NMDA receptor blockage with 2-amino-5-phosphonovaleric acid improves oxidative stress after spinal cord trauma in rats.

STUDY DESIGN: 2-amino-5-phosphonovaleric acid (APV) is an N-methyl-D-aspartate (NMDA) receptor blocker and has neuroprotective properties. This study is aimed at evaluating the effect of APV treatment on oxidative status after spinal cord injury (SCI). METHODS: The experiment was carried out on the following five groups: Group 1: sham operated, non-traumatized; Group 2: with injured spinal cord, no treatment; Group 3: with SCI, injected with 100 microg kg(-1) APV; Group 4: with SCI, injected with 200 microg kg(-1) APV; and Group 5: with SCI, injected with 400 microg kg(-1) APV. SCI was inflicted by epidural compression with a cerebral vascular clip after T9-11 laminectomy. The experiments were completed after 12 h of trauma. Spinal cords were excised for evaluation of superoxide dismutase (SOD), catalase, reduced glutathione (GSH) and malonyldialdehyde (MDA) levels. RESULTS: After SCI, SOD and GSH levels decreased and the MDA level increased significantly. APV treatment decreased the MDA level and increased SOD, catalase and GSH levels. The maximum decrease in MDA was detected in the group treated with 100 microg kg(-1) APV compared with the other groups. The GSH level was significantly increased in the group treated with 200 microg kg(-1) APV. The SOD level was significantly increased in the group treated with 200 microg kg(-1) APV. CONCLUSION: The results of this study have shown that APV treatment creates a dose-dependent antioxidant effect in rats with SCI and may be used for the treatment of SCIs.

Gangliocytic paraganglioma of the cauda equina with significant calcification: first description in pediatric age.

A 17-year-old boy was referred with a 2-month history of low back pain and bilateral sciatica and difficulty in ambulation. Neurological examination found mild muscle weakness and diminished deep tendon reflexes in his right leg. Lumbar magnetic resonance imaging revealed an intradural-extramedullary tumor at the level of the L4, exiting through the right L4-L5 intervertebral foramen into the right psoas muscle. After total resection of the tumor, histopathological diagnosis revealed a gangliocytic paraganglioma. There are 184 paraganglioma cases reported at the lumbar region to date, and only 4 of them were in the pediatric age group. This report is the fifth paraganglioma case in the lumbar region and the first gangliocytic paraganglioma case in the pediatric age population.

Spinal subdural Staphylococcus aureus abscess: case report and review of the literature.

Spinal subdural abscesses (SSA) are rare and to date only 57 cases have been reported. The exact incidence of the SSA is unknown. The most affected region is the thoraco-lumbar spine and the most common bacterial source is Staphylococcus aureus. The timing for magnetic resonance imaging is very important in these patients. Because early diagnosis and emergent treatment is vital to prevent the formation or progression of neurologic deficits.

Assessment of cerebral blood flow velocities in pre and post angiographic states with transcranial doppler.

The frequency of complications resulting from angiograms reported in the literature vary between 0.2-5 percent. This study was planned to determine the changes in cerebral blood flow velocity before and after angiography, using transcranial doppler in patients of subarachnoid hemorrhage (SAH) undergoing angiographies. Thirty patients with subarachnoid hemorrhage underwent transcranial doppler ultrasonography immediately before and after angiography. Nonionic water-soluble agents were used during the angiograms. The mean flow velocity (MFV) and pulsatility index (PI) at the M1 segment of both middle cerebral arteries was simultaneously measured. When the patients (11 male, 19 female, mean age+SD; 52.45+12.06) were compared according to changes in MFV and PI, pre and post-angiography, there was no statistical difference in MFV (p=0.51 and p=0.99, left and right side respectively), and in PI (p=0.48 and p=0.66) pre and post angiography. Although angiogram can be used to detect vasospasm in SAH, it can also be cause of vasospasm, partially due to the effect of the contrast agent on the cerebral arteries. This study proposes that the angiographic method is still safe and TCD can be used to follow up any possible changes in diameter of cerebral arteries before and after angiography.

