were not able to tolerate this treatment. These patients had control CT scans two hours after the operation.

RESULTS

Patient age ranged from 2 to 82 years (mean 48 years). Stereotactic biopsy was performed in 112 patients. Cyst and abscess aspiration, intracystic catheter replacement and tumor resection with stereotactic craniotomy were among the other procedures. The diagnostic yield was 93%, and the histological accuracy was 63% with no mortality. Craniotomy and hematoma evacuation were required in two cases. The patients were followed up from one month to 17 years.

CONCLUSION

Frame-based stereotactic biopsy is a safe and efficacious method with acceptable complications. Experience is important, but not sufficient for preventing complications and performing procedures accurately. Necrosis and gliosis are the most common non-diagnostic findings. Empirical treatment with presumptive diagnoses based on clinical and radiological findings and close clinical follow-up may not affect patients adversely. The follow-up of patients through examination and imaging is important to allow the revision of treatment when necessary.

The Effect of Ozone Therapy on Experimental Vasospasm in the Rat Femoral Artery

AIM

Oxidation products following subarachnoid hemorrhage (SAH) are among the causative substances of cerebral vasospasm and poor outcome. Ozone (O3) is a gas that contains three atoms of oxygen with a cyclic structure. It has been suggested that application of low-dose ozone has an antioxidant effect and provides resistance to oxidative stress. We investigated the effect of oxygen-ozone therapy on rat femoral artery vasospasm.

MATERIAL AND METHODS

Twenty-four male Sprague-Dawley rats were randomly separated into vasospasm, vasospasm + ozone and control groups. The femoral artery vasospasm model was used. Rats in the vasospasm + ozone group were given 4 mL of ozone (20 μ/mL) daily for 7 days. Femoral arteries were examined by light microscopy for histological changes and morphometric analysis. Kruskal Wallis test and Mann Whitney U tests were used for the statistical analysis. The values of p < 0.01 and p < 0.05 were recognized as statistically significant.

RESULTS

Ozone treatment reduced the morphometric changes as irregularity of the elastic lamina, disruption of the endothelial cells, vacuolization and hemorrhages that caused by vasospasm. The measurements of the wall thickness (p=0.003; p < 0.01) and lumen diameter (p=0.001; p < 0.01) showed statistically significant difference (p < 0.01) between the vasospasm and vasospasm+ozone groups.

CONCLUSION

Ozone therapy may be useful in the treatment of post-hemorrhagic vasospasm.

Vascular Variations Associated with Intracranial Aneurysms

AIM

To investigate the vascular variations in patients with intracranial aneurysm in circle of Willis.

MATERIAL AND METHODS

We used the data on 128 consecutive intracranial aneurysm cases. Cerebral angiography images were analyzed retrospectively. Arteries were grouped as anterior cerebral arterial system (ACS), posterior cerebral arterial system (PCS) and middle cerebral arterial system (MCS) for grouping vascular variations. Lateralization, being single/multiple, gender; and also any connection with accompanying aneurysms" number, localization, dimension, whether bleeding/incidental aneurysm has been inspected.

RESULTS

Variations were demonstrated in 57.8% of the cases. The most common variation was A1 variation (34.4%). The rate of variations was 36.7%, 24.2% and 10.2% respectively in ACS, PCS and MCS. MCS variations were significantly higher in males. Anterior communicating artery (ACoA) aneurysm observance rates were significantly higher and posterior communicating artery (PCoA) aneurysm and middle cerebral artery (MCA) aneurysm observance rates were significantly lower when compared to "no ACS variation detected" cases. In "PCS variation detected" cases, PCoA aneurysm observance rates and coexistence of multiple variations were significantly higher.

CONCLUSION

The rate of vascular variations in patients with aneurysms was 57.8%. Arterial hypoplasia and aplasia were the most common variations. ACS was the most common region that variations were located in; they were mostly detected on the right side. Coexistence of ACoA aneurysm was higher than PCoA and MCA aneurysms. In the PCS variations group, PCoA aneurysms were the most common aneurysms that accompanying the variation and multiple variations were more common than in the other two groups. The variations in MCS were most common in males.

