Morphometric analysis of significant vascular structures in posterior disc surgery with computed tomography angiography.

BACKGROUND: Vascular injuries, which are rarely seen in all spinal area procedures, especially lumbar disc surgery, are vitally important. The relationship between the course of the iliac artery and vein and intervertebral disc distance was studied morphometrically in patients who had undergone computed tomography angiography for abdominal aorta. METHODS: This study was carried out retrospectively. A total of 100 patients who had undergone computed tomography angiography participated in the study. The aorta bifurcation, right and left common iliac artery (R/LCIA) and vein (R/LCIV), and the location of the common iliac artery bifurcation were investigated. The location of these vascular structures at the level of the spinal vertebral body and at the intervertebral disc level, determination of a fat plane between them, and the anterior longitudinal ligament (ALL) were analyzed. RESULTS: At the L4-5 intertransversarius dorsalis (IDL), the RCIV was determined to be at the 12 o'clock position RCIA in 51% of cases and between the ratio of 67% ALL. The LCIA was at the 1 o'clock position in 72% and adjacent to the ALL in 47%. The RCIV was located in the 11 o'clock position and there was no fat plane between the RCIV and the ALL in 92%. In 80%, the LCIV was located at the 11-12 o'clock position and in 18% transversely along the 12-1-2 o'clock region. There was no fat plane between the LCIV and the ALL in any patient. At the L5-S1 IDL, the RCIA was observed at the 10 o'clock position in 63%, and there was no fat plane between the RCIA and the ALL. The LCIA was at the 2 o'clock position in 72% and the LCIV was between the ALL and the LCIA in 92%. The RCIV was located at the 9-10 o'clock position in 95% and no fat plane was found between the ALL and the RCIV in 60%. The LCIV was located at the 1-2 o'clock position in 96% and there was no fat plane between the LCIV and the ALL in 92%; it was located close to the ALL. CONCLUSION: The L4-5 IDL RCIA was located at the midline and at a 30° angle position. The LCIV was located between them. The L5-S1 IDL located at LCIA left at 60° position was quite close to ALL with LCIV. When the distance from the ALL was compared and the frequency of fat planes between the ALL and the CIAs are considered, it can be noted that the RCIA in the L4-L5 IDL (p<0.001) and the LCIA in the L5-S1 IDL (p<0.001) were located remotely and in a more protected position. It should be kept in mind that the LCIV can progress along the L4-5 ID level, adjacent to the ALL, as well as transversely.

Endoscopic Removal of a Bullet That Migrated to the Third Ventricle Causing Hydrocephalus.

BACKGROUND: Hydrocephalus caused by an intraventricular bullet is a rare event. We report a case of endoscopic removal of an intraventricular bullet. CASE DESCRIPTION: A 66-year-old man was admitted with a gunshot wound to the head after a suicide attempt. The bullet migrated from the frontal parenchyma to the third ventricle day 4 of admission. On day 21 of admission, the patient developed hydrocephalus with obstruction of the cerebral aqueduct. The bullet was accessed through an endoscopic third ventriculostomy and removed using an endoscope. CONCLUSIONS: Hydrocephalus may develop in patients with intraventricular foreign objects. When such objects must be removed, the endoscopic approach is a safe, efficient, and minimally invasive procedure. To our knowledge, this is the first case in the literature of foreign object removal from the ventricle via a transcortical endoscopic approach.

Chiari Type I malformation yielded to the diagnosis of Crouzon syndrome.

Chiari malformation Type I (CM-I) related to syndromic craniosynostosis in pediatric patients has been well-studied. The surgical management consists of cranial vault remodeling with or without posterior fossa decompression. There were also cases, in whom CM-I was diagnosed prior to the craniosynostosis in early childhood. We present a 16-year-old boy who admitted with symptoms related to CM-I. With careful examination and further genetic investigations, a diagnosis of Crouzon syndrome was made, of which the patient and his family was unaware before. The patient underwent surgery for posterior fossa decompression and followed-up for Crouzon's syndrome. To our knowledge, this is the only case report indicating a late adolescent diagnosis of Crouzon syndrome through clinical symptoms of an associated CM-I.

An upper thoracic spinal cord tumor presenting as hemifacial hyperhidrosis.

BACKGROUND: Hyperhidrosis as the sole presenting symptom of an upper thoracic intramedullary tumor has never been reported in the English literature. CASE DESCRIPTION: A 17-year-old boy presented with a long history of hemifacial flushing and hyperhidrosis on the left side of his face and neck. The MRI revealed a large spinal cord tumor at the T1-T2 levels. The patient underwent total excision of the intramedullary tumor via a posterior myelotomy. The histopathological diagnosis was low-grade astrocytoma. The symptoms resolved immediately after the surgery and did not return during the follow-up period of 9 months. CONCLUSIONS: We suggest that sympathetic irritation on the left side is the mechanism behind this clinical presentation. Its unusual presentation and lack of motor and sensory deficits resulted in delayed diagnosis of this potentially disabling lesion. When autonomic dysfunction of the face and neck is encountered, in addition to the cranial and cervical regions, the upper thoracic levels should be investigated using MRI.