Apoptosis and necrosis in the circumventricular organs after experimental subarachnoid hemorrhage as detected with annexin V and caspase 3 immunostaining.

OBJECTIVES: The circumventricular organs (CVOs) are essential for most autonomic and endocrine functions. Trauma and bleeding can affect their function. The aim of this study was to investigate apoptosis and necrosis in CVOs in the early period after experimental subarachnoid hemorrhage (SAH) in rats, using annexin V affinity and caspase 3 immunostaining. METHODS: Three experimental groups were used: Days 1 and 2 after SAH, and a control group, seven Wistar albino rats each. Subarachnoid hemorrhage was accomplished by transclival basilar artery puncture. Rats were perfused with 0.9% NaCl and 0·1M phosphate buffer pH 7.4 until heart stoppage. Apoptosis and necrosis in CVOs were measured by flow cytometry with annexin V staining, and by caspase 3 immunostaining. RESULTS: Apoptosis in the organum vasculosum lamina terminalis (OVLT), median eminence (ME), and area postrema (AP) was significantly higher in the Day 1 group than in the control group. Apoptosis in the subfornicial organ (SFO), OVLT, ME, and AP was significantly higher in the Day 2 group than in the control group. There were significant differences between the Day 1 and Day 2 groups, except for AP. Necrosis in SFO and OVLT was significantly higher in the Day 2 group than in the Day 1 or control groups, whereas necrosis in the ME and AP did not differ between the three groups. Caspase 3-positive cell density was more intense in the Day 2 group than in the Day 1 and control groups. DISCUSSION: Prevention of apoptosis may potentially improve impaired functions of CVOs after SAH.

Successful obturator nerve repairing: Intraoperative sural nerve graft harvesting in endometrium cancer patient.

INTRODUCTION: Intraoperative injury of obturator nerve is a rare complication of gynecologic surgeries, it has been reported especially in patients with endometriosis and genitourinary malignancies. Gynecologic patients undergoing open lymphadenectomy are at increased risk of obturator nerve injury. PRESENTATION OF CASE: A 60-year-old woman with FIGO stage II Grade II endometrial adenocarcinoma underwent bilateral pelvic paraaortic lymphadenectomy. During right obturator lymph node dissection, the right obturator nerve was inadvertently transected with Harmonic scalpel sealing system. The graft was used to anastomose epyneurium of distal segment of obturator nerve to its counterpart in the proximal segment with 10-0 prolen suture. DISCUSSION: In case of iatrogenic nerve transection, microsurgical end to end tension-free coaptation is advocated. In case of the obturator nerve is fixed and because of the thermal injury end to end alignment can not be achieved, nerve grafting is necessary. CONCLUSION: According to our knowledge, successful immediate grafting of iatrogenically damaged obturator nerve during pelvic lymphadenectomy in our patient is the third report of such a case, but also it has a unique feature of being the first obturator nerve repairing case after dissected with tissue sealing system which causes large sealed area that does not make it possible to make end-to-end anastomosis without nerve harvesting.

Ischemia modified albumin increase indicating cardiac damage after experimental subarachnoid hemorrhage.

BACKGROUND: Cardiac complications are often developed after subarachnoid hemorrhage (SAH) and may cause sudden death of the patient. There are reports in the literature addressing ischemia modified albumin (IMA) as an early and useful marker in the diagnosis of ischemic heart events. The aim of this study is to evaluate serum IMA by using the albumin cobalt binding (ACB) test in the first, second, and seventh days of experimental SAH in rats.Twenty-eight Wistar albino rats were divided into four groups each consisting of seven animals. These were classified as control group, 1st, 2nd and 7th day SAH groups. SAH was done by transclival basilar artery puncture. Blood samples were collected under anesthesia from the left ventricles of the heart using the cardiac puncture method for IMA measurement. Histopathological examinations were performed on the heart and lung tissues. Albumin with by colorimetric, creatine kinase (CK), aspartate aminotransferase (AST), lactate dehydrogenase (LDH) were determined on an automatic analyser using the enzymatic method. IMA using by ACB test was detected with spectrophotometer. RESULTS: Serum IMA (p = 0.044) in seventh day of SAH were higher compared to the control group. Total injury scores of heart and lung tissue, also myocytolysis at day 7 were significantly higher than control group (p = 0.001, p = 0.001, p = 0.001), day 1 (p = 0.001, p = 0.001, p = 0.001) and day 2 (p = 0.001, p = 0.007, p = 0.001). A positive correlation between IMA - myocytolysis (r = 0.48, p = 0.008), and between IMA - heart tissue total injury score (r = 0.41, p = 0.029) was found. CONCLUSION: The results revealed that increased serum IMA may be related to myocardial stress after SAH.