Functional and structural changes of the urinary bladder following spinal cord injury; treatment with alpha lipoic acid

BACKGROUND & AIM

Alpha lipoic acid (LA) was shown to exert neuroprotection in trauma-induced spinal cord injury (SCI), which is frequently associated with urinary bladder complaints in patients with SCI. Accordingly, the protective effects of LA on biochemical and histological changes in bladder as well as functional studies were assessed.

METHODS

Wistar albino rats were divided as control, SCI, and LA (50 mg/kg/day, ip) treated SCI groups (SCI+LA). The standard weight-drop (100 g/cm force at T10) method was used to induce a moderately severe SCI. One week after the injury, neurological examination was performed and the rats were decapitated. Bladder samples were taken for histological examination, functional (isolated tissue bath) studies, and for the measurement of biochemical parameters (malondialdehyde, MDA; gluthathione, GSH; nerve growth factor, NGF; caspase-3, luminol and lucigenin chemiluminescences).

RESULTS

SCI caused a significant (P < 0.001) increase in the detrusor muscle thickness. It increased the contractility responses to carbachol and relaxation responses to papaverine (P < 0.05-0.001). There were also significant alterations in MDA, caspase-3, luminol, and lucigenin chemiluminescences with concomitant decreases in NGF and GSH (P < 0.05). LA treatment reversed histological and functional (contraction and relaxation responses) changes induced by SCI (P < 0.05-0.001), but no significant recovery was observed in the impaired neurological functions.

CONCLUSION

These results indicate that LA have a beneficial effect in improving the bladder tonus via its antioxidant and anti-inflammatory actions following SCI.

Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases

BACKGROUND

Uncertainty still exists regarding the treatment of the patients presenting with gunshot wounds to the spine. Neurological insults, cerebrospinal fluid fistula, infection, lead or copper toxicity, migration of bullets, and spinal instability are included among the common challenging issues.

CASE DESCRIPTION

An 18-year-old woman was admitted with low back pain following a gunshot injury five days ago. She was neurologically intact. Radiological examinations showed that a bullet was settled in L4-5 disc space. The bullet was removed with a unilateral L4-5 partial hemilaminectomy and discectomy from the left side. The second case was of a 29-year-old man admitted with radiating leg pain on the right side following a gunshot injury from his left side of lower back four months ago. He had only positive straight leg raising test. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in spinal canal that had caused a burst fracture of the L5 vertebra. Following L5 laminectomy and bilateral L5-S1 facetectomy, the bullet was removed from the spinal canal and L5-S1 transpedicular posterior stabilization was performed. The postoperative period of both patients was unremarkable.

CONCLUSION

Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. Removal of bullets provided not only pain relief in both the cases but also prevented future complications such as migration of the bullets, plumbism, and neuropathic pain and instability.

Lumbar disk herniation presented with cauda equina syndrome in a pregnant woman

Despite low back pain being common in pregnancy, cauda equina syndrome is rare. Misdiagnosis and delay in treatment may cause neurological sequelae including urinary and fecal incontinence, sexual dysfunction in patients. A case of cauda equina syndrome in a pregnant woman at 25-week gestation is presented here. The patient underwent an emergency, standard lumbar microdiscectomy under general anesthesia on prone position. Neither the patient nor the baby had any complication related to surgery.

The safety and diagnostic value of frame-based and CT-guided stereotactic brain biopsy technique

AIM

Histopathological diagnosis is always necessary to make an effective treatment plan for intracranial mass lesions. This study aimed to evaluate the diagnostic efficacy, and associated mortality and morbidity of CT-guided stereotactic biopsy procedures in a large number of patients with intracranial lesions.

MATERIAL AND METHODS

A total of 290 cases undergoing CT-guided stereotactic biopsy for intracranial lesions were included in this retrospective study. Clinical, radiological and histological data in patient records were examined.

RESULTS

The mean age of the patients was 46.6 years (range: 2-82 y). Pediatric patients comprised 6.3% (n=13) of the total population. Examination of paraffin embedded histological preparations revealed a tumoral mass in 240 (82.8%), a non-tumoral mass in 37 (12.8%), and non-definable lesions in 13 (4.5%). Therefore, the diagnostic value in this series was 95.5%. Postoperative mortality rate was 0.8% (n=2). When histopathological diagnoses made after biopsy and surgical resection were compared in 42 patients with available data, a complete or partial agreement was present in 90.5%.

