Decompressive craniectomy for acute subdural haematoma: an overview of current prognostic factors and a discussion about some novel prognostic parametres.

OBJECTIVE: To identify specific factors that can be used to predict functional outcome and to assess the value of decompressive craniectomy in patients with acute subdural haematoma. METHODS: The retrospective study was done at the Zonguldak Karaelwas University Practice and Research Hospital, Turkey, and included 34 trauma patients who had undergone decompressive craniectomy for acute subdural haematoma from 2001 to 2009. At the 30th day of the operation, the patients were grouped as survivors and non-survivors. Besides, based on their Glasgow Outcome Scale, which was calculated 6 months postoperatively, the patients were divided into two functional groups: favourable outcomes (4-5 on the scale), and unfavourable outcomes (1-3 on the scale). The characteristics of the groups were compared using SPSS 15 for statistical analysis. RESULTS: One-month mortality was 38.2% (n = 13) and 6-month total mortality reached 47% (n = 16). Patients with higher pre-operative revised trauma score, Glasgow coma scale, partial anterial pressure of carbon dioxide, arterial oxygen pressure, Charlson co-morbidity index score, blood glucose level, blood urea nitrogen, and lower age had a higher rate of survival and consequently a favourable outcome. Higher platelet values were only found to be a determinant of higher survival at the end of the first month without having any significant effect on the favourable outcome. CONCLUSION: In patients of traumatic acute subdural haematoma whose Glasgow coma scale on arrival was < or = 8, a massive craniectomy along with the evacuation of the haematoma, may be considered as a treatment option for intra-operative and post-operative brain swelling. But in patients with a score of 3 on arrival and bilaterally fixed and dilated pupils, decompressive craniectomy is unnecessary.

Migration of a bullet in the spinal canal.

Migration of a bullet within the spinal canal after gunshot injury is rare. We report here the case of a penetrating gunshot injury of the lumbar spine at L3 with migration of the bullet within the spinal canal S2. The patient had marked paraparesis (proximal 1/5, distal 0/5 muscle strength) and anaesthesia at L3 and below, and had a hypocompliant, hyper-reflexive bladder with decreased capacity, and absent anal tonus. We removed osseous fragments in the canal with an L3 laminectomy and extracted the bullet by S2 laminectomy. After surgery, we observed an improvement in paraparesis, an increase in bladder capacity and urinary compliance, and improvement in anal tonus. The appropriate course of action in this type of injury remains unclear, because the number of cases described in the literature is not sufficient to provide a basis on which to make a definitive therapeutic decision. We herein review the literature describing cases in which a bullet in the spinal canal has migrated; we describe the treatment used and the outcomes in these cases.

Giant unruptured anterior communicating artery aneurysm presenting with seizure.

Giant aneurysms of the anterior communicating artery (AComA) are rare. The clinical presentation of giant AComA aneurysms is usually associated with the mass effect of the space-occupying lesion or with subarachnoid haemorrhage. A giant AComA aneurysm presenting with a seizure has only been reported twice previously. We report a 70-year-old female patient, in whom a single seizure was the only symptom of a giant AcomA aneurysm, with no neurological deficit. The diagnosis of unruptured giant AComA aneurysm was made with cranial CT, MRI and angiography. The patient refused surgical intervention, was treated with anti-epileptic therapy and has been asymptomatic for 7 months. We suggest that elderly patients presenting with a first seizure need detailed evaluation and giant aneurysms, which may be confused with other intracranial space-occupying lesions, need to be considered in the differential diagnosis.

Primary spinal extranodal Hodgkin's disease at two levels.

