Anterior cervical foraminotomy for unilateral spondylotic radiculopathy.

Anterior cervical foraminotomy (ACF) was developed under the concept of functional spine surgery, which directly eliminates compressive pathological factors while preserving functional anatomic features. The authors reviewed their results to determine the efficacy of the approach for unilateral cervical spondylotic radiculopathy (CSR). Nineteen patients were treated with the ACF with a follow-up from 12 to 36 months. There were 10 men and 9 women (mean age 49.8). Fourteen patients had a single ACF, and 5 had procedures at adjacent levels. The procedure involves microsurgical removal of the lateral portion of the uncinate process to identify the nerve root. Seventeen patients (89.5 %) were symptom-free or clearly improved, one (5.3 %) was unchanged and one patient (5.3 %) was worse in the visual analogue scale (VAS) score for radicular pain. One patient had developed contralateral foraminal stenosis at the level of the surgery and had undergone anterior discectomy and fusion. ACF provided good or excellent outcomes, with minimal morbidities, for patients with CSR. The advantages of ACF include direct decompression of the nerve root, and the preservation of the intervertebral disc and the motion segment. Thus, fusion-related sequelae, including graft-related complications, graft site complications and the adjacent level disease are avoided. The ACF procedure appears to be a good alternative for carefully selected patients with unilateral CSR.

Is skull fracture necessary for developing an intradiploic pseudomeningocele as a complication of head injury in adulthood?

We report the case of an adult with a posttraumatic intradiploic pseudomeningocele which caused an expanded osteolytic skull lesion. Local pain and swelling, the only symptoms of the lesion, regressed after surgery. Intradiploic pseudomeningocele must be distinguished from intradiploic leptomeningeal cyst, which is of traumatic origin or arachnoid cyst and epidermoid cyst, which are of congenital origin. We also discuss the development of intradiploic pseudomeningoceleafter head trauma without skull fracture in adulthood and suggest a possible mechanism.

Surgical treatment of thalamic hematomas via the contralateral transcallosal approach.

Acute management of deep-seated hematomas remains controversial. Since patients with these hematoma later tend to develop severe edema and necrosis around the lesion, when surgery is indicated it should be done as early as possible. The purpose of this study was to compare whether early surgical removal and conservative treatment of primary thalamic hematoma correlated with improved neurological outcome. Last year, 61 patients with primary thalamic hematomas were admitted to our institution. Of these, 21 underwent surgery via contralateral transcallosal approach during the ultraearly stage (within 6 hours) after the apoplectic attack, and 24 patients were treated conservatively. Another 16 patients were excluded from the study due to systemic disease, mild hematoma (<40 cc), and deep coma associated with absence of brain stem reflexes. Initial Glasgow coma scores (GCS) at admission were similar for operated and nonoperated patients (8.64 +/- 1.93 versus 9.50 +/- 2.10, P>0.05). In the operated group, two patients had good recoveries and returned to normal life (Glasgow Outcome Score, or GOS, I), four had moderate disability and needed partial care (GOS II), six had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). However, in the nonoperated group, one patient had good recovery and returned to normal life (GOS I), two had moderate disability and needed partial home care (GOS II), three had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). In this group, the 30-day mortality rate was 50%. Mortality was markedly lower in the operated group (14.3%) than the nonoperated group. and this difference was statistically significant (chi2=3.33, P<0.05). From this study, we believe that evacuation of primary thalamic hematoma via the contralateral transcallosal microsurgical approach may be useful for deciding on the indication and predicting the functional prognosis.

The effect of allopurinol on focal cerebral ischaemia: an experimental study in rabbits.