CONCLUSION

Our findings support that frame based-stereotactic biopsy is a safe and valuable technique that allows the neurosurgeon to obtain tissue samples for histopathological diagnosis of intracranial mass lesions in almost any region.

Pseudoaneurysm of the superficial temporal artery following revision of a middle cerebral artery aneurysm clipping: case report and review of the literature

Pseudoaneurysms of the superficial temporal artery are mostly traumatic in origin. Here, a case of a superficial temporal artery aneurysm that emerged following a recraniotomy is presented. A 59-year-old woman was admitted with subarachnoid hemorrhage. She underwent a pterional craniotomy and clipping of a saccular aneurysm of middle cerebral artery bifurcation. A control digital subtraction angiography on the 3rd postoperative day revealed partial filling of the aneurysm and a revision was performed. The second control digital subtraction angiography on the 4th postoperative day of the revision showed a pseudoaneurysm of the left superficial temporal artery. The pseudoaneurysm was excised successfully under local anesthesia. In conclusion, pseudoaneurysm of the superficial temporal artery should be considered among the early postoperative complications of the surgical procedures at the superficial temporal artery territory. Although some conservative approaches are used, excision of the aneurysm is recommended for treatment.

Meloxicam exerts neuroprotection on spinal cord trauma in rats

Traumatic injury to the central nervous system results in the delayed dysfunction and neuronal death. Impaired mitochondrial function, generation of reactive oxygen species (ROS), and lipid peroxidation occur soon after traumatic spinal cord injury (SCI), while the activation of compensatory molecules that neutralize ROS occurs at later time points. The aim of the current study was to investigate the putative neuroprotective effect of the COX2 inhibitor meloxicam in a rat model of SCI. In order to induce SCI, a standard weight-drop method that induced a moderately severe injury (100 g/cm force) at T10, was used. Injured animals were given either 2 mg/kg meloxicam or saline 30 min postinjury by intraperitoneal injection. At seven days postinjury, neurological examination was performed and rats were decapitated. Spinal cord samples were taken for histological examination or determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity and DNA fragmentation. Formation of ROS in spinal cord tissue samples was monitored by using a chemiluminescence (CL) technique. SCI caused a significant decrease in spinal cord GSH content, which was accompanied with significant increases in CL, MDA levels, MPO activity, and DNA damage. On the other hand, meloxicam treatment reversed all these biochemical parameters as well as SCI-induced histopathological alterations. Furthermore, impairment of the neurological functions due to SCI was improved by meloxicam treatment. The present study suggests that meloxicam, reduces SCI-induced oxidative stress and exerts neuroprotection by inhibiting lipid peroxidation, GSH depletion, and DNA fragmentation.

Diagnostic and therapeutic role of CT-guided stereotactic surgery in the management of intracranial tuberculomas

AIM

CT-guided stereotactic methods have long been used for the diagnosis and treatment of intracranial masses. Intracranial tuberculoma is a rare form of extrapulmonary tuberculosis. Histological confirmation is the gold standard for a correct diagnosis. However, histopathological diagnosis and excision of these lesions have advantages over open surgical methods. This study presents our experience on the use of stereotactic biopsy and excision in the management of intracranial tuberculomas.

MATERIAL AND METHODS

Thirteen patients with intracranial masses underwent stereotactic procedures for tissue samples to establish histopathological diagnosis. In 6 suitable patients, stereotactic microsurgical excision was performed for both diagnostic and therapeutic purposes, whereas only stereotactic biopsy was conducted in the remaining subjects.

RESULTS

The tuberculoma diagnosis was established in 12 out of 13 cases (92%). Seizure control was achieved in all patients admitted with a history of seizures. There was no procedure-related mortality, none of the patients suffered permanent disability and most procedures were uneventful. Total resection without any residual mass was done. All patients responded to antituberculous treatment with complete lesion disappearance.

