A Rare Entity in the Lumbar Epidural Region: T-Cell Lymphoblastic Lymphoma.

BACKGROUND: T-cell lymphoblastic lymphoma is a rare disease and an aggressive neoplasm of precursor lymphoblasts. We present a case of lumbar epidural T-cell lymphoblastic lymphoma which appeared with clinical features of epidural spinal cord compression. METHODS: A 38-year-old male patient presented with weakness in the lower extremities and newly developed urinary incontinence. His medical history included precursor T-cell acute lymphoblastic leukemia and treatment with allogeneic bone-marrow transplantation 5 years previously. Spinal magnetic resonance imaging (MRI) revealed an epidural mass lesion at L2-L4 levels and there was no sign of leukemia or lymphoma in clinical, laboratory, and radiological examinations. Surgery was planned for obtaining diagnostic material. Decompressive laminectomy and subtotal excision of the tumor were performed. RESULTS: At surgery, the tumor consisted of yellow-colored and hypovascular soft tissue fragments. It was encircling the spinal cord and spreading through the left L3 foramen. The patient underwent adjuvant chemoradiotherapy after the histopathological evaluation. At 2-month follow-up, the patient was able to walk without assistance, but the urinary incontinence was the same. At 5-month follow-up, the disease progressed, and the patient passed away because of infective endocarditis. CONCLUSION: Spinal lymphomas may display its characteristic "wrap-around" fashion in the MRI. In this report, we shared the microsurgical appearance of this fashion. As the lymphomas are chemoradiosensitive tumors, the treatment should be managed with a multidisciplinary approach.

Neuroprotective Effects of Vigabatrin on Spinal Cord Ischemia-Reperfusion Injury.

OBJECTIVE: Spinal cord ischemia is a serious and catastrophic clinicopathologic condition. Despite studies reported over the last 20 years, alternative and efficient treatment options remain unclear. We examined the neuroprotective effects of vigabatrin on a spinal ischemia-reperfusion model. METHODS: We divided 24 New Zealand rabbits into 4 groups (control, ischemia reperfusion, and low-dose and high-dose vigabatrin). The control group underwent only abdominal surgery, whereas an abdominal aortic cross-clamp model of spinal ischemia was performed in the other groups. Clips were removed after 30 minutes and 50 and 150 mg/kg vigabatrin was administered intraperitoneally to the low-dose and high-dose groups, respectively. Neurologic examination was performed for 48 hours, after which the rabbits were sacrificed and a blood sample obtained. Biochemical examination of malondialdehyde, advanced oxidation protein products, total nitric oxide, and glutathione levels and superoxide dismutase activities in plasma and tissue sample, and histopathologic examination of the spinal cord were performed and statistical results compared between the groups. RESULTS: Low-dose vigabatrin had statistically significant effects of neuroprotection on spinal ischemia. Although high-dose vigabatrin had similar effects, the results were not statistically significant for all parameters of biochemical analysis. In addition, histopathologic examination showed some toxic effects of high-dose vigabatrin. CONCLUSIONS: Neuroprotective effects of vigabatrin are shown. For clinical use, further studies are needed.

Neuroprotective effects of Quercetin on radiation-induced brain injury in rats.

Extensive research has been focused on radiation-induced brain injury. Animal and human studies have shown that flavonoids have remarkable toxicological profiles. This study aims to investigate the neuroprotective effects of quercetin in an experimental radiation-induced brain injury. A total of 32 adult male Wistar-Albino rats were randomly divided into four groups (control, quercetin, radiation, and radiation+quercetin groups, with eight rats in each group). Doses (50 mg/kg) of quercetin were administered to the animals in the quercetin and radiation+quercetin groups; radiation and radiation+quercetin groups were exposed to a dose of 20 Gy to the cranium region. Tissue samples, and biochemical levels of tissue injury markers in the four groups were compared. In all measured parameters of oxidative stress, administration of quercetin significantly demonstrated favorable effects. Both plasma and tissue levels of malondialdehyde and total antioxidant status significantly changed in favor of antioxidant activity. Histopathological evaluation of the tissues also demonstrated a significant decrease in cellular degeneration and infiltration parameters after quercetin administration. Quercetin demonstrated significant neuroprotection after radiation-induced brain injury. Further studies of neurological outcomes under different experimental settings are required in order to achieve conclusive results.