Spinal toxoplasmic arachnoiditis associated with osteoid formation: a rare presentation of toxoplasmosis.

STUDY DESIGN: An extremely rare presentation of an isolated spinal toxoplasmic arachnoiditis is described. OBJECTIVE: To draw attention to the fact that spinal arachnoid membranes may be a potential reservoir for Toxoplasma gondii. SUMMARY OF BACKGROUND DATA: Central nervous system toxoplasmosis is a common manifestation in patients who are immunodeficient. Reports on the spinal toxoplasmosis are rare and focused on spinal cord involvement. METHODS: An adult patient presented with symptoms of spastic paraparesis that had begun 13 years before admission. Thoracic spinal magnetic resonance imaging showed small lesions in posterior subarachnoid space at Th7-Th8. A Th7-Th8 laminectomy was performed. Intradural-extramedullary lesions were excised. RESULTS: Clinical, immunologic, and pathologic examinations showed adhesive spinal arachnoiditis associated with osteoid formation caused by past toxoplasmic infection. There was no impairment of the immunologic defense system. CONCLUSION: Where no causative factor is found in serious spinal adhesive arachnoiditis, the possibility of spinal toxoplasmosis should also be investigated.

Indications of Philadelphia collar in the treatment of upper cervical injuries.

The principles of the management of upper cervical injuries remain controversial. The specific anatomical conditions render upper cervical injuries more problematic than lower cervical injuries. Here we present and discuss our experiences with upper cervical injury, comparing them with other treatment modalities. The 24 patients admitted to our department with upper cervical injury were treated surgically or conservatively according to their neurological and radiological status. Five patients were treated surgically due to neurological abnormality associated with compression to neural structures observed in computerized tomography/magnetic resonance imaging (CT/MRI). Patients with no neural compression were managed conservatively, with the Philadelphia collar. All patients showed stable fracture healing and experienced no additional clinical disability on follow-up after a minimum of 3 months, except one who died due to cardiac and respiratory failure. Regardless of the type of injury, indication for surgery in many cases of upper cervical injury is neurological abnormality associated with radiologically observed neural compression. It is our belief that, in the absence of both neurological abnormality and compression to neural structures observed in CT/MRI, treatment with the Philadelphia collar alone is safe, cost-effective and easily applicable for many cases of upper cervical injury.

Injury caused by deeply penetrating knife blade lodged in infratemporal fossa.

Knife-inflicted, deeply penetrating head and neck trauma is an uncommon life-threatening injury and a challenging problem. An examination of the neurovascular and systemic physical status is a first requirement and the decision as to which approach to adopt for the removal of the blade is of critical importance. Here we report a rare case of a pre-auricular stab wound with the knife blade deeply lodged in the extracranial infratemporal fossa. Radiological investigations showed that the knife blade had entered from the temporomandibular joint and become lodged through the anterior margin of foremen magnum below the petrosal bone. Minimal left vocal cord paresis, left palatal weakness and a slight deviation of the tongue towards the left side were observed. The other neurological and systemic physical evaluations were normal. Simple withdrawal of the blade in the operating room did not cause serious neurovascular injury. Here we discuss and compare the expanded exposure of anatomical structures for blade removal and simple withdrawal in similar injuries.

Multiple nocardial abscesses of cerebrum, cerebellum and spinal cord, causing quadriplegia.

In this paper we present a case of a diabetic patient with nocardial abscesses of cerebrum, cerebellum and the spinal cord. The present case is the first case in the literature of solitary intramedullary abscess in cervical spinal cord, causing tetraplegia. Nocardia asteroides grew in a culture of the abscess pus. After either surgical excision or drainage of lesions, a triple combination regimen of chemotherapy (amikacin, ceftriaxone and trimethoprim-sulfamethoxazole) was given, but the patient was lost in the postoperative period. This case gives suggestive evidence of an association between cervical spinal cord involvement and poor prognosis in CNS nocardiosis.

