Demographic and anatomical comparison of ruptured and unruptured intracranial aneurysms: a case control study.

BACKGROUND: Our understanding of the pathophysiology and management of intracranial aneurysms (IAs) continuously advances. This case-control study analyzed the demographics of patients with IAs and the morphological Digital Subtraction Angiography (DSA) characteristics of ruptured and unruptured IAs. METHODS: Two patient groups with saccular ruptured and unruptured IAs eligible for coiling were prospectively analyzed during a 3-year period. Patient groups were compared regarding gender, age, arterial vasculature side, anatomical location, diameter, preoperative DSA appearance, aneurysmal and anatomical Circle of Willis variations (CWV) co-existence. RESULTS: One hundred and three patients with ruptured and eighty-six patients with unruptured IAs were studied. Anterior communicating and internal carotid artery IAs were the dominant locations: 42.7 % and 23.3 % in ruptured and 29 % and 41.9 % in unruptured IAs, respectively. The female-to-male ratio was 1.78 in ruptured and 2.44 in unruptured IAs (p =0.317), while the rupture was more frequent in younger patients (p =0.034). Angiographically, smaller diameter (p =0.01), abnormal morphology (p =0.0001), and co-existence of CWV (p =0.016) were reported in ruptured IAs. Location at bifurcation/trifurcation (p =0.487) and the co-existence of additional or mirror IA did not differ significantly (p =0.879). CONCLUSIONS: On DSA, ruptured and unruptured IAs differed in size, morphology, and co-existence of CWV; findings that may favor the treatment of specific unruptured IAs. However, a higher level of evidence is needed to include all these factors in the treatment decision process, provide patient-oriented treatment and reliably identify unruptured IAs at greater risk. HIPPOKRATIA 2021, 25 (3):100-107.

Association of the bleeding time test with aspects of traumatic brain injury in patients with alcohol use disorder.

BACKGROUND-AIM: Traumatic brain injury (TBI) and alcohol use disorder (AUD) can occur concomitantly and be associated with coagulopathy that influences TBI outcome. The use of bleeding time tests in TBI management is controversial. We hypothesized that in TBI patients with AUD, a prolonged bleeding time is associated with more severe injury and poor outcome. MATERIAL AND METHODS: Moderate and severe TBI patients with evidence of AUD were examined with bleeding time according to IVY bleeding time on admission during neurointensive care. Baseline clinical and radiological characteristics were recorded. A standardized IVY bleeding time test was determined by staff trained in the procedure. Bleeding time test results were divided into normal (≤ 600 s), prolonged (> 600 s), and markedly prolonged (≥ 900 s). Normal platelet count (PLT) was defined as > 150,000/µL. This cohort was compared with another group of TBI patients without evidence of AUD. RESULTS: Fifty-two patients with TBI and AUD were identified, and 121 TBI patients without any history of AUD were used as controls. PLT was low in 44.2% and bleeding time was prolonged in 69.2% of patients. Bleeding time values negatively correlated with PLT (p < 0.05). TBI patients with markedly prolonged values (≥ 900 s) had significantly increased hematoma size, and more frequently required intracranial pressure measurement and mechanical ventilation compared with those with bleeding times < 900 s (p < 0.05). Most patients (88%) with low platelet count had prolonged bleeding time. No difference in 6-month outcome between the bleeding time groups was observed (p > 0.05). Subjects with TBI and no evidence for AUD had lower bleeding time values and higher platelet count compared with those with TBI and history of AUD (p < 0.05). CONCLUSIONS: Although differences in the bleeding time values between TBI cohorts exist and prolonged values may be seen even in patients with normal platelet count, the bleeding test is a marker of primary hemostasis and platelet function with low specificity. However, it may provide an additional assessment in the interpretation of the overall status of TBI patients with AUD. Therefore, the bleeding time test should only be used in combination with the patient's bleeding history and careful assessment of other hematologic parameters.

Endonasal endoscopic repair of cerebrospinal fluid leaks versus craniotomy: comparison of the outcomes.

BACKGROUND: Cerebrospinal fluid (CSF) leaks have been traditionally managed via craniotomy with an intradural repair. The endonasal endoscopic approach represents a minimally invasive alternative. This study aimed to compare the outcomes of the two methods. CASE SERIES: This is a prospective case series of 18 consecutive patients who underwent endonasal repair of a CSF leak. Thirteen variables were evaluated during the study, including age, gender, body mass index, site of the defect, CSF leak etiology, days of hospitalization, use of lumbar drainage, the success of repair, complications, recurrence, duration, and cost of surgery as well as patient satisfaction. The outcomes were compared with a historical cohort of 25 patients treated for CSF leaks with a craniotomy. Though we found no significant difference in the success of the repair, the endoscopic group had a significantly shorter duration of the procedure and hospitalization, a lower rate of complications, lower cost, and higher patient satisfaction. CONCLUSION: The presented data further solidify the endoscopic approach as the preferred method to address CSF leaks located in the anterior and middle skull base in cases not associated with complex intracranial pathology. Hippokratia 2016, 20(4): 299-302.