Prophylactic Anticonvulsants in Patients Undergoing Craniotomy: A Single-Center Experience.

BACKGROUND There is no consensus on the efficacy of seizure prophylaxis in patients undergoing craniotomy. Some studies show that antiepileptic use decreases the risk of seizures, but other studies do not support this. The present study investigated the role of antiepileptic drugs in patient undergoing craniotomy due to various intracranial pathologies. MATERIAL AND METHODS A retrospective review was performed in adult patients undergoing craniotomy between January 2013 and June 2017. Results of 282 patients who did not have a history of seizures and had craniotomies for various reasons were included. In all patients with craniotomy planned, prophylactic AEDs were initiated pre-operatively. RESULTS The incidence of postoperative seizures was 17.7% when all craniotomized patients were considered. The most commonly used anticonvulsant agent was phenytoin (75.2%). No serious antiepileptic drug reaction occurred requiring cessation of treatment. CONCLUSIONS Prophylactic antiepileptic treatment of patients undergoing craniotomy should not be continued beyond the first perioperative week if there is no serious brain injury. The intra- or extra-axial placement of the tumor affects the prophylaxis. Further randomized controlled studies are warranted in the future to investigate the efficacy of these medications.

Is the recurrence rate of chronic subdural hematomas dependent on the duration of drainage?

OBJECTIVES: Chronic subdural hematoma (CSDH) is the most frequent type of intracranial hemorrhage which especially affects the elderly. Various surgical techniques have been reported for CSDH treatment; optimal treatment methods are still controversial. In this study, the effects of long drainage durations on results and recurrences were investigated in patients on whom closed system drainage with burr hole craniotomy was applied due to CSDH. METHODS: 90 patients with 105 CSDH were operated between 2008 and 2016. Patients were divided into two groups based on the duration of drainage. Group A (n = 40) was determined as 2-4 days of closed-system drainage, while Group B (n = 50) was recorded as 5-7 days of closed-system drainage. Recurrence was defined as accumulation of blood in the operation area and recurrence of symptoms within the monitoring period of six months. RESULTS: Recurrence was observed in 7 (15.6) of the Group A patients and 2 (3.3%) of the Group B patients. There was a statistically significant difference between groups in terms of recurrence rate (p = 0.04). Postoperative thickness of hematoma was measured in the first month follow-up computerized tomography. There was a statistically significant difference between groups in terms of postoperative thickness of residual hematoma (p = 0.05). CONCLUSION: 2-4 days of closed system drainage following burr hole craniotomy is an effective and reliable choice of treatment in CSDH. Nevertheless, increasing the duration of drainage to 5-7 days provided better results without increasing the risk of complication.

Unilaterally posterior lumbar interbody fusion with double expandable peek cages without pedicle screw support for lumbar disc herniation.

OBJECTIVES: Posterior lumbar interbody fusion (PLIF) is usually bilateral procedure, and it is combined with posterior by bilateral pedicle screw support or with fixation. The purpose of this retrospective study was to compare the surgical outcomes of simple discectomy and PLIF without pedicle screw support in patients with lumbar disc herniation (LDH). PATIENTS AND METHODS: 60 patients with single segment LDH were operated between February 2010 and June 2013. 40 patients were treated with simple discectomy (Group 1) and 20 patients were treated with PLIF using double expandable polyetheretherketone (PEEK) cages without instrumentation (Group 2) unilaterally. Pain and function were evaluated by the visual analog scale (VAS) and Oswestry disability index (ODI) before and 18 months after surgery. Besides, PLIF patients were evaluated with computerized tomography (CT) scan of lumbar vertebra for the evaluation of the height of the disc, instability and fusion. RESULTS: Both leg and low back pain VAS scores were significantly improved 18 months after surgery in both of the groups (p<0.001). Significant decrease in VAS low back pain scores was seen in group 2 when compared to group 1 (p<0.001). Height of the intervertebral disc space was preserved and no instability was detected in group 2. No recurrence and 80% fusion rate was achieved in group 2. CONCLUSION: This study showed that unilateral PLIF intervention with double expandable PEEK cages without pedicle screw support would be sufficient in the management of single segment lumbar disc herniation in patients whom are thought to have lumbar stabilization.