Cystain C and neuropeptid Y levels in brain tissues after experimental subarachnoid hemorrhage.

The aim of this study was to investigate the changes in the levels of cystatin C, which protects neurodegeneration in the central nervous system with the inhibition of cysteine protease and by inducing autophagy in the pathogenesis of cerebral vasospasm and levels of vasoconstrictive neuropeptid Y (NPY) in the brain tissue homogenates of rat model of subarachnoid hemorrhage (SAH). Three experimental groups were used: Day 2 and Day 7 groups after SAH, and also a control group. There were seven Wistar albino rats in each group. SAH was accomplished by transclival basilar artery puncture. Rat cystatin C, rat NPY were determined with ELISA in brain tissue homogenates. Day 2 group showed significantly enhanced cystatin C values in comparision with the control group (P=0.048). NPY levels between the Day 2 and Day 7 groups and the control groups were not significantly different (P=0.315). In histopathological examination, there was less neuronal loss in the Day 2 group than in the Day 7 group. Regarding our results, it would be more valuable to measure NPY levels in specific brain areas. The increased cystatin C levels on the second day after SAH is probably a pathophysiologic mechanism to organize protease activity.

Decompressive craniectomy for acute subdural haematoma: an overview of current prognostic factors and a discussion about some novel prognostic parametres.

OBJECTIVE: To identify specific factors that can be used to predict functional outcome and to assess the value of decompressive craniectomy in patients with acute subdural haematoma. METHODS: The retrospective study was done at the Zonguldak Karaelwas University Practice and Research Hospital, Turkey, and included 34 trauma patients who had undergone decompressive craniectomy for acute subdural haematoma from 2001 to 2009. At the 30th day of the operation, the patients were grouped as survivors and non-survivors. Besides, based on their Glasgow Outcome Scale, which was calculated 6 months postoperatively, the patients were divided into two functional groups: favourable outcomes (4-5 on the scale), and unfavourable outcomes (1-3 on the scale). The characteristics of the groups were compared using SPSS 15 for statistical analysis. RESULTS: One-month mortality was 38.2% (n = 13) and 6-month total mortality reached 47% (n = 16). Patients with higher pre-operative revised trauma score, Glasgow coma scale, partial anterial pressure of carbon dioxide, arterial oxygen pressure, Charlson co-morbidity index score, blood glucose level, blood urea nitrogen, and lower age had a higher rate of survival and consequently a favourable outcome. Higher platelet values were only found to be a determinant of higher survival at the end of the first month without having any significant effect on the favourable outcome. CONCLUSION: In patients of traumatic acute subdural haematoma whose Glasgow coma scale on arrival was < or = 8, a massive craniectomy along with the evacuation of the haematoma, may be considered as a treatment option for intra-operative and post-operative brain swelling. But in patients with a score of 3 on arrival and bilaterally fixed and dilated pupils, decompressive craniectomy is unnecessary.

Effect of coenzyme Q10 on ischemia and neuronal damage in an experimental traumatic brain-injury model in rats.

