Posterior Epidural Migration of a Sequestered Lumbar Intervertebral Disc Fragment.

AIM: Posterior epidural migration of a sequestered lumbar intervertebral disc fragment (PEMSLIDF) is an extremely rare condition published so far only as case reports or small case series (ranging between 2 to 8 cases). Diagnosing this condition is often challenging and the diagnosis is usually made intraoperatively. The affected patients usually suffer cauda equina syndrome (CES). In the present study, we aimed to discuss the clinical and radiological findings, types and features of surgical therapies, and outcomes of 9 patients with PEMSLIDF. MATERIAL AND METHODS: This study included 9 (0.36%) patients with PEMSLIDF among 2470 patients who underwent lumbar disc hernia surgery between August 2002 and September 2012. The preoperative clinical and radiological properties of the patients were evaluated. The postoperative outcomes were assessed using neurological examination, radiological imaging, visual analog scale (VAS) and modified Odom criteria. RESULTS: As far as we know, this study is the largest case series examining the characteristics of PEMSLIDF. Seven (77.8%) of our patients were male and 2 (22.2%) were female and they had a mean age of 49.5 years (range 28-70 years). The mean duration from symptom onset to hospital admission was 7.4 days. Seven patients had CES. All patients underwent sequestrectomy and discectomy via posterior microsurgery. The patient outcomes were evaluated by the Modified Odom criteria and the outcome was excellent in two (22.2%) patients, good in 4 (44.5%), fair in 2 (22.2%), and poor in 1 (11.1%). CONCLUSION: The entire free fragment can usually be excised via the posterior microsurgery technique. Early surgical treatment is of great importance to prevent more serious neurological deficits.

Serum neuron-specific enolase as a predictor of short-term outcome and its correlation with Glasgow Coma Scale in traumatic brain injury.

Elevated serum neuron-specific enolase levels are correlated with brain cell damage. Low scores according to Glasgow Coma Scale are also considered as serious poor prognostic factor. The aims of the study were to investigate whether there is a correlation between the two measurements in patients with traumatic brain injury and whether serum neuron-specific enolase levels have potential as a screening test to predict outcome. A total of 169 consecutive patients with traumatic brain injury admitted to our clinic between 2002 and 2005 are included in this study. Those patients, who had any major health problem before trauma, were excluded from the study. However, patients with isolated head injury were included in the study. Serial serum neuron-specific enolase concentrations taken at the first 2, 24, and 48 h after traumatic brain injury were analyzed. A computed tomography was performed on each patient on admission. Their Glasgow Coma Scale scores were recorded serially. The relationship between Glasgow Coma Scale scores and the serum neuron-specific enolase levels were assessed by statistical methods. There was a significant negative correlation between the serum neuron-specific enolase levels and Glasgow Coma Scale scores. The levels of neuron-specific enolase were significantly higher in the patients who died in 30 days after trauma and whose scores were lower than or equal to 8 points in Glasgow Coma Scale. Although there are several serious limitations of the use of neuron-specific enolase as a biomarker in traumatic brain injury (i.e., hypoperfusion, extracranial trauma, bleeding, liver, or kidney damage also increase the level of neuron-specific enolase), its concentrations may be useful as a practical and helpful screening test to identify neurotrauma patients who are at increased risk and may provide supplementary estimation with radiological and clinical findings.

Spontaneous migration of a bullet into the brain.

We report the case of a 20-year-old man with a gunshot injury as an example of spontaneous migration of a metallic foreign body within the brain. Computed tomography (CT) showed the bullet in the left temporoparietal region. At 10 days follow-up, CT revealed that the bullet had migrated posteriorly, due to the effect of gravity, lodging in the occipital lobe. Although there are a few literature reports of spontaneous migration of a bullet within the brain, this case was unique as the patient was fully conscious without any neurological deficit.

Cerebral hydatid disease: CT and MR imaging findings.

OBJECTIVE: Cerebral hydatid disease is very rare, representing only 2% of all cerebral space occupying lesions even in the countries where the disease is endemic. The aim of this paper is to describe the characteristic features of cerebral hydatid disease in computed tomography (CT) and magnetic resonance imaging (MRI). METHODS: We retrospectively reviewed the CT and MR imaging findings of 18 patients with pathologically confirmed cerebral hydatid disease over a period of 13 years (1990-2002). RESULTS: The study group consisted of 17 cases of Echinococcus granulosus and 1 case of Echinococcus multilocularis (alveolaris). They were 12 male (66.7%), and 6 female patients (33.3%), ages ranging from 7 to 50 years with an average age of 20.3 years. Headache, vomiting and seizures were the predominant symptoms. Papilloedema was present in 14 patients (77.7%). Common CT and MR imaging findings of E. granulosus lesions were welldefined, smooth thin-walled, spherical, homogeneous cystic lesions with no contrast enhancement, no calcification, and no surrounding oedema. The lesion seen with E. multilocularis was a well-defined multiseptated mass consisting of solid and cystic components with calcification in the solid portion. Cystic lesions with surrounding hyperintensity of perifocal oedema with complete or incomplete rim enhancement were seen in two patients, and were labeled as complicated and infected cysts. CONCLUSION: Although cystic cerebral hydatid disease is well demonstrated by CT and MR examinations, CT is superior in detecting calcification in the cyst, when present, MR is better in demonstrating cyst capsule, detecting multiplicity and defining the anatomic relationship of the lesion with the adjacent structures, and it is more helpful in surgical planning.

