Fatty filum with different histological features. Case report.

Split cord malformation and fatty filum are completely different clinical entities and thought to arise via different pathophysiologies. Recognition of these distinct lesions in the same patient is important for appropriate diagnosis and management. A 3 year-old boy presented with skin lesions and mild leg weakness suggestive of spinal malformation. Magnetic resonance imaging revealed type II split cord malformation at T12-L1, syringomyelia at T8-T10 levels associated with tethered cord and fatty filum terminale. The patient underwent a T12-L1 laminotomy for the removal of fibrous band between the 2 hemicords and L4-L5 laminotomy for transection of the fatty filum. Histopathological examination of the filum confirmed the presence of bone, fat, and ciliated epithelial cells associated with meningothelial proliferation in the same specimen. We report an unusual case of type II split cord malformation coexisting with a fatty filum which have different histological patterns. To the best of our knowledge, this histological appearance of a fatty filum has not yet been reported and this raises the question of a possible associative or causative relationship between these distinct pathologies.

Fatty filum with different histological features. Case report

Split cord malformation and fatty filum are completely different clinical entities and thought to arise via different pathophysiologies. Recognition of these distinct lesions in the same patient is important for appropriate diagnosis and management. A 3 year-old boy presented with skin lesions and mild leg weakness suggestive of spinal malformation. Magnetic resonance imaging revealed type II split cord malformation at T12-L1, syringomyelia at T8-T10 levels associated with tethered cord and fatty filum terminale. The patient underwent a T12-L1 laminotomy for the removal of fibrous band between the 2 hemicords and L4-L5 laminotomy for transection of the fatty filum. Histopathological examination of the filum confirmed the presence of bone, fat, and ciliated epithelial cells associated with meningothelial proliferation in the same specimen. We report an unusual case of type II split cord malformation coexisting with a fatty filum which have different histological patterns. To the best of our knowledge, this histological appearance of a fatty filum has not yet been reported and this raises the question of a possible associative or causative relationship between these distinct pathologies. (AU)

La diastematomielia y el filum lipomatoso son entidades clínicas completamente diferentes y cuya patogenia se considera diferente. El reconocimiento de estas lesiones en el mismo paciente es importante para el diagnóstico y manejo apropiados. Un niño de 3 años de edad se presentó con marcas cutáneas y moderada debilidad en piernas sugestivos de malformación espinal. La resonancia magnética reveló duplicación de la médula de tipo II y siringomielia T12-L1, que se asoció con anclaje medular y filum terminale lipomatoso. El paciente fue sometido a una laminotomía T12-L1 para la eliminación de la banda fibrosa entre las dos hemimédulas y laminotomía L4-L5 con sección del filum lipomatoso. El estudio anatomopatológico del filum confirmó la presencia de hueso, grasa, y células epiteliales ciliadas, que se asociaron con proliferación meningotelial. Informamos un caso excepcional de diastematomielia tipo II que coexiste con un filum lipomatoso con patrón histológico diferente. En nuestra opinion, este patrón histológico correspondiente al filum lipomatoso no ha sido documentado previamente, y ello suscita cuestiones sobre una posible relación, sea de asociación o cusal, entre estas dos patologías (AU)

Simultaneously occurring vestibular schwannoma and meningioma in the cerebellopontine angle: case report and literature review.

Simultaneously occurring multiple primary brain tumors of different histological types are rare, and the coexistence of schwannoma and meningioma in the same cerebellopontine angle (CPA) without neurofibromatosis is extremely rare. A 57-year-old female patient presented with headache, speech disturbance, left facial numbness and deafness in the left ear. Magnetic resonance imaging demonstrated two different tumors in the left CPA. These tumors were not in continuity. The tumors were totally removed through the left suboccipital approach. Histopathological examination revealed that the large tumor was a vestibular schwannoma and the smaller was a meningioma. Neurofibromatosis was not diagnosed in the patient. No recurrence was observed at the end of 9 years after the operation. The simultaneous occurrence of vestibular schwannoma and meningioma in the CPA appears coincidental. This association must be kept in mind if two different tumors are detected radiologically in the same CPA.

Head injuries due to landmines.