BACKGROUND: Head trauma is one of the most important clinical issues that not only can be fatal and disabling, requiring long-term treatment and care, but also can cause heavy financial burden. Formation or distribution of free oxygen radicals should be decreased to enable fixing of poor neurological outcomes and to prevent neuronal damage secondary to ischemia after trauma. Coenzyme Q10 (CoQ10), a component of the mitochondrial electron transport chain, is a strong antioxidant that plays a role in membrane stabilization. In this study, the role of CoQ10 in the treatment of head trauma is researched by analyzing the histopathological and biochemical effects of CoQ10 administered after experimental traumatic brain injury in rats. A traumatic brain-injury model was created in all rats. Trauma was inflicted on rats by the free fall of an object of 450 g weight from a height of 70 cm on the frontoparietal midline onto a metal disc fixed between the coronal and the lambdoid sutures after a midline incision was carried out. RESULTS: In the biochemical tests, tissue malondialdehyde (MDA) levels were significantly higher in the traumatic brain-injury group compared to the sham group (p < 0.05). Administration of CoQ10 after trauma was shown to be protective because it significantly lowered the increased MDA levels (p < 0.05). Comparing the superoxide dismutase (SOD) levels of the four groups, trauma + CoQ10 group had SOD levels ranging between those of sham group and traumatic brain-injury group, and no statistically significant increase was detected. Histopathological results showed a statistically significant difference between the CoQ10 and the other trauma-subjected groups with reference to vascular congestion, neuronal loss, nuclear pyknosis, nuclear hyperchromasia, cytoplasmic eosinophilia, and axonal edema (p < 0.05). CONCLUSION: Neuronal degenerative findings and the secondary brain damage and ischemia caused by oxidative stress are decreased by CoQ10 use in rats with traumatic brain injury.

Penetrating spinal injury with a wooden fragment: a case report and review of the literature.

STUDY DESIGN: Case description. OBJECTIVES: To present a case of a missed diagnosis of penetrating spine injury by wood and review of the literature. SUMMARY OF BACKGROUND DATA: Penetrating spinal injuries by wood are rare injuries. Less than 10 cases with penetrating spine injuries by a wooden fragment had been reported earlier. METHODS: A 23-year-old man had fallen from 3 m high tree and sustained a penetrating wound on his right lower back. As the direct radiographic evaluation was normal, the diagnosis of foreign body was missed. Eventually, the diagnosis was made on admission of the patient with purulent discharge from his wound, 1-week postprimary closure. Hypoesthesia of S1, S2, and S3 alone, were noted neurologically. The computed tomography and magnetic resonance imaging of patient revealed an intraspinal foreign body pierced through the S1-S2 interlaminary space. Extraction of the wooden fragment was then performed by limited S1 laminectomy and the dural defect was also repaired. RESULTS: With appropriate antibiotherapy, patient recovered, with no sequela. CONCLUSION: Due to its density and radiologic properties, it is not unusual for wood to be overlooked, unless detailed imaging with computed tomography or magnetic resonance imaging is used.

Syringomyelia and intradural extramedullary tuberculoma of the spinal cord as a late complication of tuberculous meningitis.

Intradural extramedullary (IDEM) tuberculomas account for only 1% of all spinal tuberculomas. Concurrent IDEM tuberculoma and syringomyelia arising as a complication of tuberculous meningitis (TM) is extremely rare and only two cases have been reported to date. There is yet no report in the literature describing syringomyelia presenting as a delayed complication of IDEM tuberculoma. Here we present such a case. A 21 year-old male patient underwent partial decompression for thoracolumbar IDEM tuberculoma as a late complication of tuberculous meningitis. Spinal magnetic resonance imaging (MRI) of the patient suffering from progression of paraparesia six months after the operation revealed a syringomyelia occupying the space from T1 to T9, remote from the operation site, and syringo-peritoneal shunt placement was performed.

A rare complication of spinal surgery: cerebellar hemorrhage.

Remote cerebellar hemorrhage (RCH) after spinal surgery is encountered extremely rarely. A 64 year-old female patient developed symptoms of deteriorating consciousness and diplopia arising on the first postoperative day after recurrent spinal surgery. Cranial CT scan showed cerebral edema and evidence of a cerebellar hemorrhage. Urgent suboccipital decompressive craniectomy and expanded duraplasty were performed. Repeat CT at 24 h revealed hydrocephalus and an external ventricular drain (EVD) was inserted for 20 days. The patient's consciousness deteriorated after withdrawal of the EVD and a ventriculoperitoneal shunt was placed. The patient recovered completely except for gait ataxia and left foot drop. Although the exact cause is unknown iatrogenic dural opening resulting in excessive cerebrospinal fluid (CSF) drainage and secondary development of venous infarction have been suggested to lead to RCH.

Effect of vardenafil on cerebral vasospasm following experimental subarachnoid hemorrhage in rats.