CONCLUSION

These findings suggest that CT-guided stereotactic surgery of intracranial tuberculomas has advantages over other methods, with a potential to become the first-line modality, particularly as a diagnostic tool, in the management of these lesions.

Neuroprotective effects of alpha-lipoic acid in experimental spinal cord injury in rats

BACKGROUND

Oxidative stress is a mediator of secondary injury to the spinal cord following trauma.

OBJECTIVE

To investigate the putative neuroprotective effect of alpha-lipoic acid (LA), a powerful antioxidant, in a rat model of spinal cord injury (SCI).

METHODS

Wistar albino rats were divided as control, vehicle-treated SCI, and LA-treated SCI groups. To induce SCI, a standard weight-drop method that induced a moderately severe injury (100 g/cm force) at T10 was used. Injured animals were given either 50 mg/kg LA or saline at 30 minutes postinjury by intraperitoneal injection. At 7 days postinjury, neurologic examination was performed, and rats were decapitated. Spinal cord samples were taken for histologic examination or determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity, and DNA fragmentation. Formation of reactive oxygen species in spinal cord tissue samples was monitored by using a chemiluminescence (CL) technique.

RESULTS

SCI caused a significant decrease in spinal cord GSH content, which was accompanied with significant increases in luminol CL and MDA levels, MPO activity, and DNA damage. Furthermore, LA treatment reversed all these biochemical parameters as well as SCI-induced histopathologic alterations. Conversely, impairment of the neurologic function caused by SCI remained unchanged.

CONCLUSION

The present study suggests that LA reduces SCI-induced oxidative stress and exerts neuroprotection by inhibiting lipid peroxidation, glutathione depletion, and DNA fragmentation.

Clinical, pathological and radiological features of paraspinal textiloma: report of two cases and review of the literature

Textiloma is a term used for retained cottonoid or surgical sponge in the operation field. Although they occur mostly after thoracic or abdominal operation, they can also be encountered after surgery of extremities or the spine. There are few reports of spinal cases in which MR and CT imaging findings of textilomas have been described. In this report, two additional cases with MR, CT and pathological features of paraspinal textilomas are described. CT image demonstrated a paraspinal mass simulating a malignant tumour. While T1-weighted MR images showed the masses with low signal intensity, T2-weighted MR images showed heterogeneous masses with low and high signal intensities.

Tentorial solitary fibrous tumour: case report and review of the literature

Solitary fibrous tumours (SFT) were first described by Klemperer and Rabin in 1931. They are quite rare in the central nervous system and some histopathological or radiological similarities to meningiomas and haemangiopericytomas can lead to misdiagnoses as these tumours enhance homogeneously in postcontrast images, and even dural tail sign can be demonstrated. To date, only 10 tentorial SFT cases have been reported. In this study, a case of tentorial SFT in a 38-year-old female patient is presented. The patient had a mass lesion located in the left transverse-sigmoid sinus junction with strong contrast enhancement. The surgical treatment enabled gross total removal of a dural-based tumour resembling a meningioma; pathological assessment revealed a solitary fibrous tumour arising from the tentorium. During 47 months of follow-up the patient remained asymptomatic and had no recurrence.

Intra-operative real time intracranial subarachnoid haemorrhage during glial tumour resection: A case report

Glial tumours associated with subarachnoid haemorrhage are very rare. A 64-year-old woman admitted with a history of 3 weeks seizures and a left sided hemiparesis and dysphasia. The magnetic resonance disclosed heterogeneously enhancing a right temporal mass. During surgery, suddenly an abrupt and extensive swelling had occurred both in tumour and the brain tissue. The surgery was completed with a gross total tumour resection together with a partial temporal lobectomy. Postoperative computerized tomography demonstrated a massive subarachnoid hemorrhage (SAH). A cerebral Magnetic Resonance (MR) angiography showed neither an aneurysm nor arteriovenous malformation. Coincidence of an intracerebral tumour and subarachnoid haemorrhage would be devastating.