BACKGROUND: Landmine explosions cause most of the war injuries in the battlefield and pose a substantial public health risk. Although the lower limbs are usually affected, head injuries also occur. The aim of this study is to describe the types of head injuries caused by the explosion of landmines and the management of the victims. PATIENTS AND METHOD: Fifteen patients who sustained a head injury due to a landmine explosion were treated in the Department of Neurosurgery between 2000 and 2006. The average age of the patients was 22.5 (range between 20 and 33). The Glasgow Coma Scale (GCS) score ranged between 3 and 15 and was 8 or less in 4. Shrapnel, stone and earth were the wounding agents. Four patients underwent neurosurgical treatment and 11, apart from simple scalp closure, had conservative treatment. Ten patients had associated lesions in the other parts of the body including thorax, upper and lower limbs, and the abdomen. FINDINGS: Two patients died. At the time of admission, one had a GCS score of 3 and the other a score of 4. Infection was observed among 4 patients and a cerebrospinal fluid (CSF) fistula in 1 patient. CONCLUSION: Landmines occasionally cause head injuries. Surgical intervention is seldom required and survival is likely unless the patient is in deep coma. Multidisciplinary approaches are required in case there are associated lesions in the other parts of the body.

The microsurgical anatomy of the ciliary ganglion and its clinical importance in orbital traumas: an anatomic study.

The ciliary ganglion can easily be injured during surgery for the repair of orbital fractures and laterally situated intraorbital mass lesions. The aim of this study is to elucidate the microsurgical anatomy of the ciliary ganglion and to emphasize its clinical importance in orbital traumas and surgeries. The orbits of 10 adult cadavers were fixed with 10 % formalin and dissected under the microscope with special attention to the presence and location of the ciliary ganglion. The motor (parasympathetic), sympathetic, and sensory roots, and the short ciliary nerves were exposed. Its relationship with other intraorbital neural and vascular structures were investigated. Some anatomic landmarks were determined and the distances between these landmarks were measured. The ciliary ganglion is an intraorbital neural structure approximately 3 mm in size, situated near the orbital apex, posterolateral to the globe in loose areolar tissue between the optic nerve and lateral rectus muscle. The mean distance between the ganglion and the optic nerve was 2.9 mm (range: 2.70 - 3.10 mm) and the mean distance between the lateral rectus muscle and the ganglion was 10.4 mm (range: 9.20 - 11.20 mm). Six to 10 short ciliary nerves arise from the ganglion and run forward in a curving manner with the ciliary arteries above and below the optic nerve. The ciliary ganglion should be taken into the account especially during lateral approaches to the orbit and the patients should be warned before the surgery about possible mydriatic or tonic pupils as a complication.

Parry-Romberg syndrome in association with anti-dsDNA antibodies: a case report.

Parry-Romberg syndrome (PRS) is a rare and puzzling disorder that is characterized by progressive hemifacial atrophy. It involves mainly some or all tissues of one side of the face. A case of 21-year-old Caucasian man with hemifacial atrophy in the right facial region is reported. Serological studies with anti-single-stranded DNA (anti-ssDNA), anti-double-stranded DNA (anti-dsDNA), anticentromere (ACA) and antinuclear (ANA) antibodies were done. Anti-dsDNA antibodies was found positive, but the others were negative. Rheumatoid factor (RF) was also negative. Since PRS is rare and its association with anti-dsDNA antibodies was not reported before, this case appears to be the first report.

Lumbosacral spinal epidural abscess caused by Brucella melitensis.

Spinal epidural abscess is a rare condition that can lead to irreversible complications and death if untreated. Rarely, Brucella melitensis may produce spondylodiscitis, which may be complicated by spinal epidural abscess. We report a case of lumbosacral spinal epidural abscess caused by Brucella melitensis. Spinal brucellosis should be kept in mind in the differential diagnosis of low back pain.

Management of the large cranial osteoma: experience with 13 adult patients.

BACKGROUND: Large osteomas are benign, slow-growing and rare neoplasms of the skull, which are usually asymptomatic but may need surgical resection. PATIENT AND METHODS: We reported a series of 13 adult patients who had large cranial osteomas and who underwent surgical treatment over a period of 5 years. All of the patients were male and the mean age was 21.8 years. FINDINGS: Craniectomy associated with cranioplasty was performed in 10 patients and drilling of the bone tumor was performed in 3 patients. Tumour regrowth was not observed in any patient. CONCLUSION: Although most of the cranial osteomas are asymptomatic, surgical treatment is indicated for large ones. Each patient must be individualized and the selection of the type of surgery depends on the shape and growth pattern of the osteoma.