About 90% of Hodgkin's disease cases originate from lymph nodes whereas 10% from extranodal regions. Patients rarely present with spinal cord compression due to epidural Hodgkin's disease. Primary spinal extradural Hodgkin's disease which does not have any other organ involvement in the body is even rarer. A 39-year-old male patient who complained of lumbar pain had normal findings upon neurological examination. Radiological examination revealed a mass on the epidural space at level L3 and the involvement of the vertebral corpus accompanied by the involvement of C6 vertebral body. Primary focus could not be identified despite further investigation. The patient underwent L3 laminectomy and posterior decompression and biopsy was obtained from the lesion extending to epidural space. The pathological result was reported as lymphocyte dominant type Hodgkin's disease. Flow cytometry was performed to the lesion, also. The patient was evaluated as Stage 4A according to Ann Arbor classification. Postoperative radiotherapy was applied to lumbar and cervical region. In the literature we have not come across any case of primary spinal extranodal Hodgkin's disease with involvement at two levels. In conclusion, although it might be extremely rare, primary spinal extranodal Hodgkin's disease with involvement at two levels might be observed.

Ultrastructural changes in the circumventricular organs after experimental subarachnoid hemorrhage.

OBJECTIVES: Circumventricular organs (CVOs) are fine, periventricular, neurotransmitter-rich structures that are devoid of a blood-brain barrier and are known for their secretory role controlling fluid and electrolyte balance, thirst and even reproduction. Common pathologies of the brain such as trauma or bleeding affect CVOs, and hence their function. However, at what stage of these disease processes are CVOs affected and the time sequence of their recovery is still not clear. The aim of this study was to detect the morphological changes in CVOs using electron microscopy after experimental subarachnoid hemorrhage (SAH). METHODS: Experimental SAH was induced by transclival puncture of the basilar artery. Both scanning and transmission electron microscopic examination of the representive sections from each CVO was undertaken. RESULTS: Electron microscopy has shown that after SAH, the cells that form the CVOs exhibit signs of cellular necrosis with margination of the nucleus as well as cytoplasmic, mitochondrial and axonal edema. The subfornicial organ and organum vasculosum lamina terminalis appear to be more vulnerable to the effects of SAH than the median eminence or area postrema. DISCUSSION: Considering the fact that the experimental SAH model we have used is very similar to the momentary rupture of an aneurysm with secondary reflex spasm to seal the hole, it will not be unrealistic to consider that similar effects may also take place in the clinical setting.

A training model for lumbar discectomy.

Training models are becoming increasingly important for gaining surgical skills. We present an easy to prepare and cheap model using cadaver sheep spine appropriate to learn and practice various discectomy procedures.

Neuroprotective effects of ebselen on experimental spinal cord injury in rats.

Spinal cord injury (SCI) results in rapid and significant oxidative stress. This study was aimed to investigate the possible beneficial effects of Ebselen in comparison with Methylprednisolone in experimental SCI. Thirty six Wistar albino rats (200-250 g) were divided in to six groups; A (control), B (only laminectomy), C (Trauma; laminectomy + spinal trauma), D (Placebo group; laminectomy + spinal trauma + serum physiologic), E (Methylprednisolone group; laminectomy + spinal trauma + Methylprednisolone treated), F (Ebselen group; laminectomy + spinal trauma + Ebselen treated), containing 6 rats each. Spinal cord injury (SCI) was performed by placement of an aneurysm clip, extradurally at the level of T11-12. After this application, group A, B and C were not treated with any drug. Group D received 1 ml serum physiologic. Group E received 30 mg/kg Methylprednisolone and, Group F received 10 mg/kg Ebselen intraperitoneally (i.p.). Rats were neurologically examined 24 h after trauma and spinal cord tissue samples had been harvested for both biochemical and histopathological evaluation. All rats were paraplegic after SCI except the ones in group A and B. Neurological scores were not different in traumatized rats than that of non-traumatized ones. SCI significantly increased spinal cord tissue malondialdehyde (MDA) and protein carbonyl (PC) levels and also decreased superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) enzyme activities compared to control. Methylprednisolone and Ebselen treatment decreased tissue MDA and PC levels and prevented inhibition of the enzymes SOD, GSH-Px and CAT in the tissues. However, the best results were obtained with Ebselen. In groups C and D, the neurons of the spinal cord tissue became extensively dark and degenerated with picnotic nuclei. The morphology of neurons in groups E and F were very well protected, but not as good as the control group. The number of neurons in the spinal cord tissues of the groups C and D were significantly less than the groups A, B, E and F. We concluded that the use of Ebselen treatment might have potential benefits in spinal cord tissue damage on clinical grounds.