Spinal schwannomatosis: case report of a rare condition

Schwannomatosis is a rare tumour syndrome characterized by more than one schwannoma without any sign of neurofibromatosis (NF). A 22-year-old male patient was admitted with weakness in his extremities. Neurological examination revealed a tetraparesis syndrome below the C6 level. Magnetic resonance (MR) imaging showed a demarcated mass with strong enhancement at the C4-7 levels. The patient improved rapidly after removal of the tumour. The histological diagnosis was schwannoma. Two years later, the same patient was admitted with the complaint of severe low back and leg pains. The neurological examination was normal except bilateral positive straight leg raising test and dysesthesia at the L3,4 and 5 dermatomes. MR showed a wellcircumscribed lesion at L4-5. Laminectomy and tumour excision relieved his complaints. The histological diagnosis was schwannoma. A detailed clinical examination and MR scanning of the central nervous syndrome excluded NF2. In conclusion, although schwannomatosis is a benign condition, symptomatic tumours should be resected surgically.

Chondromyxoid fibroma of frontal bone: a case report and review of the literature

Chondromyxoid fibroma is an unusual benign tumor of cartilaginous tissues that may be confused with other some malign tumors. It is rarely seen in the skull. A 45-year-old female was admitted with painless bony swelling in the forehead. Computerized tomography demonstrated a well-defined expansive lesion with a sclerotic margin measuring approximately 3 cm in diameter in the right frontal bone. On MRI, T1-weighted images revealed a well circumscribed, lobulated and strongly enhancing lesion. On the T2-weighted images, the lesion showed high heterogeneous signal intensity. The patient underwent tumor excision with craniectomy, then acrylic cranioplasty. The histopathological diagnosis was chondromyxoid fibroma. There was no recurrence in a period of 22-months. In conclusion, chondromyxoid fibroma is a benign primary bone tumor that is located extremely rarely in the frontal bone. Accurate initial diagnosis of such tumors are important for appropriate treatment. En block surgical resection of the tumor is the cornerstone of treatment.

Case report on a patient with neurofibromatosis type 1 and a frontal cystic glioblastoma

Neurofibromatosis type 1 (NF1) is one of the most common dominantly inherited disorders. Astrocytomas, especially low-grade optic nerve tumours, are frequently harboured in these patients. In this paper, a case of a lobar cystic glioblastoma and NF1 in a 28-year-old woman is presented. This patient underwent a resection of the glioblastoma, followed a multimodal therapy including radiotherapy and chemotherapy, and survived 41 months. Neurofibromatosis is a multifaceted disease in which primary malignant CNS tumours, such as glioblastoma, can be identified. Glioblastomas in these patients should be managed like the usual ones. They may benefit from treatment with temozolomide, as can GBM patients without NF, thus potentially increasing the patient's overall survival.

Management of bacterial brain abscesses

✓ Brain abscesses are well-known lesions that have been reported from the beginning of the Hippocratic era. They continue, however, to be characterized by problematic and fatal features, even though there have been enormous developments in treatment and diagnostic technologies—especially in the areas of computed tomography (CT), surgery, anesthesia, bacterial isolation techniques, and new antibiotics. The predisposing factors may change according to patient age, geographic location, and socioeconomic conditions of the community, but patients frequently have a contiguous infection such as otitis or mastoiditis. The clinical signs and symptoms of brain abscesses are nonspecific. Patients typically present with signs and symptoms due to mass effects, accompanied by high fever and seizure. The main treatment is surgical, although medical therapy can be used for selected cases. The treatment of choice is aspiration, which may be performed with the aid of an endoscope or free hand, with or without stereotactic or intraoperative ultrasound guidance. Excision is valuable in some cases. The success of the treatment, whether surgical or medical, mostly depends on the success of isolation of the causative organism, which provides essential data for accurate medical treatment. Third-generation cephalosporins and metronidazole are the most commonly used antimicrobial agents in the treatment of brain abscesses. Use of corticosteroids may be acceptable when lesions are accompanied by edema. Prophylactic antiepileptic therapy is strongly recommended. The patient's Glasgow Coma Scale score at presentation is one of the most important factors predicting outcome.