Comparison of clinical outcomes between anteroposterior and lateral penetrating craniocerebral gunshot wounds.

OBJECTIVE: To investigate and compare, using a retrospective clinical study, the clinical outcomes of penetrating craniocerebral gunshot wounds (PCGW) with respect to the trajectory of penetration in the axial plane. METHODS: In total, 22 patients with PCGW caused by conflict, suicide attempt, or accidental firing were included in this study. They were divided into two groups: anteroposterior and lateral. All patients underwent surgical treatment following emergency intervention. RESULTS: Of the 22 patients, 16 had anteroposterior and 6 had lateral penetrating injury. Four patients with anteroposterior and five patients with lateral injury died despite surgical treatment. Mortality rate was 25% in the anteroposterior and 83% in the lateral injury group. CONCLUSION: We found that lateral PCGW is the most devastating type of missile injury to the head.

Effect of mannitol in experimental spinal cord injury: an ultrastructural and electrophysiological study.

BACKGROUND: Although many experimental and clinical studies were performed on the pathophysiology and treatment of spinal cord injury (SCI), the electrophysiological and ultrastructural changes of the spinal cord were not precisely evaluated. AIMS: To investigate the effect of mannitol on Somatosensory Evoked Potentials (SSEP), postoperative neurological recovery and ultrastructural findings after an experimental SCI. SETTING: The experimental microsurgery laboratory of a university hospital. DESIGN: A prospective, randomized animal study. MATERIAL AND METHODS: Sprague-Dawley rats were used and divided into three groups (Groups I-III) for this study. Those in Group I were control animals who underwent laminectomy only, and non-traumatized spinal cord samples were obtained 2 weeks later. SCI was produced in Groups II and III using clip compression technique, and cord samples were obtained 2 weeks later. The rats in Group II received 2 g/kg of 20% mannitol intraperitoneally, immediately and three hours after trauma was induced; and those in Group III received the same amount of 0,9% NaCl in the same manner. Preoperative and postoperative SSEP records at the end of 2 weeks were obtained. Electron microscopy examination of the cord samples was done at 2 weeks postoperatively. STATISTICAL ANALYSIS USED: Fischer's Exact Test. RESULTS: SSEP records, ultrastructural findings and clinical recovery showed that minor neural damage and significant recovery occurred in Group II. CONCLUSION: This study demonstrates that the administration of 2 g/kg of 20% mannitol produces significant improvement in the neural structures and protects the spinal cord following injury.

Diencephalic tumours presenting as psychosis.

BACKGROUND: Diencephalic tumours are usually presented with the sign and symptoms of increased intracranial pressure, endocrinological changes and visual disturbances. Psychiatric manifestation of such rare tumours is not well known. OBJECTIVE: To investigate the challenges and benefits of psychiatric evaluation on the diagnosis of diencephalic tumours and to emphasize the presence of psychosis as an initial phenomenon. METHODS AND RESULTS: Two cases who presented with the characteristic symptoms of psychosis and diagnosed diencephalic tumour are reported. A detailed radiological examination confirmed such diagnosis in both cases and surgical treatment was done. CONCLUSION: First, all patients who presented with a history of unexplained behaviour change must be evaluated by psychiatrists to exclude an organic pathology. Secondly, until the diagnosis of diencephalic tumour is confirmed, the surgical management must be performed.

The effect of cranioplasty on cerebral hemodynamics: evaluation with transcranial Doppler sonography.

BACKGROUND: The purpose of cranioplasty is not only cosmetic repair but also neurological improvement. The effect of cranioplasty on the cerebral hemodynamics flow has not been investigated by ultrasonographic techniques. AIMS: To investigate changes of cerebral hemodynamics after cranioplasty in patients with cranial defect using transcranial Doppler sonography (TCDS). SETTING: The Departments of Neurosurgery and Radiology of a university hospital. DESIGN: A prospective clinical study. MATERIAL AND METHODS: We prospectively examined the cerebral hemodynamics with TCDS pre- and postoperatively in 18 patients with cranial defect who underwent cranioplasty. All postoperative studies were done between the 7th and 15th day after cranioplasty. The anterior cerebral artery was examined through the transtemporal and transorbital windows, the middle cerebral artery through the transtemporal window, and the posterior cerebral artery through the transforaminal window. Bilaterally, the peak systolic, end diastolic and mean blood flow velocities of these arteries were measured. STATISTICAL ANALYSIS: Wilcoxon matched-pairs signed-ranks test. RESULTS: Before cranioplasty all the velocities ipsilateral to the cranial defect were significantly low, while in the contralateral side they were near normal. Ipsilateral low cerebral blood flows increased and reached normal levels (P<0.05) after cranioplasty. During the follow-up, neurological improvement was observed. CONCLUSION: Cranioplasty is carried out not only for preserving normal appearances and physical barrier but also for neurological improvement. This should be explained by the normalization of cerebral hemodynamics.