Malignant cerebral infarction secondary to internal carotid injury in closed head trauma: good outcome with aggressive treatment--a case report.

A 25-year-old male patient in whom occlusion of the internal carotid artery developed secondary to a skull base fracture is presented. The diagnosis of internal carotid artery occlusion was reached 12 hours after the admission and 17 hours after the injury. The patient was initially treated for ischemic edema and when the patient showed signs of cerebral herniation, decompressive craniectomy was necessary. The outcome was good. The clinical and radiologic characteristics of internal carotid artery occlusion in closed head injury are highlighted and treatment options are reviewed in light of pertinent literature.

Dispersion of cerebral temperature, cerebral perfusion and intracranial pressure in rabbits placed with epidural balloons.

This study examines the intracranial pressure and temperature dispersion in a rabbit model after epidural balloon compression. Right and left supratentorial, intraventricular and infratentorial pressures and temperatures of the rabbits have been measured before epidural balloon was placed. Afterwards, the epidural balloon was placed in right parietal epidural area. The intracranial pressure and temperature dispersion values were recorded after inflation with 0.3 and 0.6 ml, respectively. The control values of intracranial pressure measurements of four different brain regions were found to be similar. When the balloon was inflated to 0.3 ml, the intracranial pressure distribution was found to be equal in all the fields. After the balloon was inflated up to 0.6 ml, right and left supratentorial intracranial pressure values were found to be equal. However, infratentorial pressure values were lower and intraventricular pressure values were higher when compared with the right hemisphere. Before the inflation and at two different inflation volumes, perfusion pressure and temperature dispersion were found to be similar between right hemisphere and other compartments. We conclude that, the effective mechanism in cerebral temperature regulation may be related to preserved cerebral perfusion pressure and cerebral blood flow.

[Endovascular coil embolization with balloon remodelling technique after partially clipped ica aneurysm (case report)]. / Parsiyel klipslenmis ika anevrizmasinin balon modelleme teknigi ile endovasküler koil embolizasyonu.

The presence of aneurysm remnant after incomplete or unsuccessful surgical clipping is associated with persistent risk of regrowth and rupture, and additional treatment is generally recommended. Advances in aneurysm coiling techniques and technology have allowed for more remnants to be treated safely. We present a 47-year-old woman with residual internal carotid artery aneurysm after surgical clipping with coils and balloon remodeling technique.

[The role of three dimensional MR myelography in lumbar discogenic disease]. / Lomber disk hastaliginda üç boyutlu MR myelografinin yeri.

PURPOSE: To evaluate the role of the three dimensional (3D) MR myelography (MRM) in the diagnosis of the lumbar discogenic disease compared with conventional MR imaging. MATERIALS AND METHODS: Fifty consecutive patients with clinical symptoms of lumbar disc herniation were enrolled for the study. Conventional MR imaging and coronal 3D MRM were performed on a 1.5 T MR system. At each disc space level, the presence and the location of disc herniation and nerve root compression were evaluated. Note was also made if MRM had additional contribution to the determination of most significant level in the cases of multilevel disc disease and lumbar spinal stenosis. RESULTS: Disc herniation was found in 60 disc space levels on conventional MR imaging and in 54 disc space levels on 3D-MRM imaging. As regards to disc herniation, the sensitivity, specificity, and accuracy of 3D-MRM was 90%, 100%, and 96%, respectively. Nerve root compression was seen in 91 levels on conventional MR images, as opposed to 98 on 3D-MRM. Regarding nerve root compression, the sensitivity, specificity, and accuracy of 3D-MRM was 100%, 97%, and 98%, respectively. In all of 13 patients with multilevel disc disease and lumbar spinal stenosis, 3D-MRM had additional contribution. CONCLUSION: Scan time of 3D-MRM is short. It can be easily added to routine lumbar MR imaging. It may be a valuable modality in the diagnosis of the lumbar discogenic disease. The presence of false-negative and false-positive examinations necessitates caution in interpreting 3D-MRM images. 3D MRM technique may be useful in selected cases such as patients with multilevel disc abnormalities or lumbar spinal stenosis where it allows a rapid and easy appreciation of the level most likely to account for the pathology.