In this experimental study, the neuroprotective effect of the xanthine oxidase inhibitor allopurinol on focal cerebral ischaemia created by permanent middle cerebral artery occlusion (MCAO) was investigated. Using high performance liquid chromatography (HPLC), we measured hypoxanthine, xanthine, and uric acid (UA) levels in rabbit brains following focal cerebral ischaemia. Rabbits were randomly and blindly assigned into four groups of eight animals each. The control groups received 2% carboxymethylcellulose solution, while 10% allopurinol 150 mg/kg was given to the treatment group 1 h before ischaemia. Each group was subdivided into two groups which were sacrificed 4 h or 24 h after ischaemia, respectively. UA and xanthine values of the rabbits in the control groups were quite high at both times and highest after 24 h, particularly in the centre of the ischaemia. A significant decrease in UA and xanthine values was observed in rabbits that were given allopurinol (P<0.05). According to our results, it was concluded that allopurinol pretreatment protects neural tissue in the early period after arterial occlusion and prevents cerebral injury in the late period, especially in the perifocal area, possibly by preventing the formation of free radicals with xanthine oxidase inhibition.

Posterolaterally displaced type IIA odontoid fractures.

A case of type IIA odontoid fracture with posterolateral dislocation accompanied by spinal cord injury is presented. Cervical traction was employed but reduction could not be achieved with up to 8 kg of traction. The patient was treated with intraoperative reduction and C1-2 posterior transarticular screw fixation with supplemental bone-wire fusion, and rigid fixation was obtained without any complication.

Intradural lumbar disc herniation: report of two cases.

Intradural lumbar disc herniation (ILDH) is a rare pathology. The pathogenesis of ILDH is not known with certainty. Adhesions between the ventral wall of the dura and the posterior longitudinal ligament (PLL) could act as a preconditioning factor. Diagnosis of ILDH is difficult and seldom suspected preoperatively. Prompt surgery is necessary because the neurologic prognosis appears to be closely linked to preoperative duration of neurologic symptoms. Despite preoperatively significant neurological deficits, the prognosis following surgery is good. We report on two new cases of ILDH of high lumbar locations L1-2 and L2-3 with difficult differential diagnoses, and the possible pathogenic factors are discussed.

Hemilaminectomy for the removal of the spinal lesions.

OBJECTIVE: We evaluated 20 patients with spinal lesions with respect to the value of unilateral hemilaminectomy at the Department of Neurosurgery, Erciyes University, Medical Faculty, Kayseri, Turkey. The operative technique of the limited approach for spinal lesions is described. METHODS: The study is based on 20 prospective consecutive patients with spinal lesions who had unilateral hemilaminectomy. There were 12 women and eight men. Age ranged from 17 to 63 years mean (42 years) with a slight preponderance of women patients (60%). Spinal lesions were cervical in three cases, lumbar in five cases, and thoracic in 12 cases. Hemilaminectomy was performed by using a high speed drill. RESULTS: Postoperative neurological status was unchanged in six cases, improved in 11 cases, and worsened in three cases. We only observed two cases of wound infections that were not related to our surgical approach. At the follow-up evaluation, which occurred approximately 25 months after surgery none of the patients showed spinal deformity or spinal instability. CONCLUSION: The rationale of attempting unilateral approach is to avoid damage to the dorsal static structures of the vertebral column. With the precise preoperative definition of the relationship of tumor to the surface of the spinal cord by contrast enhanced MRI, unilateral approaches might be more applicable to spinal lesions except invasive extradural lesions.

Effect of EGb-761 on vasospasm in experimental subarachnoid hemorrhage.