Orbital manifestation of multiple myeloma: case report.

Orbital involvement is a rare manifestation of multiple myeloma. Therefore, the correct diagnosis and appropriate management are usually difficult and generally require biopsy. We report a 60-year-old woman having multiple myeloma with orbital involvement. Right orbitozygomatic craniotomy was carried out and the mass lesion was removed. After the histological examination, the diagnosis of multiple myeloma was confirmed. The clinical course and the treatment modalities of this entity are discussed in view of the literature.

Lateral intrathoracic meningocele associated with a spinal intradural arachnoid cyst.

A case of lateral intrathoracic meningocele associated with a spinal intradural arachnoid cyst is reported and the cases from the literature are reviewed. Both of these lesions were detected by magnetic resonance imaging and treated surgically. Intrathoracic meningoceles are often asymptomatic and diagnosed incidentally during the evaluation of an unrelated pathology. A patient with a spinal intradural arachnoid cyst may present with paraparesis mimicking an intradural tumor, and lateral intrathoracic meningocele may seldom accompany this lesion. A comprehensive radiological examination must be conducted and a higher index of suspicion by neurosurgeons is necessary.

Multiple sclerosis with mass effect: case report.

Multiple sclerosis (MS) may rarely present as a cerebral mass with the clinical features and computed tomography (CT) scan appearance of a cerebral tumor. We report a case of MS with large cranial involvement showing a mass effect. We carried out a complete examination, including contrast enhancement, with neuroimaging studies. The operative procedure associated with medical treatment was performed and we obtained a good result.

Subdural and intraventricular traumatic tension pneumocephalus: case report.

Simple pneumocephalus most frequently arises as a complication of a head injury in which a compound basal skull fracture with tearing of the meninges allows entry of air into the cranial cavity. It can also follow a neurosurgical operation. Tension traumatic pneumocephalus with intraventricular extension is an extremely rare, potentially lethal condition that requires prompt diagnosis and treatment. We report the case of subdural and intraventricular accidental tension pneumocephalus occurring in a 26-year-old man as a result of skull fracture. This case is combined with rhinorrhea and meningitis that suggest some difficulties to treat. The operative procedure associated with medical treatment was performed and a good result was obtained.

The human tail associated with intraspinal lipoma: case report.

A case of a tail in a 9-month-old baby is reported. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the spinal canal. A few medical-historical aspects are discussed. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation and microsurgery.

The tanycytic ependymoma of the lateral ventricle: case report.

The tanycytic ependymoma is an extremely rare, primitive neuroectodermal tumor, arising from the ependymoglial cells or tanycytes. Such cells are generally seen in the primitive nervous system instead of the mature ependymal cells. The tanycytic ependymoma described in this report was found in a 42-year-old man. Histological analysis strongly suggested that this tumor originated from a primitive progenitor cell, the ependymoglia or the tanycyte in the lateral ventricle.

Orbital foreign bodies after penetrating gunshot wounds: retrospective analysis of 22 cases and clinical review.

We conducted a retrospective analysis of 22 patients having orbital penetrating gunshot wounds treated over a 4-years period. The neurological status and the site of injury for each patient are evaluated in this study. We propose a practical protocol in the management of these orbital foreign bodies. Surgical treatment was performed in 4 patients (had functional deficit) with medial orbitotomy in 2, lateral orbitotomy in 1, and superior orbitotomy in 1. 3 of them are improved, in one case the blindness has been continued. 18 patients were treated conservatively and all of them are improved. All patients were followed-up for 2 years with cranial X-rays and CT scans. Neurological sequelae were regressed which existed before the surgery. In conservatively treated cases, infection, migration and functional deficit were not seen. In conclusion, orbital penetrating gunshot wounds must be evaluated precisely by the surgeon and this evaluation sets the guidelines for management. The operation should be reserved for the patients in whom the necrotic soft tissues or orbital damages restrict ocular movements.