Firearm-related mortality: a review of four hundred-forty four deaths in Diyarbakir, Turkey between 1996 and 2001.

The current study is based on a retrospective investigation of firearm deaths in Diyarbakir, which were autopsied by the Diyarbakir Branch of the Council of Forensic Medicine during the 6- year period. Four hundred-forty four deaths were investigated from January 1996 through December 2001, including homicide (296 cases, 66.7%), suicide (120 cases, 27%) and accidental shootings (28 cases, 6.3%). The age range of all firearm deaths in the study period was 5 to 75 years with a median age of 29.8 years. The majority were in the groups aged 16-25 years (38.7%). In the homicide group, 248 subjects (83.8%) were male, and 48 (16.2%) were female. The 31.1% of the homicide victims were in the group aged at 20-30 years. Of the 120 suicide victims, 56 (46.7%) were in the group aged 16-20 years. The head was by far the favoured site, accounting for 82 (68.3%) deaths: entry wounds in the right temple accounted for 72 of these. Twenty-eight cases were accidental shootings and 18 of them were male (64.3%). Twelve of the 28 accidental victims (42.9%) were in the group aged 0-10 years. The eight cases were due to their own accidental shootings, and the remaining 20 cases were shot by others. Our findings show that the contributing factors for increasing death by firearm are terrorists' activities, traditional habits of obtaining and using guns and blood feuds.

Preventive effects of intracisternal alphatochopherol on cerebral vasospasm in experimental subarachnoid haemorrhage.

Vasospasm is an important cause of morbidity and/or mortality with a subarachnoid haemorrhage (SAH). The roles of lipid peroxidation in a vasospasm caused by a SAH remain to be investigated. The effect of an intracisternal administration of alphatochopherol on a cerebral vasospasm was investigated in an experimental model. The authors assessed whether the administration of alphatochopherol reduced the vasospasm. By means of an intracisternal blood injection model, a SAH was induced in 30 rats, which were randomly divided into three groups, as follows: group I (G1), without a SAH and drug, group II (G2), a SAH alone, group III (G3), a SAH and alphatochopherol. Following the withdrawal of cerebrospinal fluid (CSF), a fresh unheparinized arterial blood was injected into the cisterna magna to induce a SAH. In G3, 20 U (0.4ml) alphatochopherol was intracisternally injected forty-five hours after induction of the SAH. All rats were sacrificed 72 hours after the induction. The basilar artery, with surrounding tissue, was removed from the cranium. The cross-sectional diameter of the lumen and vessel wall of the rat basilar artery was assessed from a planimetric analysis, and changes compared with G1 and G2. The reduction in the luminal cross-sectional diameter of the vessels exposed to subarachnoid blood was found to be 29.01 % (p=0.001). The group treated with alphatochopherol had a 9% reduction (p=0.004). The role of lipid peroxidation on a vasospasm caused by SAH is well known to be critical. Data from the present study indicated that antioxidant therapy, with topical alphatochopherol, may be promising on a vasospasm caused by a SAH.

Timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus.

Hydrocephalus is a common complication of tuberculous meningitis (TBM) in children. The aims of this study are to review our experience of hydrocephalus in childhood TBM and to evaluate the effect of the timing of ventriculoperitoneal shunting (VPS) on the final outcome. In this study, 156 patients with TBM and hydrocephalus were reviewed retrospectively between 1990 and 2000. Patients' ages ranged from 6 months to 15 years, with a mean age of 4.1 years. There were 85 boys, and the male-to-female ratio was 1.19:1.0. Sixty-two percent of the children were younger than 6 years old. VPS was performed 2 days after the diagnosis in 100 patients, and in the remaining 56 patients, 3 weeks after the diagnosis. The average follow-up period was 8.5 months. Good recovery or minor sequelae was seen in 82 patients (52.6%), and 51 died (12.3%). The timing of the VPS procedure and cerebral complications had an effect on the final outcome. Early VPS gave a better outcome in mild and moderate hydrocephalus (p = 0.040). This study has shown that early surgical procedure for mild/moderate hydrocephalus has a positive effect on the morbidity and mortality of hydrocephalus in childhood TBM (p = 0.014, p = 0.040, respectively). In severe hydrocephalus, there was a tendency for early shunting to have a positive effect on morbidity, although this did not reach statistical significance.

Analysis of 107 civilian craniocerebral gunshot wounds.

In this study, we present a retrospective analysis of 107 cases due to civilian craniocerebral gunshot wounds that were treated by the medical faculty of Dicle University during a period of 7 years (January 1993 to January 2000). Twenty patients died at the hospital, and the deaths were determined to result from direct effects of brain damage. Coma was the best prognostic guideline. Diffuse brain damage and ventricular injury, particularly infections, were associated with poor outcome.

Coexistence of a cerebellopontine epidermoid cyst with a pituitary adenoma.

We report on an 18-year-old girl with the coexistence of an epidermoid cyst in the cerebellopontine angle (CPA) with a pituitary adenoma. The clinical course and histopathological characteristics were reviewed. The patient presented with headache, vision loss and amenorea. Computerised tomographic (CT) scan and magnetic resonance imaging (MRI) examinations demonstrated a solid sellar lesion with supra-sellar extension. There was another mass lesion in the CPA with prepontine extension. The tumours were removed surgically. Histopathological examination revealed an epidermoid cyst in the prepontine area and a pituitary adenoma in the sellar region. This has been the second case to be reported in the literature with the coexistence of an epidermoid cyst and a pituitary adenoma.