Based on the previously suggested hypothesis that the generation of free radicals leading to lipid peroxidation is involved in the genesis of vasospasm and vasculopathy following subarachnoid hemorrhage, the therapeutic effect of EGb 761 as an antioxidant on experimental vasospasm and vasculopathy was evaluated in a double hemorrhage dog model of chronic cerebral vasospasm. For this study 14 dogs were randomly assigned to two groups, a control and a Ginkgo biloba group. The control group was only administered saline in a volume equivalent to a dose of 100 mgEGb 761/kg while the treatment group was given 100 mg EGb 761/kg. The diameter of the basilar artery decreased from 1.95 +/- 0.16 mm at day 0 to 1.11 +/- 0.07 mm at day 8 in the control group, while in the treatment group the vessel diameter decreased from 2.01 +/- 0.17 mm at day 0 to 1.72 +/- 0.16 mm at day 8. These results correspond a decrease in vessel diameter of 15.1% in the treatment group and of 43.1% in the control group (P < 0.05). Histopathological studies of the specimens obtained from basilar arteries showed that pathological signs of proliferative vasculopathy, including narrowing of the vessel lumen, corrugation of the lamina elastica and subendothelial thickening, were present in all the animals in the control group, while they could not be demonstrated in the Ginkgo biloba group. These results suggest that Ginkgo biloba may have a protective effect against subarachnoid hemorrhage-induced vasospasm and vasculopathy as a result of antioxidants.

Therapeutic effect of tirilazad mesylate (U-74006F), mannitol, and their combination on experimental ischemia.

The effect of tirilazad mesylate (U-74006F), mannitol, and their combination was investigated on focal cerebral ischemia induced by permanent middle cerebral artery (MCA) occlusion in rabbits. Rabbits were divided into four groups receiving vehicle, U-74006F, mannitol, and U-74006F plus mannitol. Hematocrit (hct), glucose, mean arterial blood pressure (MABP), pH, PCO2, and PO2 were measured both before and after occlusion. Seventy-two hours following the permanent MCA occlusion, the neurological outcome was assessed and a quantitative neuropathologic examination was performed in all rabbits. The neurological outcome was better in the rabbits treated with U-74006F plus mannitol than in the other groups. The size of infarction of the affected hemisphere following MCA occlusion was 49.7% in the control group, 30.6% in the U-74006F group, 47.6% in the mannitol group, and 24.1% in the U-74006F plus mannitol group. There was a statistically significant reduction in infarct size in the U-74006F plus mannitol group compared with the other groups (P < 0.05). The ratio of ischemic neurons to total neurons in the cortex was smaller in the U-74006F plus mannitol group than in the other groups. The ratio of ischemic neurons to total neurons in the subcortex was significantly lower in the U-74006F plus mannitol group than in the other groups (P < 0.05). Our data provide evidence for the beneficial effects of both U-74006F and U-74006F plus mannitol in promoting neurological recovery and preservation of the ischemic area.

Successful surgical treatment of a thalamic hydatid cyst with contralateral transcallosal approach. Case report and review of the literature.

An extremely rare case of a thalamic hydatid cyst is presented and the literature is reviewed. A right thalamic hydatid cyst without rim enhancement or perifocal edema was detected by computed tomography and magnetic resonance. This lesion was extirpated successfully with intact contents via contralateral transcallosal approach. To our knowledge, this is the second hydatid cyst of the thalamus, an unusual location, and the first hydatid cyst to be removed completely with intact contents reported in the literature.

Failure of open third ventriculostomy for shunt infections in infants.

Open third ventriculostomy (OTV) was performed on 4 infants with noncommunicating hydrocephalus and intractable shunt infections. All patients were resistant or relapsed after treatment with intravenous and intraventricular antibiotics along with change of the shunt apparatus. We performed phase-contrast cine magnetic resonance imaging (MRI) for preoperative and postoperative evaluation of cerebrospinal fluid (CSF) flow at the aqueduct of Sylvius. All patients required a second OTV approximately 3 weeks after the first OTV due to closure of the patency. Our experience led us to view OTV as an unsuccessful procedure in infantile noncommunicating hydrocephalus due to an insufficiently developed subarachnoid space. The patients' data, operative findings and probable causes of failure are presented here.

Lipid peroxidation and oedema in experimental brain injury: comparison of treatment with methylprednisolone, tirilazad mesylate and vitamin E.