Primary and coupled motions after cervical total disc replacement using a compressible six-degree-of-freedom prosthesis.

This study tested the hypotheses that (1) cervical total disc replacement with a compressible, six-degree-of-freedom prosthesis would allow restoration of physiologic range and quality of motion, and (2) the kinematic response would not be adversely affected by variability in prosthesis position in the sagittal plane. Twelve human cadaveric cervical spines were tested. Prostheses were implanted at C5-C6. Range of motion (ROM) was measured in flexion-extension, lateral bending, and axial rotation under ± 1.5 Nm moments. Motion coupling between axial rotation and lateral bending was calculated. Stiffness in the high flexibility zone was evaluated in all three testing modes, while the center of rotation (COR) was calculated using digital video fluoroscopic images in flexion-extension. Implantation in the middle position increased ROM in flexion-extension from 13.5 ± 2.3 to 15.7 ± 3.0° (p < 0.05), decreased axial rotation from 9.9 ± 1.7 to 8.3 ± 1.6° (p < 0.05), and decreased lateral bending from 8.0 ± 2.1 to 4.5 ± 1.1° (p < 0.05). Coupled lateral bending decreased from 0.62 ± 0.16 to 0.39 ± 0.15° for each degree of axial rotation (p < 0.05). Flexion-extension stiffness of the reconstructed segment with the prosthesis in the middle position did not deviate significantly from intact controls, whereas the lateral bending and axial rotation stiffness values were significantly larger than intact. Implanting the prosthesis in the posterior position as compared to the middle position did not significantly affect the ROM, motion coupling, or stiffness of the reconstructed segment; however, the COR location better approximated intact controls with the prosthesis midline located within ± 1 mm of the disc-space midline. Overall, the kinematic response after reconstruction with the compressible, six-degree-of-freedom prosthesis within ± 1 mm of the disc-space midline approximated the intact response in flexion-extension. Clinical studies are needed to understand and interpret the effects of limited restoration of lateral bending and axial rotation motions and motion coupling on clinical outcome.

Restoration of spinal alignment and disk mechanics following polyetheretherketone wafer kyphoplasty with StaXx FX.

BACKGROUND AND PURPOSE: EPFs sustained during VCFs degrade the disk's ability to develop IDP under load. This inability to develop pressure in combination with residual kyphotic deformity increases the risk for adjacent vertebral fractures. We tested the hypothesis that StaXx FX reduces kyphosis and endplate deformity following vertebral compression fracture, restoring disk mechanics. MATERIALS AND METHODS: Eight thoracolumbar, 5-vertebrae segments were tested. A void was selectively created in the middle vertebra. The specimens were compressed until EPF and to a grade I-II VCF. PEEK wafer kyphoplasty was then performed. The specimens were then tested in flexion-extension (±6 Nm) under 400-N preload intact, after EPF, VCF, and kyphoplasty. Endplate deformity, kyphosis, and IDP adjacent to the fractured body were measured. RESULTS: Vertebral body height at the point of maximal endplate deformity decreased after EPF and VCF and was partially corrected after StaXx FX, remaining less than intact (P = .047). Anterior vertebral height decreased after VCF (P = .002) and was partially restored with StaXx FX, remaining less than intact (P = .015). Vertebral kyphosis increased after VCF (P < .001) and reduced after StaXx FX, remaining greater than intact (P = .03). EPF reduced IDP in the affected disk in compression-flexion loading (P < .001), which was restored after StaXx FX (P = 1.0). IDP in the unaffected disk did not change during testing (P > .3). CONCLUSIONS: StaXx FX reduced endplate deformity and kyphosis, and significantly increased anterior height following VCF. Although height and kyphosis were not fully corrected, the disk's ability to pressurize under load was restored.

Clinical outcome following surgical treatment for bilateral cerebellar infarction.