We examined the effects of the phosphodiesterase 5 (PDE-5) inhibitor vardenafil on cerebral vasospasm in an experimental rat subarachnoid hemorrhage (SAH) model. Thirty-two albino Wistar rats were divided into five groups: G1, no experimental intervention; G2, administered subarachnoid physiological saline after sham surgery; G3, subjected to SAH; G4, subjected to SAH and administered low-dose (0.5 mg/kg) vardenafil treatment; and G5, subjected to SAH and administered high-dose (5 mg/kg) vardenafil treatment. For animals in G3, G4 and G5, SAH was induced by an injection of autologous non-heparinized blood into the cisterna magna. Immediately after SAH, for animals in G4 and G5, vardenafil was administered by gavage at intervals of 8 hours for 2 days. The rats were then decapitated, and basilar arteries and blood samples were taken for biochemical and histopathological examination. Malonyldialdehyde values in G2 (p = 0.004) and G3 (p = 0.002) were significantly higher than those in G1. G4 and G5 had significantly lower values than G2 and G3 (p = 0.014, G4 v. G2; p = 0.005, G4 v. G3; p = 0.005, G5 v. G2; p = 0.002, G5 v. G3). Total antioxidant capacity (TAC) values in G3 were significantly lower than those in G1 (p = 0.041). TAC values in G4 and G5 were significantly higher than those in G3 (p = 0.043). Mean luminal diameter in G3 was significantly smaller compared with G1 and G2 (p = 0.002), but larger in G4 (p = 0.002) and G5 (p = 0.001) compared with G3. Mean luminal diameter was also significantly larger in G5 than in G2 (p = 0.008) and G4 (p = 0.038). Mean wall thickness in G2 (p = 0.015) and G3 (p = 0.002) was significantly thicker compared with G1. Wall thickness was significantly thinner in G4 and G5 compared with G2 and G3 (p = 0.008, G4 v. G2; p = 0.001, G4 v. G3; p = 0.005, G5 v. G2; p = 0.001, G5 v. G3). Our results confirm that vardenafil may induce vasodilatation and provide potential benefits in SAH therapy by preventing vasospasm.

The effects of dexmedetomidine dosage on cerebral vasospasm in a rat subarachnoid haemorrhage model.

We investigated the effect of two different doses of dexmedetomidine on vasospasm in a rat model of subarachnoid haemorrhage (SAH). SAH was induced by injecting 0.3 mL blood into the cisterna magna in all rat groups except the control (Group C). At 1 hour and 24 hours after SAH, 5 microg/kg dexmedetomidine was given to group D5, and 10 microg/kg dexmedetomidine was given to group D10. No medication was administered to the haemorrhage group (Group H). Malondialdehyde (MDA) and paraoxonase (PON) levels were measured at 48 hours after SAH. Mean wall thickness (MWT), mean luminal diameter (MLD), and proliferating cell nuclear antigen (PCNA) expression of the basilar artery were evaluated. MDA levels and MWT were lower in the dexmedetomidine groups. The lowest MDA levels and MWT were found in Group D10. The MLD was lowest in Group H. PCNA expression was observed only in Group D10. We concluded that dexmedetomidine reduces oxidative stress and vasospasm following SAH in a dose-dependent manner.

Effects of ebselen versus nimodipine on cerebral vasospasm subsequent to experimental subarachnoid hemorrhage in rats.

We investigated the effect of ebselen relative to nimodipine in an animal model of subarachnoid hemorrhage. Thirty Wistar albino rats were divided into 5 groups: G1, no intervention; G2, sham surgery without subarachnoid hemorrhage (SAH); G3, SAH only; G4, SAH plus nimodipine treatment; G5, SAH plus ebselen treatment. For G2 animals, physiological saline (0.9% NaCl) was injected into the cisterna magna. For G3, G4 and G5 animals, SAH was induced by injecting autologous non-heparinized blood into the cisterna magna. One hour after injection, G4 animals received nimodipine at 6-hour intervals and G5 animals received ebselen twice a day for 48 hours. After treatment, brain tissue and blood samples were taken for biochemical and histopathological examination. Mean malonyldialdehyde concentration was significantly higher in G3 than in G1 (p<0.0001), G2 (p=0.01), G4 (p=0.002) and G5 (p=0.014), and significantly higher in G5 than in G1 (p=0.013). Mean superoxide dismutase activity was significantly lower in G4 than in both G1 (p=0.025) and G2 (p=0.02). Mean wall thickness was significantly greater in G3 than in G1 (p<0.0001), G2 (p=0.01), G4 (p<0.0001) and G5 (p<0.0001). Mean wall thickness was also significantly greater in both G1 and G2 than in G4 (p<0.0014 and p<0.0001) and G5 (p<0.0001 and p<0.0001). Mean luminal diameter of the basilar artery was significantly smaller in G3 than in G2 (p=0.02), G4 (p<0.018) and G5 (p<0.001). Our results confirm that ebselen may have neuroprotective effects by acting to prevent vasospasm.