Postdural puncture subdural hematoma or postdural puncture headache?: two cases report.

Spinal anesthesia is widely used for many obstetric, gynecological, orthopedic, and urological operations. Subdural hematomas may occur after trauma and are associated with high morbidity and mortality rates. Postdural puncture headache (PDPH) is a benign condition and the most frequent complication of spinal anesthesia. The high rate of headache after spinal anesthesia may mask or delay the diagnosis of subdural hematoma. The true incidence of postdural puncture subdural hematoma (PDPSH) is unknown because most affected patients are probably managed without investigation. Therefore, the true incidence of PDPSH may be greater than suggested by previous reports. The differentiation of headache associated with subdural hematoma from PDPH is crucial. We herein report two cases of bilateral subdural hematoma after epidural anesthesia and emphasize the importance of suspicion for PDPSH and careful evaluation of patients with headache after spinal anesthesia.

Primary Intracerebral Alveolar Soft Part Sarcoma in an 11-Year-Old Girl: Case Report and Review of the Literature.

Alveolar soft part sarcoma (ASPS), a rarely observed tumor, is a soft tissue sarcoma with an unidentified cell origin. It constitutes 0.5-1.0% of all soft tissue sarcomas. It may appear in various parts of the body, but mostly observed in the trunk and the extremities. It has a high metastasis potential. To the best of our knowledge, only three cases of primary intracranial ASPS without a demonstrable lesion elsewhere is encountered. An 11-year-old girl was operated because of fronto-parietal mass lesion by craniotomy. Pathological examination revealed ASPS and no primary focus was detected. In spite of radiotherapy and chemotherapy as an adjuvant therapy, after 45 months she had a second operation for recurrence of the tumor. Since it is possible to observe metastases in late phases, up to 30 years, the patients must be followed up for a long period. Although radiotherapy and chemotherapy followed by surgery is the most accepted treatment strategy, the prognosis is still poor.

Coexistence of cervico-thoracic extradural en-plaque meningioma with multiple intracranial meningiomas.

Meningioma is one of the most common tumors in the spinal cord. Extradural and en-plaque variety of meningioma occur less frequently. A 47-year-old woman is presented with radiculopathy signs. Magnetic resonance imaging revealed a lesion from C6 through T3 vertebral levels compressing the cord both anteriorly and posteriorly. Subtotally excision was performed and histopathologic signs showed transitional type of meningioma (WHO Grade 1). Post operatively, she had good neurological recovery. Intraoperative findings point out that the en-plaque meningioma was pure extradural. Twelve cases of pure extradural en-plaque meningioma have been reported in the literature. Besides, to the best our knowledge coexistence of "en plaque" spinal epidural meningioma with meningiomas in cranial cavity has not been reported. Complete resection is mandatory to prevent recurrence. Moreover, it is considerably difficult to remove the parts of tumor over anterior of the dura without complication.

A Perfusion-based Human Cadaveric Model for Management of Carotid Artery Injury during Endoscopic Endonasal Skull Base Surgery.

Objective To create and develop a reproducible and realistic training environment to prepare residents and trainees for arterial catastrophes during endoscopic endonasal surgery. Design An artificial blood substitute was perfused at systolic blood pressures in eight fresh human cadavers to mimic intraoperative scenarios. Setting The USC Keck School of Medicine Fresh Tissue Dissection Laboratory was used as the training site. Participants Trainees were USC neurosurgery residents and junior faculty. Main Outcome A 5-point questionnaire was used to assess pre- and posttraining confidence scores. Results High-pressure extravasation at normal arterial blood pressure mimicked real intraoperative internal carotid artery (ICA) injury. Residents developed psychomotor skills required to achieve hemostasis using suction, cottonoids, and muscle grafts. Questionnaire responses from all trainees reported a realistic experience enhanced by the addition of the perfusion model. Conclusions The addition of an arterial perfusion system to fresh tissue cadavers is among the most realistic training models available. This enables the simulation of rare intraoperative scenarios such as ICA injury. Strategies for rapid hemostasis and implementation of techniques including endoscope manipulation, suction, and packing can all be rehearsed via this novel paradigm.