OBJECTIVES: To analyze the initial clinical and radiological findings, the surgical treatment, and the clinical outcome following surgical decompression in patients with space-occupying bilateral cerebellar infarction. MATERIALS AND METHODS: Ten patients with expansive bilateral cerebellar infarction and decreased level of consciousness were operated with suboccipital craniectomy, removal of the infarcted tissue, and placement of external ventricular drainage. Long-term outcome was assessed using the modified Rankin scale (mRS). RESULTS: Mean Glasgow coma scale (GCS) score before surgery was 8.9 ± 3.3 and improved to 12.6 ± 3.6 at discharge. At the long-term follow-up (median 57.6 months), six patients had a favorable outcome (mRS 1.3 ± 0.8). Four patients, all with an associated brain stem infarct, had a poor outcome. CONCLUSIONS: In the absence of brain stem infarcts, surgical treatment resulted in a favorable clinical outcome and should be considered a treatment option for patients with expansive bilateral cerebellar infarction.

Spondylolysis: a review and reappraisal.

The aim of this review was to provide of the current knowledge in pathophysiology, diagnosis and management of spondylolysis based on the authors' experience and the pertinent medical literature. Spondylolysis represents a weakness or stress fracture in one of the bony bridges that connect the upper with the lower facet joints of the vertebra. It is the most common cause of low back pain in young athletes. One-half of all paediatric and adolescent back pain in athletic patients is related to various disturbances in the posterior elements including spondylolysis. The most common clinical presentation of spondylolysis is low back pain. This is aggravated by activity and is frequently accompanied by minimal or no physical findings. A pars stress fracture or early spondylolysis are common and a misdiagnosis is often made. Plain radiography with posteroanterior (P-A), lateral and oblique views have proved very useful in the initial diagnostics of low back pain, but imaging studies such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans are more sensitive in the establishment of the diagnosis. Several treatment options are available. Surgical treatment is indicated only for symptomatic cases when conservative methods fail. The fact that early and multiple imaging studies may have a role in the diagnosis of pars lesions and the selection of the optimal treatment approaches is also highlighted.

An immunohistochemical study of mechanoreceptors in lumbar spine intervertebral discs.

There are limited data concerning mechanoreceptors in normal human lumbar intervertebral discs. The aim of our study was to determine the types of mechanoreceptors in the two lower intervertebral discs in normal adult cadaveric donors and to review the literature. Twenty-five lumbar (L4-5 and L5-S1) intervertebral discs were retrieved from 15 fresh cadavers. We utilized immunoreactivity against the S-100 protein to localize specialized nerve endings. Immunoreactivity showed receptors in 92% of discs. The most frequent type had morphology resembling the Ruffini type receptor (88%), followed by the Golgi type. Free nerve fibers were frequently present. All neural structures were found in the superficial layers of the annulus fibrosus, in longitudinal ligaments, or between these two. The anterior part of the L5-S1 disc had a greater frequency of encapsulated receptors than the other parts (p=0.022), which may be correlated with the high shear forces to which the lumbosacral junction is subjected.

Long-term follow-up of a non-infantile desmoplastic ganglioglioma.

Desmoplastic gangliogliomas are mixed cerebral tumors traditionally reported in infants. However, a few non-infantile cases have been documented. A case of a desmoplastic ganglioglioma in a 16-year male is presented. The patient reported severe headaches. Radiological examination revealed a large mass occupying the right frontal lobe. The lesion was totally excised. Histopathological examination confirmed the diagnosis of a desmoplastic ganglioglioma. The postoperative course was excellent. At the 10(1/2) year follow-up there was no evidence of tumor recurrence. Although desmoplastic gangliogliomas have aggressive features, complete surgical removal is the treatment of choice obviating the need for adjuvant therapy.

Methicillin resistant staphylococcus aureus thoracic spondylitis late after cervical spine surgery.

BACKGROUND: Spondylodiscitis is a known and serious complication of spinal surgery. A rare case of a late and remote thoracis spondrylitis due to methicillin resistant staphylococcus aureus following cervical surgery is presented. CASE REPORT: A 50 year-old-male was treated for cervical degenerative disease via a combined anterior and posterior cervical approach (discectomy with fusion and laminectomy). Three years later a cervical epidural abscess was formed which was treated successfully conservatively. After 18 months he developed spondylitis of the second thoracic vertebra. The patient was further treated surgically via a dorsolateral extracavitary thoracic approach. Laboratory analysis revealed Methicillin Resistant Staphylococcus Aureus (MRSA) spondylitis sensitive to linezolid. Inflammation markers declined and clinical symptoms ameliorated. At 12-month follow-up the patient did not show any evidence of recurrence of the infection. CONCLUSIONS: A high rate of suspicion must be maintained in patients presenting with signs of spinal infection and neurological impairment even many years after the initial operation. Optimal investigation and outcome require close clinical monitoring and a well coordinated multidisciplinary approach.