The effectiveness of dexmedetomidine in experimental spinal cord injury compared to methylprednisolone in rats.

The present study aimed to investigate the neuroprotective efficacy of dexmedetomidine in a rat experimental spinal cord injury model. The rats (n=40) were equally divided into four groups: G1, G2, G3, and G4. Rats in the G1 group underwent a laminectomy only. For the rats in the G2, G3, and G4 groups, spinal cord injury was induced by placing an aneurysm clip extradurally for 60 s at T10. The rats in G2 did not receive any post-injury treatment. Immediately after trauma was induced, rats in G3 were given methylprednisolone (30 mg/kg) and in G4, dexmedetomidine (10 microg/kg), both intraperitoneally. The rats were sacrificed under anesthesia 24 hours later and 1.5 cm lengths of injured spinal cord were obtained. Malonyldialdehyde values were significantly increased in G2 compared to G1, G3 and G4 (p<0.05). The neuronal cell count in G1 was significantly higher than in G2 and G3 (p=0.0001; p=0.007). G4 had higher cell counts compared to G2 and G3 (p=0.0001; p=0.05). These findings indicated that dexmedetomidine might have neuroprotective effects in spinal cord injury.

Spherical amyloid deposition in a prolactin-producing pituitary adenoma.

A 41-year-old man presented with headache, right-sided ophthalmic pain and visual deficit. His neurological examination was normal except for bitemporal hemianopsia and right lower quadranopsia. MRI demonstrated a mass arising from the pituitary gland. Hormonal analysis revealed an elevated prolactin level of 4700 ng/mL (normal 4.04-15.2 ng/mL). MRI revealed hypointense signal on T2-weighted images. Moreover, we also concluded that foci with no intravenous contrast enhancement represent the amyloid deposits. The patient underwent trans-sphenoidal resection of the pituitary adenoma. Histological examination revealed an adenoma with spheroid amyloid deposits adjacent to prolactin-staining adenoma cells. The patient recovered from the surgery without complications.

Noncommunicating thoracolumbar intradural extramedullary arachnoid cyst in an 8-year-old boy: intact removal by spontaneous delivery.

Noncommunicating spinal intradural extramedullary arachnoid cysts are an extremely rare cause of spinal cord compression. An 8-year-old boy presented with progressive paraparesis. Magnetic resonance imaging revealed a posterior intradural extramedullary arachnoid cyst extending from T(11) to L(3) vertebral bodies. The multilevel noncommunicating cyst was totally removed by simple delivery without rupture through a single-level laminoplasty. To our knowledge, no such case has been reported in the literature.

Conus ependymoma with holocord syringohydromyelia and syringobulbia.

We report a 24-year-old woman with an intramedullary conus ependymoma associated with holocord syringohydromyelia and syringobulbia. The tumor was removed and surgery for decompression of the syringohydromyelia was not considered at the first operation. In the follow-up examinations, MRI showed significant and steady improvement of syringohydromyelia. Symptoms associated with syringohydromyelia also disappeared. The cause of syringohydromyelia accompanying intradural spinal cord tumors appears to be either direct blockade of the central canal or secondary interruption of the central canal flow by compression of the perimedullary cerebrospinal fluid flow. As removal of the mass often corrects both these likely causes of the syringohydromyelia, no additional treatment for the drainage of the hydromyelia cavity syrinx is usually necessary.

Migration of a bullet in the spinal canal.