The redundant nerve root syndrome of the Cauda equina

The redundant nerve root syndrome is defined as the association of high-grade extradural lumbar spinal stenosis with large, elongated and tortuous nerve roots. Acquired elongation of nerve roots due to the mechanical trapping at the level of lumbar spinal stenosis is assumed to be the possible mechanism. It is believed that the cause is a squeezing force due to the chronic compression. The most common clinical symptoms are low back pain and leg pain. Although lumbar spinal canal stenosis is common, the entity has rarely been discussed in the literature. Here we present the MR imaging and intraoperative appearance of the condition with a brief discussion in a 71-year-old woman.

Anti-inflammatory effect of meloxicam on experimental vasospasm in the rat femoral artery

Cerebral vasospasm influences morbidity and mortality following subarachnoid haemorrhage (SAH). Inflammation is believed to play a role in post-haemorrhagic vasospasm. Meloxicam is a non-steroidal anti-inflammatory drug. We investigated the effect of meloxicam on a rat femoral artery vasospasm model using the radial wall thickness and cross-sectional lumen area as parameters under light, scanning and transmission electron microscopy examination. Rats were randomly separated into SAH, SAH+ meloxicam and control groups. Rats in the SAH+ meloxicam group were given meloxicam at 2 mg/kg daily for 7 days. Femoral arteries were examined by light microscopy and scanning and transmission electron microscopy, and for morphometric analysis. A statistically significant difference (p<0.001) was detected between the SAH and SAH+ meloxicam groups. Meloxicam treatment reduced ultrastructural and morphometric vasospastic changes. These findings support the hypothesis that inflammation may play a role in the pathophysiologyical pathways of post-haemorrhagic cerebral vasospasm.

Pregnancy-related spinal epidural capillary-cavernous haemangioma: Magnetic resonance imaging and differential diagnosis

Epidural haemangiomas are very rare tumours of the spine. Only a few case reports have been published and most of them were cavernous or capillary. To the best of our knowledge, we report the first case of a histologically confirmed epidural capillary-cavernous haemangioma of the thoracic spine presented in the MRI.

Cystic schwannoma of the falx cerebri

Intracranial parenchymal schwannomas unrelated to a major cranial nerve are uncommon and dural schwannomas are rare. We report a 23-year-old woman without neurofibromatosis admitted with a 3-month history of seizures and left hemiparesis. Radiological investigation revealed a huge cystic tumour in the right cerebral hemisphere, attached to the falx cerebri. The solid part of the tumour showed contrast enhancement. The patient underwent excision of the tumour via a right-sided parietal craniotomy. The histological diagnosis was schwannoma. Recognition of these potentially curable tumours is important and they should be excised if possible.

Bacterial brain abscesses: prognostic value of an imaging severity index

AIM

To assess the correlation between imaging findings [computed tomography (CT) or magnetic resonance imaging (MRI)] and neurological status before and after the treatment of bacterial brain abscesses.

MATERIALS AND METHODS

CT and MRI images of 96 patients with brain abscesses were retrospectively evaluated in terms of the number, location and size of lesions, and the presence and extent of perilesional oedema and midline shift. An imaging severity index (ISI) based on these different radiological parameters was calculated. Initial Glasgow Coma Scale (GCS) scores and ISI were assessed and the prognostic value of these two indices was calculated. The Pearson correlation test, Mann-Whitney test, Chi-square test, receiver-operating characteristic (ROC) analysis, together with comparison of ROC analyses and Fisher's exact test were used.

RESULTS

There was a negative correlation between ISI and the initial GCS values: ISI increased as the GCS score decreased, indicating an inverse relationship (r=-0.51, p<0.0001). There was a significant difference between the ISI and GCS scores of patients with an adverse event compared with patients with good recovery. Outcome was significantly worse in patients with initial ISI over the calculated cut-off values of 8 points or GCS scores under the cut-off value of 13 points.

CONCLUSION

ISI is a useful prognostic indicator for bacterial brain abscess patients and correlates strongly with the patient outcome for all parameters studied. ISI score had a better prognostic value than GCS.

Imaging features of unusual intracranial cystic meningiomas

OBJECTIVE

To describe the imaging features of unusual intracranial cystic meningiomas in infants and adults.

METHODS

We retrospectively reviewed the magnetic resonance and computed tomography findings for 2 female patients and 3 male patients, ranging in age from 1 to 73 years (median 41 years), with histopathologically proven cystic meningioma.