Multifocal glioblastoma with remote cutaneous metastasis: a case report and review of the literature.

BACKGROUND: Remote extracranial mestastases of glioblastoma multiforme (GBM) are uncommon, while cutaneous seeding at a distance from the operative site appears to be even more unusual. CASE REPORT: A 63-year-old man presented with focal seizures and mental impairment. Computed tomography (CT) scan revealed a left frontoparietal mass. He underwent a gross total removal of the tumor. The tissue diagnosis was that of a GBM. Seven months later, the patient developed a left scapular subcutaneous mass. Fine-needle aspiration cytology (FNAC) was performed and the cytological findings disclosed again a GBM. One month later, after clinical deterioration, a repeat magnetic resonance imaging (MRI) scan was carried out which demonstrated two new distinct lesions in the opposite hemisphere, as in a multifocal GBM. Both lesions were biopsed under stereotactic guidance and the recurrence of GBM was confirmed. The patient died ten months after the primary diagnosis of the intracranial GBM. CONCLUSION: Improved diagnostic modalities and prolonged survival have increased the likelihood of detection of extracranial mestastases from GBM. This potential may be greater in multifocal GBM. FNA is a valuable method for the definite diagnosis of metastatic GBMs. Although several theories have been postulated, the route of remote cutaneous dissemination and the mechanism of multifocal recurrence remain to be elucidated.

Intracranial arachnoid cyst associated with traumatic intracystic hemorrhage and subdural haematoma.

BACKGROUND: Brain arachnoid cysts are fluid collections of developmental origin. They are commonly detected incidentally in patients imaged for unrelated symptoms. CASE DESCRIPTION: A 15-year-old healthy boy with a recent history of head trauma experienced headache that gradually worsened over the course of 10 days. He underwent CT and MRI brain scans which revealed the presence of subdural haematoma caused by the rupture of a middle cranial fossa arachnoid cyst. This was accompanied by intracystic haemorrhage. The subdural haematoma was removed, while communication of the cyst with the basal cisterns was also performed. The postoperative course of the patient was uneventful. CONCLUSIONS: The annual haemorrhage risk for the patients with middle cranial fossa cysts remains very low. However, when haemorrhage occurs, in most occasions it can be effectively managed only with haematoma evacuation.

Evidence of lateral antebrachial cutaneous nerve entrapment during autopsy.

Compression of the lateral cutaneous nerve of the forearm is a rare clinical entrapment syndrome. This report describes the compression of the lateral antebrachial cutaneous nerve at the level of the lateral margin of the biceps brachii tendon identified during autopsy. This is the first cadaveric case reported in the literature. The anatomy, the possible areas of entrapment, the most frequent diagnostic problems and the main therapeutic options for this rare occurrence are also discussed.

Variability in superior hypogastric plexus morphology and its clinical applications: a cadaveric study.

BACKGROUND: The superior hypogastric plexus (SHP) that is formed anterior to the aorta and the sacral promontory and is located anterior to the L5-S1 vertebrae, normally continues as the inferior hypogastric plexus. Several variations have been described from a single trunk to a plexiform arrangement. MATERIALS AND METHODS: The SHP was dissected in 35 formalized cadavers. RESULTS: A single thin and rounded nerve was found in 17.14% of subjects. The type of a wide reticular formation was observed in 28.57% of specimens. Interestingly, a band-like nerve trunk consisting of nerve bundles connected with loose connective tissue was evident in 22.85% of cadavers. Eventually, two distinct nerves at a short distance with each other were found in 31.44% of subjects. Furthermore, we found that branches of the major and minor splanchnic nerves contributed to SHP constitution. We provided, additionally, the topographic anatomy of the SHP with regard to the sacral promontory and the abdomen midline. CONCLUSION: A detailed knowledge of the course, the morphology, the various forms and the topography of the SHP is of outmost significance for several clinical specialties.

Persistent primitive hypoglossal artery: an incidental autopsy finding and its significance in clinical practice.

Persistent primitive hypoglossal artery (PPHA) is a recognised, albeit infrequent, intracranial vascular anomaly usually detected during angiography. Its presence is associated with an increased incidence of aneurysm, arteriovenous malformation and ischaemic stroke. A unique case of PHHA discovered during autopsy is described. Additionally, the significance of PPHA in neuroscience is discussed in detail.

Coexistence of spinal intramedullary teratoma and diastematomyelia in an adult.