Intraventricular dysembryoplastic neuroepithelial tumour: case report.

Dysembryoplastic neuroepithelial tumour (DNT) is located in the cerebral cortex with very few exceptions. In this article, an extremely rare case of intraventricular DNT originating from the septum pellucidum is reported. A 25-year-old woman presented with 5-month history of headache. Cranial magnetic resonance imaging (MRI) scans revealed a mass in the right lateral and third ventricle which was hypointense on T1-weighted image, and hyperintense on T2-weighted images. No contrast enhancement was detected. The lesion was excised totally using a transcallosal-transventricular approach. Immunohistochemical examination revealed DNT. The patient was discharged without any neurological deficits. Intraventricular DNT presents with symptoms of increased intracranial pressure rather than seizures. Distinguishing DNT from other intraventricular tumours is essential as DNT is characterized by benign clinical course and does not require adjuvant therapy.

Neuroprotective effects of gabapentin on spinal cord ischemia-reperfusion injury in rabbits.

OBJECT: Extensive research has been focused on neuroprotection after spinal cord trauma to alleviate the effects of secondary injury. This study aims to investigate the neuroprotective effects of gabapentin in an experimental spinal cord ischemia reperfusion injury. METHODS: Thirty-two adult male New Zealand white rabbits received spinal cord ischemic injury using the aortic occlusion model. Animals were divided into 4 groups (sham, control, low-dose, and high-dose treatment groups; 8 rabbits in each group). High (200 mg/kg) and low (30 mg/kg) doses of gabapentin were administered to the animals in the treatment groups after spinal cord ischemic injury. Neurological status of the animals, ultrastructural findings in injured tissue samples, and levels of tissue injury markers in these 2 groups were compared with findings in the animals that did not receive the ischemic procedure (sham-operated group) and those that received normal saline after administration of ischemia. RESULTS: Regarding levels of tissue injury marker levels after ischemic injury, animals in the gabapentin-treated groups demonstrated better results than animals in the other groups. The ultrastructural findings and caspase-3 activity were similar. The treatment groups demonstrated better results than the other groups. CONCLUSIONS: Gabapentin demonstrated significant neuroprotection after early phases of ischemic injury. Further studies with different experimental settings including neurological outcome are required to achieve conclusive results.

Two meningiomas with different histological grades in the same patient. Case report.

A 56-year-old female presented with two intracranial meningiomas with different grades manifesting as speech disorder for one week. Neurological and radiological evaluations showed two distinct tumors suggestive of multicentric meningiomas. Surgical resection of both masses was performed in the same procedure. Histological examination found both meningothelial and atypical meningiomas. Concurrency of meningiomas with different grades in same patient is extremely rare. The present case emphasizes the need for follow up of all patients with meningioma even if the neuroimaging features indicate benign character.

Anti-apoptotic and neuroprotective effects of α-lipoic acid on spinal cord ischemia-reperfusion injury in rabbits.