RESULT

Although cystic meningiomas usually appear as solid and cystic masses, they may present as a mainly multicystic lesion. The wall of a cystic part of the meningioma may include both enhancing and unenhancing areas at imaging. The cystic portion of a meningioma is hypointense on diffusion-weighted images and markedly hyperintense on corresponding apparent diffusion coefficient maps.

CONCLUSION

Cystic meningiomas may vary in appearance at imaging. They can be very challenging when present in infants. Knowledge of imaging findings and awareness of variability in the differential diagnosis can help to avoid preoperative diagnostic pitfalls.

Bacterial brain abscesses: An evaluation of 96 cases

OBJECTIVES

Although the decline of the morbidity and mortality in recent years, brain abscess is still one of the most important problems in Neurosurgery.

METHODS

Ninety-six patients with brain abscess are analysed retrospectively, that treated between 1988 and 2001, according to age, the clinical symptoms, etiologic factors, infecting organisms, prognostic factors, localization, diagnostic and treatment methods and outcome.

RESULTS

Seventy-two patients treated with aspiration (streotactic aspiration in 12 cases), 14 patients with excision. Ten patients treated medically alone. Seven patients in the aspiration group and one patient in the excision group were died. Cure without any morbidity obtained in 55 patients. A significant correlation determined with initial neurologic grade, meningismus, high fever (>38.50), leucocytosis (>20.000/mm3) and mortality. There were no significant correlation the age groups and outcome, treatment groups and location of abscess, period of treatment, number of abscess, outcome according to GOS and factor, treatment period and received antibiotic.

CONCLUSIONS

In appropriate cases, medical treatment can be successful alone but surgery, aspiration, is gold standard for brain abscesses. In that way, definite diagnosis is obtained and pathogen is identified and cure is obtained in a short time.

Pineal germinoma associated with multiple congenital melanocytic nevi: A unique presentation

Intracranial germ cell tumors are rarely seen and typically localize in the pineal or suprasellar region. The largest category of germ cell tumors is the germinoma. There have been reported associations of malignant tumors and chromosomal abnormalities in germ cell tumors. In this study, we present a 22-year-old man with multiple congenital melanocytic nevi in association with pineal tumor. Congenital melanocytic lesions greater than 2 cm were counted to be 54 in number, and those smaller than 1 cm in diameter were found to be 25 in number. The pathological diagnosis of the pineal tumors was germinoma, and the lesions located in the occipital region and trunk were compound congenital nevi. To our knowledge, a relationship between multiple congenital melanocytic nevi and germ cell tumors has not been reported before. The connection between them remains to be clarified.

Accuracy and diagnostic yield of stereotactic biopsy in the diagnosis of brain masses: Comparison of results of biopsy and resected surgical specimens

The aim of this retrospective study was to investigate the diagnostic yield and accuracy of stereotactic biopsy in patients harboring brain mass. Stereotactic biopsy was performed in 130 patients between 1995 and 2000 in an educational and research hospital in Turkey. The results of histological analysis were compared to the resected specimens in 23 patients. The lesions were lobar in 62% of cases and deep-seated in 38% of cases. During the biopsy procedures, the pathologist was in the operating theatre and a very small fragment was used for cytological examination. No frozen section was used in any of the cases. Samples were diagnostic in 122 cases. The overall diagnostic yield of the procedure was 94%. A definitive histological diagnosis was not made in eight patients. The histological diagnoses of the two procedures were identical (complete agreement) in 16 cases. In three cases, the histological diagnoses between the two procedures were slightly different without impact on patient care (minor disagreement). The diagnosis of the stereotactic biopsy was completely changed after craniotomy in four cases (major disagreement). The accuracy of the histological diagnosis was 83%. There was only one major complication, which involved intracerebral hemorrhage. Despite the limited number of patients who underwent resection, our data suggest that stereotactic biopsy of brain masses is a safe and accurate technique that can obtain adequate tissue for histological diagnosis, thus providing the best avaible treatment for patients. Cytological evaluation of the streotactic biopsy also is a highly effective tool for obtaining sufficient material during the procedure in many cases.