Migration of a bullet within the spinal canal after gunshot injury is rare. We report here the case of a penetrating gunshot injury of the lumbar spine at L3 with migration of the bullet within the spinal canal S2. The patient had marked paraparesis (proximal 1/5, distal 0/5 muscle strength) and anaesthesia at L3 and below, and had a hypocompliant, hyper-reflexive bladder with decreased capacity, and absent anal tonus. We removed osseous fragments in the canal with an L3 laminectomy and extracted the bullet by S2 laminectomy. After surgery, we observed an improvement in paraparesis, an increase in bladder capacity and urinary compliance, and improvement in anal tonus. The appropriate course of action in this type of injury remains unclear, because the number of cases described in the literature is not sufficient to provide a basis on which to make a definitive therapeutic decision. We herein review the literature describing cases in which a bullet in the spinal canal has migrated; we describe the treatment used and the outcomes in these cases.

Giant unruptured anterior communicating artery aneurysm presenting with seizure.

Giant aneurysms of the anterior communicating artery (AComA) are rare. The clinical presentation of giant AComA aneurysms is usually associated with the mass effect of the space-occupying lesion or with subarachnoid haemorrhage. A giant AComA aneurysm presenting with a seizure has only been reported twice previously. We report a 70-year-old female patient, in whom a single seizure was the only symptom of a giant AcomA aneurysm, with no neurological deficit. The diagnosis of unruptured giant AComA aneurysm was made with cranial CT, MRI and angiography. The patient refused surgical intervention, was treated with anti-epileptic therapy and has been asymptomatic for 7 months. We suggest that elderly patients presenting with a first seizure need detailed evaluation and giant aneurysms, which may be confused with other intracranial space-occupying lesions, need to be considered in the differential diagnosis.

Primary spinal extranodal Hodgkin's disease at two levels.

About 90% of Hodgkin's disease cases originate from lymph nodes whereas 10% from extranodal regions. Patients rarely present with spinal cord compression due to epidural Hodgkin's disease. Primary spinal extradural Hodgkin's disease which does not have any other organ involvement in the body is even rarer. A 39-year-old male patient who complained of lumbar pain had normal findings upon neurological examination. Radiological examination revealed a mass on the epidural space at level L3 and the involvement of the vertebral corpus accompanied by the involvement of C6 vertebral body. Primary focus could not be identified despite further investigation. The patient underwent L3 laminectomy and posterior decompression and biopsy was obtained from the lesion extending to epidural space. The pathological result was reported as lymphocyte dominant type Hodgkin's disease. Flow cytometry was performed to the lesion, also. The patient was evaluated as Stage 4A according to Ann Arbor classification. Postoperative radiotherapy was applied to lumbar and cervical region. In the literature we have not come across any case of primary spinal extranodal Hodgkin's disease with involvement at two levels. In conclusion, although it might be extremely rare, primary spinal extranodal Hodgkin's disease with involvement at two levels might be observed.

Ultrastructural changes in the circumventricular organs after experimental subarachnoid hemorrhage.

OBJECTIVES: Circumventricular organs (CVOs) are fine, periventricular, neurotransmitter-rich structures that are devoid of a blood-brain barrier and are known for their secretory role controlling fluid and electrolyte balance, thirst and even reproduction. Common pathologies of the brain such as trauma or bleeding affect CVOs, and hence their function. However, at what stage of these disease processes are CVOs affected and the time sequence of their recovery is still not clear. The aim of this study was to detect the morphological changes in CVOs using electron microscopy after experimental subarachnoid hemorrhage (SAH). METHODS: Experimental SAH was induced by transclival puncture of the basilar artery. Both scanning and transmission electron microscopic examination of the representive sections from each CVO was undertaken. RESULTS: Electron microscopy has shown that after SAH, the cells that form the CVOs exhibit signs of cellular necrosis with margination of the nucleus as well as cytoplasmic, mitochondrial and axonal edema. The subfornicial organ and organum vasculosum lamina terminalis appear to be more vulnerable to the effects of SAH than the median eminence or area postrema. DISCUSSION: Considering the fact that the experimental SAH model we have used is very similar to the momentary rupture of an aneurysm with secondary reflex spasm to seal the hole, it will not be unrealistic to consider that similar effects may also take place in the clinical setting.