Effect of cerebrospinal fluid leakage on wound healing in flap surgery: histological evaluation.

The aim of this study was to find out the effect of CSF leakage on wound healing after flap surgery. Sixteen male Wistar rats were used. The superiorly based rectangular dorsal skin flap 3 x 3 cm was elevated at the interscapular region. Through this opening, paraspinal muscle dissection and three-level bilateral laminectomy were done. Finally, a dura defect with a diameter of 3-4 mm was created. In the control group, laminectomy was performed as in the study group but the dura was left intact. Persistent CSF leakage was confirmed using isotope cisternography. At the end of 2-week study period, there was no necrosis, infection, or dehiscence of the flap in either group. On necroscopy, cyst formation over the dura defect was detected in 4 animals of the study group. Another gross finding in this group was intensive vascularization of the undersurface of the flap and wound bed. With HE staining, the tissue sections from the study group revealed new vessel formation with small diameter, increase in the reactional mesenchymal tissue, granulation tissue, degeneration of the striated muscle fibers, dystrophic calcifications, fat necrosis, and coagulation necrosis (ischemic necrosis). In the control group, there was only minimal lymphocytic invasion of the subdermal plane. In this study, we have shown that CSF leakage itself has effects on wound healing in the absence of known causative factors.

Late recurrent bleeding after surgical treatment for pituitary apoplexy.

Pituitary apoplexy is an uncommon syndrome characterised by sudden onset of headache, meningeal signs, visual disturbances, ophthalmoplegia and confusion. Documented recurrent apoplexy or treated apoplexy is even rarer with only few reports in the literature. Between 1994 and 2001, 18 patients were treated for pituitary apoplexy at Bayindir Medical Centre through transsphenoidal route. In all, topical bromocriptine was applied after tumour resection as described by Ozgen. We hereby present the cases of two patients with recurrent apoplexy 3 and 7 years after the initial surgical treatment for pituitary adenoma with apoplexy. The patients were treated non-surgically with success. Additional treatment in the form of radiosurgery was found necessary for the first patient. Surgical excision of the pituitary tumours with apoplexy reduces the risk of recurrent bleedings but eradication is not a rule. These patients need to be followed closely in the postoperative period for possible recurrence of bleeding.

[High resolution MR neurography in patients with cervical radiculopathy]. / Servikal radikülopatili hastalarda yüksek çözünürlüklü MR nörografi.

PURPOSE: To image the cervical spinal nerves directly in patients with clinical and radiographic evidence of cervical radiculopathy via high resolution MR neurography by means of a qualitative and quantitative analysis. MATERIALS AND METHODS: Twenty symptomatic patients with cervical radiculopathy and five asymptomatic volunteers were examined. A phased-array coil system was used to obtain high-resolution coronal T1-weighted spin echo and coronal/axial short tau inversion recovery (STIR) images of the cervical spine and spinal nerves. On the axial STIR images, nerve/muscle signal intensity ratio of the cervical spinal nerves were measured on both sides and compared with paired samples t test. P values below 0.05 were considered statistically significant (p<0.05). RESULTS: A markedly increased signal in the distal portion of the affected spinal nerves was found. Nerve/muscle signal intensity ratio measurements of the affected spinal nerves showed a significantly increased intensity compared with the noninvolved spinal nerves (p<0.05). In controls, nerve/muscle signal intensity rate was nearly identical on both sides (p>0.05). CONCLUSION: Magnetic resonance neurography performed with phased-array coils can detect signal abnormalities within compressed cervical spinal nerves in patients with corresponding radicular symptoms and findings. This technique may be helpful especially in evaluating patients with multi-level disc disease of the cervical spine.