Trauma-induced lipid peroxidation (LP) is one of the most important factors that produces tissue damage in head trauma. In the present study, the protective effects of free radical suppression with methylprednisolone (MP), tirilazad mesylate (TM) and vitamin E on the development of cerebral LP and oedema resulting from head trauma have been investigated. Rats were divided randomly into four groups. Bolus injections of physiological saline, MP (initial 30 mg/kg for 1 h, continuing administration of 5.4 mg/kg per hour until 24 h), TM (10 mg/kg), or vitamin E (30 mg/kg) were given 1 h after the head trauma. The animals were killed 24 h after the weight-drop injury for removal of the brain, and the malondialdehyde (MDA) level and water content of the brain were determined. Rats treated with TM had MDA levels which decreased significantly in comparison with the control group (P<0.03), and none of the drugs had an effect on LP and water content of the brain (P>0.05) that was statistically different. These findings demonstrated the beneficial effect of TM in this model of experimental brain injury.

Growing skull fracture of the orbital roof. Case report.

Growing skull fractures are rare complications of head trauma and very rarely arise in the skull base. The clinical and radiological finding and treatment of a growing fracture of the orbital roof in a 5-year-old boy are reported, and the relevant literature is reviewed. The clinical picture was eyelid swelling. Computed tomography (CT) scan was excellent for demonstrating the bony defect in the orbital roof. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Growing skull fracture of the orbital roof should be considered in the differential diagnosis in cases of persistent ocular symptoms. Craniotomy with excision of gliotic brain and granulation tissue, dural repair and cranioplasty is the treatment of choice.

Effect of methylprednisolone, tirilazad mesylate and vitamin E on lipid peroxidation after experimental spinal cord injury.

Effect of methylprednisolone (MP), tirilazad mesylate (TM) and vitamin E on lipid peroxidation (LP) was evaluated in an experimental model of spinal cord compression injury in anesthetized rats. Forty rats, divided randomly into four groups, were injured by compressing on the spinal cord at Th 3 for 1 min. Bolus injections of saline solution, MP (30 mg/kg bolus and 5.4 mg/kg/h), TM (10 mg/kg four times per day), or vitamin E (30 mg/ kg four times per day) were begun 1 h after the spinal cord injury (SCI). Twenty-four hours after treatment, the rats were killed, and malondialdehyde (MDA), a LP product, was measured in the spinal cord tissues. Rats treated with MP, TM and vitamin E had significantly decreased MDA levels (P<0.01) than rats in the control group. The lowest MDA levels were found in the TM group. These results suggest that MP, TM and vitamin E may have a protective effect against SCI in rats by its antioxidant effect.

Extradural hematoma of the posterior cranial fossa.

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological finds are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Acute spontaneous subdural hematoma of arterial origin: a report of five cases.

Acute spontaneous subdural hematoma of arterial origin is very rare. We report five patients who presented with a history of sudden onset of severe headache and vomiting and who developed progressive neurologic deficits, three becoming comatose. The symptomatologic onset was indistinguishable from other cerebrovascular disorders; none of the patients had a history of head trauma. In all our patients, the source of bleeding was identified at operation as a cortical artery located near the Sylvian region. Comparable cases in the literature are reviewed and the etiologic possibilities are discussed.

Postoperative mutism after the clipping of a distal anterior cerebral artery aneurysm. A case report.

A 40-year-old man with mutism developed after clipping a left distal anterior cerebral artery aneurysm is presented. The most characteristic presenting symptom was complete absence of speech with unimpaired consciousness which occurred on the fourth day after operation. The patient recovered spontaneously within three weeks. In this paper we discuss the possible pathogenesis and anatomical location of mutism related to a distal anterior cerebral aneurysm in view of the literature.

Acute subdural hematoma: outcome and outcome prediction.

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome. Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively. Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9-15) and 23% of patients with a low GCS score (3-8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21-40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion. Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.

Ganglioglioma of conus medullaris: a case report.

A case of a ganglioglioma of the conus medullaris extending between T-12 and L2 segments is reported. The tumor was successfully removed by third stage operation. Ganglioglioma located in the conus medullaris is extremely rare. The best treatment of spinal cord ganglioglioma is totally tumor excision even when multiple stage operations are necessary.