PURPOSE: Radical oxygen species produced after injury counteracts antioxidant activity and frequently causes severe oxidative stress for the tissues. Alpha-lipoic acid is a powerful metabolic antioxidant with immunomodulatory effects which provides neuroprotection. The aim of this study is to investigate the neuroprotective and anti-apoptotic effects of alpha-lipoic acid on spinal cord ischemia-reperfusion. METHODS: Twenty-four adult, male, New Zealand rabbits were divided into sham (n = 8), control (n = 8), and treatment groups (n = 8). The abdominal aorta was clamped for 30 min by an aneurysm clip, approximately 1 cm below the renal artery and 1 cm above the iliac bifurcation in control and treatment groups. Only laparotomy was performed in the sham group. Twenty-five cubic centimeters of saline in control group and 100 mg/kg lipoic acid were administered intraperitoneally in the treatment group after closure of the incision. The animals were killed 48 h later. Spinal cord segments between L2 and S1 were harvested for analysis. Levels of nitric oxide, glutathione, malondialdehyde, advanced oxidation protein products, and superoxide dismutase were analyzed as markers of oxidative stress and inflammation. Caspase-3 activity was analyzed to detect the effect of lipoic acid on apoptosis. RESULTS: In all measured parameters of oxidative stress, administration of lipoic acid significantly demonstrated favorable effects. Both plasma and tissue levels of nitric oxide, glutathione, malondialdehyde, and advanced oxidation protein products significantly changed in favor of antioxidant activity. There was no significant difference between the plasma superoxide dismutase levels of the groups. Histopathological evaluation of the tissues also demonstrated significant decrease in cellular degeneration and infiltration parameters after lipoic acid administration. However, lipoic acid has no effect on caspase-3 activity. CONCLUSIONS: Although further studies considering different dose regimens and time intervals are required, the results of the present study prove that alpha-lipoic acid has favorable effects on experimental spinal cord ischemia-reperfusion injury.

A spontaneous spinal epidural hematoma in a hemodialysis patient: a rare entity.

Hemodialysis patients are at an increased risk of bleeding due to the platelet dysfunction caused by uremia and the use of anticoagulants during dialysis. Spontaneous spinal hematoma is a rare disorder as a complication in hemodialysis patients. Also it includes the hematoma secondary to coagulopathy, vascular malformation and hemorrhagic tumors. Here, we report the case of 77-year-old woman who presented with spinal cord compression due to spontaneous spinal epidural hematoma associated with hemodialysis. When an end-stage renal disease patient suffers from back pain and neurological deficits, the clinician should be alerted for the spontaneous spinal epidural hematoma as well as cerebrovascular events.

Effectiveness of skull models and surgical simulation: comparison of outcome between different surgical techniques in patients with isolated brachycephaly.

PURPOSE: The aim of this study was to emphasize the importance of preoperative surgical planning using 3D skull models in craniosynostosis surgery. METHODS: By using 3D polymethyl methacrylate skull models manufactured using 3D tomography images, the authors previously showed that after fronto-parietal osteotomy, instead of fixing the fronto-parietal bone flap without rotation, angled advancement with horizontal osteotomy provides maximum increase in intracranial volume, in a bilateral coronal craniosynostosis model. After changing the operation technique using data gathered from previous studies, we reviewed two bilateral craniosynostosis patients operated with the new technique and compared it with two patients that were operated with the old technique. RESULTS: Comparing cranial indexes (CI), significant improvement was detected in both groups. The decrease in CI in the second group was slightly better than the first group. In the comparison of intracranial volume (ICV), there was an increase in ICV values in both groups. The percentage of increase between two groups was similar. The morphological outcome was satisfactory in all patients. There were no major or minor complications and morbidity. CONCLUSIONS: Current multislice tomography technology and stereolithographic procedures provide an excellent surgical simulation model to find new techniques and predict the outcome. These models should be used in all complex and syndromic craniosynostosis for both better results and reducing the operative time and associated blood loss.

Seven distinct coexistent cranial and spinal anomalies.

UNLABELLED: Existence of multiple cranial and spinal anomalies in spina bifida is well known; however, coexistence of seven different severe anomalies is extremely rare. The location of the anomalies, the patient's age and presentation are other interesting aspects of the presented case. CASE REPORT: A 1-year-old girl with an enlarged head and big, infected lumbosacral myelomeningocele (MMC) was admitted to the emergency department in a comatose state. Further investigations revealed hydrocephalus, Chiari malformation, syringohydromyelia, split cord malformation, dermal sinus tract, lumbosacral MMC, and tethered cord. Unfortunately, the patient died 3 days after admission because of meningitis and sepsis. DISCUSSION: Coexistence of seven different craniospinal anomalies is extremely unusual. Further investigations with magnetic resonance imaging for associated anomalies, early shunt placement and MMC repair are required to prevent this life-threatening condition in spina bifida.