Cerebral blood flow alterations in progressive communicating hydrocephalus: transcranial Doppler ultrasonography assessment in an experimental model.

OBJECT: In many cases communicating hydrocephalus is the result of impairments in cerebrospinal fluid absorption in the arachnoid villi at the cranial convexity. Reported methods of creating experimental hydrocephalus have not sought to produce an arachnoidal adhesion in the cranial convexity. In this study the authors investigate alterations in cerebral blood flow (CBF) in experimental communicating hydrocephalus induced by the injection of kaolin into the subarachnoid space at the convexity in neonatal rats. METHODS: In neonatal rats, kaolin was injected into the subarachnoid space at the cranial convexity. Assessment of CBF alterations was performed using transcranial Doppler ultrasonography preinjection and at 10 days, 4 weeks, and 8 weeks postinjection. Light microscopy examination was also performed at 4 weeks and 8 weeks postinjection. Conspicuous lateral ventricle enlargements of different dimensions were observed in kaolin-injected rats at 4 to 8 weeks postinjection. The third and fourth ventricles were dilated to a lesser extent. Resistance to CBF and increased mean CBF velocity were apparent 8 weeks after kaolin injection. Further, destruction and even loss of ependymal layers were more prominent at the chronic stage. CONCLUSIONS: The present model may be considered a progressive communicating hydrocephalus because of marked changes in blood flow dynamics and destruction of the ependymal layer at the chronic stage.

Inadvertent insertion of a nasogastric tube in a patient with head trauma.

This is a report of a 3-year-old boy with intracranial penetration of a nasogastric tube causing brain damage in the left frontal lobe. A computed tomography (CT) showed passage of the nasogastric tube via a fracture of the cribriform plate into the intracranial cavity. The tube was manually removed under antibiotic prophylaxis. The patient then underwent dural repair for rinorrhoea and was discharged in good health.

Instrumentation for posterior stabilisation of cervical traumatic and degenerative disorders: bullet-shaped implant and titanium cable.

BACKGROUND: Numerous implants for posterior stabilisation of cervical spine have been described so far. The aims of all these implants and techniques are rigid spinal stabilisation without neurologic damage, restoration of neuroanatomy and excellent radiological studies in postoperative period. The objective of this study was to determine the effectively and clinical safety of this system. METHODS: We conducted a retrospective analysis of patients treated with posterior stabilisation system for the stabilisation of traumatic and osteodegerative disorders of lower cervical spine in our department. This posterior cervical stabilisation system consist of titanium bullet-shaped implant (Ti-Frame) and titanium cables (sof' wire). RESULTS: All patients underwent only posterior fixation except 2 (anterior decompression and posterior stabilisation in 2 stages) and postoperative early immobilisation was allowed with Philadelphia collar in all patients. At the follow-up period 15.2 months (9-25 months), none of the patients had superficial or deep infection, implant resection or failure. CONCLUSIONS: In conclusion, this system (Ti-frame and titanium cables) is a simple, safe and effective system for posterior cervical stabilisation in patients with traumatic and osteodegenerative disorders due to provide rigid fixation and allow CT and MR imaging without the significant artifact.

Cerebellar metastasis from clear cell sarcoma of the kidney. A case report with immunohistochemistry.