STUDY DESIGN: A case report of intramedullary spinal cord teratoma with remote diastematomyelia in a female adult. OBJECTIVE: To present a rare case of a dysembryogenic spinal tumor with concurrent split cord malformation and to define the importance of early surgical removal of the tumor. SETTING: A department of neurosurgery in Greece. METHODS: A 44-year old woman, presented with progressive lower limb muscle weakness, gait disturbances and dysesthesias in the trunk and lower extremity. She underwent plain radiographs, CT and MRI scan, which revealed an exophytic intramedullary spinal cord tumor at the level of T8-T10 and distant diastematomyelia in the upper lumbar spine (L2-L3). She underwent surgical intervention. The tumor was subtotally removed. No attempt was made to treat diastematomyelia. RESULTS: Postoperatively, the patient's neurological status started to improve gradually. After 1 year she exhibited better strength in the lower limb muscles and improved sensation. The histological examination demonstrated mature spinal teratoma consisting of ectodermal, mesodermal and endodermal elements. CONCLUSIONS: In adult patients with intramedullary masses of possible dysembryogenic origin, the whole spine must be examined for additional dysraphic lesions. The choice and the timing of a surgical intervention are strongly dependent on the clinical picture.

Spinal manifestation of metastasizing leiomyosarcoma.

STUDY DESIGN: Case report. OBJECTIVE: To provide additional information on possible relations between uterine and spinal manifestations of leiomyosarcoma. SUMMARY OF BACKGROUND DATA: Spinal metastases and primary spinal manifestation of leiomyosarcoma and other malignant smooth muscle tumors are rarely observed. METHODS: Clinical and radiologic follow-up of a patient with a spinal tumor. RESULTS: A 46-year-old women had rapidly progressive paraplegia caused by an extramedullary lesion in the extradural space at T2-T3, with spinal cord compression. After surgical decompression, the resected tumor was histologically classified as a leiomyosarcoma. Diagnostic work-up failed to detect the primary tumor site. Previous medical history had been uneventful except for hysterectomy 3 years earlier for a leiomyoma. Extended necroses and focal metaplasia were already described in the hysterectomy specimen indicating malignant disease; however, it was not definitely diagnosed. Multiple leiomyosarcoma metastases developed 22 months later. CONCLUSIONS: In retrospect, the origin of the leiomyosarcoma that manifested in the thoracic spine of the patient must be reconsidered. Rather than a primary dural leiomyosarcoma, this tumor represented the first evidence of recurrence of a missed diagnosis of early-stage uterine leiomyosarcoma.

Solid cerebral echinococcosis mimicking a primary brain tumor.

Solitary brain affection is rare in echinococcosis. We report the case of a 35-year-old woman presenting with symptomatic grand-mal epilepsy due to a right frontal, partially cystic space-occupying lesion. Pre-operative computed tomography and magnetic resonance imaging (MRI) suggested a cystic astrocytoma. However, histological examination yielded the diagnosis of a 'chitinoma', a rare subtype of solid cerebral hydatid disease (echinococcosis). It mimicked a primary brain tumor and, therefore, posed a diagnostic problem. We present the--to our knowledge--first MRI scans in a case of a histologically proven chitinoma.

Dermatomal SEPs--a complementary study in evaluating patients with lumbosacral disc prolapse.

We investigated the value of Dermatomal Somatosensory Evoked Potentials in 24 patients with unilateral radiculopathy due to lumbosacral disk prolapse. All patients had clinical signs and symptoms of disk prolapse and positive findings on neuroradiologic testing. We assessed the latency and the amplitude of the first positive waveform of Dermatomal SEPs, as well as conducting peripheral nerve conduction studies and electromyography. Our studies showed a clear correlation of Dermatomal SEP abnormalities and radiculopathy in up to 83.3% of subjects studied. Use of electromyography testing provided this correlation in about 62.5% of the same subjects. On the basis of these results, we propose that Dermatomal SEPs have value in complementing the routine electrophysiological testing of the patients with radiculopathy and provide a sensitive non-invasive technique for defining the level of disk prolapse.

Comparison of dermatomal SEPs and operative findings in lumbar disc disease.

This report deals with an estimation of the diagnostic value of dermatomal somatosensory evoked potentials (SEPs), by correlating the neurophysiological data to clinical, neuroradiological and operative findings in lumbar disc protrusion. Our material consists of 12, surgically treated patients with lumbar disc protrusion in which diagnostic work up included history, neurological examination, routine lumbar spine films, computerised tomography and MRI of the lumbar spine, in addition to neurophysiological investigation, especially conduction velocity studies, and SEPs recorded by the standard methods, as well as after dermatomal stimulation. The retrospective analysis disclosed a correlation for the SEPs after dermatomal stimulation and surgical findings, in 83% of our cases.