The aim of this study was to describe a child with a right cerebellar hemisphere metastasis from primary clear cell sarcoma of the kidney without evidence of bone metastases, and to investigate the immunohistochemical features of primary and metastatic tumors. A 12-month old boy was admitted our hospital due to an abdominal mass. Abdominal computed tomography revealed a large right renal tumor. Tumor was removed with nephrectomy. Histopathologic examination of tumor revealed clear cell sarcoma of the kidney. The patient received radiotherapy and chemotherapy in postoperative period. He suffered from gait disturbance and confusion 8 months later. A computed tomography scan revealed a tumor that was enhanced with contrast medium at right cerebellar hemisphere concomitant with ventricular enlargement. After ventriculo-peritoneal shunting procedure, tumor was excised totally and histopathologic diagnosis showed metastasis of clear cell sarcoma of the kidney. Immunohistochemically vimentin, actin, desmin, neuron specific enolase, cytokeratin, P 53, Ki-67 and P-170 were performed using formalin fixed, paraffin embedded sections. Both of the tumors were positive for vimentin and negative for desmin, actin, neuron specific enolase, cytokeratin and P 53. Scattered nuclei were stained by Ki-67 in primary and metastatic cerebellar tumor. Both primary and metastatic tumors were negative for p53 and P-170. The treatment consisted of surgery, radiotherapy and chemotherapy. The patient is alive and well without evidence of recurrence 16 months after second surgery. Clear cell sarcoma of the kidney is most commonly associated with bone metastasis. Cerebellar metastasis of clear cell sarcoma of the kidney is very unusual. To the best of our knowledge, this patient is second case in the English literature. With review of the literature, our immunohistochemical findings support the theory that relapse and metastasis of primary clear cell sarcoma of the kidney are not related with increase of aggressiveness.

Double meningocele. Case report.

The coexistence of two distinct meningoceles of the spine is a very unusual event. We report a three-day-old boy with double meningoceles at the thoracic and lumbar levels. The connection between the stalk of the thoracic meningocele and the spinal cord, as seen on magnetic resonance imaging, showed a neurological involvement in this lesion. Our case is only the third without association of congenital anomalies or neurofibromatosis to be reported to date.

The deletion of 22q13 region in both intracranial and spinal meningiomas in a patient (case report).

We present a 69 year old man with two simultaneous meningiomas in different compartment of neural axis, in both of which 22q13 locus is lost. Histologically the two tumours appeared to be different; meningotheliomatous and transitional with psammoma bodies, respectively. No numerical or structural chromosome abnormalities were seen in karyotype analysis of the cultured spinal and cranial meningioma samples. Since long arm structural aberrations and/or whole loss of chromosome 22 are frequently reported abnormalities of meningiomas, the tumours were also analysed by fluorescence in situ hybridisation (FISH) with different colour-labelled probes in respect to relevant chromosome. The metaphases and interphase nuclei of the samples were evaluated by the combined biotinylated 22q11 and digoxigenin-labelled 22q13 locus specific FISH probes, and 22q13 deletion was revealed in both of spinal and cranial tumour cells. In conclusion, since both tumours from the presented case show the same genetic alterations, multiplicity may be derived from the same clone of cells, and support the theory of development of multiple meningiomas from the spreading of tumour cells via cerebrospinal fluid as a possible mechanism.

Management of glioblastoma multiforme: with special reference to recurrence.

Between 1985 and 1995, 46 patients underwent craniotomy for glioblastoma multiforme. The mean age was 47, varying from 9 to 71 years. The influence of such prognostic factors as age, preoperative Karnofsky score, extent of resection, tumour site, tumour size, radiotherapy, reoperation as well as initial symptoms upon survival were studied. Of these, gross complete removal, radiotherapy, preoperative Karnofsky score, and reoperation were shown to be statistically significant to the survival time according to logrank and univariate tests. However, age, preoperative Karnofsky score, tumour size and temporal localisation remained as significant factors in multivariate analysis. The overall median survival was 53 weeks, with no patients surviving more than 3 years. Of the patients, 41% survived over a year and 8.6% lived over two years. Twenty-six patients developed a recurrent mass after an interval of 32 weeks. The median interval time from operation to recurrence was longer in those patients who underwent gross removal than in those who had a subtotal resection, 28.2 against 20 weeks (P < 0.05). Of patients who had a recurrent mass, 16 were reoperated on, with a subsequent median survival time of 26.5 weeks. Our experience suggests that the survival of patients with glioblastoma depends on many factors, including radical surgery as an initial step. In addition, the gross total removal of the tumour also delays the development of recurrence.