Vascular Decompression of Trigeminal and Facial Nerves in the Posterior Fossa under Endoscope-Assisted Keyhole Conditions.

OBJECTIVE: The aim of this study was to determine the use and safety of the endoscope as an adjunct during trigeminal and facial nerve decompression procedures performed under keyhole conditions in the posterior fossa. METHOD: We performed 67 surgeries in 65 patients with symptomatic trigeminal and facial nerve compression syndromes. The diagnosis was made mainly on the basis of clinical history, examination, and magnetic resonance imaging scans. Surgery was performed in all cases under endoscope-assisted keyhole conditions. The follow-up was 1 week postoperatively, 6 months, and then yearly up to 7 years. All 34 patients with trigeminal neuralgia received preoperative medication treatment and experienced failure with it. Eighteen patients out of 30 with hemifacial spasm had been previously treated with botulinum toxin injections. One patient suffered from both trigeminal neuralgia and facial spasm, because of a megadolichobasilar and vertebral artery with compression of both cranial nerves. RESULTS: Sixty-four of the 65 patients became symptom free after surgical treatment; one revision surgery was necessary because of disappearance of the decompression muscle piece. No mortalities or minor morbidities were observed in this series. CONCLUSION: A precise planned keyhole craniotomy and the simultaneous use of the microscope and the endoscope render the procedure of the decompression less traumatic.

Phenytoin-induced parkinsonism.

This report presents a 30-year-old man who developed subacute phenytoin-induced cerebellar ataxia and parkinsonism that resolved after discontinuation of the phenytoin treatment. Phenytoin was started for seizure prophylaxis in another health institution where he was referred for bilateral intracerebral orbitofrontal haemorrhage due to a head trauma. To our knowledge, there has been only one other case report describing phenytoin-induced parkinsonism, which was also reversible. The issue of the development of parkinsonism due to the phenytoin toxicity in the case of bilateral orbitofrontal lesion is addressed.

Trigeminal neuroma with extracranial extension: the 31st case.

Neuromas arising from the distal branches of the trigeminal nerve with extracranial extension are unusual. Here, we present the clinical features, diagnosis and treatment of 28-year-old woman with trigeminal neuroma with extension to the infratemporal fossa.

Evaluation of apoptosis in cerebrospinal fluid of patients with severe head injury.

OBJECTIVE: To determine whether sFas, caspase-3, proteins which propagate apoptosis, and bcl-2, a protein which inhibits apoptosis, would be increased in cerebrospinal fluid (CSF) in patients with severe traumatic brain injury (TBI) and to examine the correlation of sFas, caspase-3, and bcl-2 with each other and with clinical variables. METHODS: sFas, caspase-3, and bcl-2 were measured in CSF of 14 patients with severe TBI on days 1, 2, 3, 5, 7, and 10 post-trauma. The results were compared with CSF samples from control patients who had no brain and spinal pathology and had undergone spinal anesthesia for some other reason. Soluble Fas and bcl-2 were measured by ELISA while caspase-3 was measured enzymatically. RESULTS: No sFas, caspase-3, and bcl-2 activities were found in CSF of controls, but activities significantly increased in CSF of patients at all time points post-trauma (p < 0.01). Caspase-3 significantly correlated to intracranial pressure (p = 0.01) and cerebral perfusion pressure (p = 0.04). Soluble Fas and caspase-3 peaks coincided on day 5 post-trauma and there was significant association between sFas and caspase-3 increase (p = 0.01). CONCLUSION: This study indicates a prolonged activation of pro-apoptotic (sFas, caspase-3) and anti-apoptotic (bcl-2) proteins after severe TBI in humans. The degree of activation of particularly caspase-3 may be related to the severity of the injury. Parallel increases of these three molecules may indicate a pivotal role of apoptosis in the pathophysiology of post-traumatic brain oedema, secondary cell destruction and chronic cell loss following severe TBI and may open new targets for post-traumatic therapeutic interventions.

Percutaneous endoscopic transforaminal lumbar discectomy: a critical appraisal.

Percutaneous endoscopic transforaminal lumbar discectomy (PETD) is one of the surgical techniques for the treatment of the lumbar disc herniations. Fenestration of the annulus and partial resection of the nuclear substance are achieved percutaneously by a posterolateral approach under local anaesthesia. The results of the first 42 patients are evaluated regarding the learning curve and indications for this procedure. The mean follow-up time was 15 months. Excellent and good results were evaluated as successful and the overall success rate is 77 %. All six patients with foraminal disc herniations in whom a free fragment could be removed had excellent results. Military personnel can return to work quickly without deficits with the use of this technique.

Intradural migration of a bullet following spinal gunshot injury.

STUDY DESIGN: Case report. OBJECTIVES: To report a penetrating gunshot injury at L1 with migration within the spinal canal to S2. SETTING: Istanbul, Turkey. METHODS: A 44-year-old man was admitted with an entrance gunshot wound on the left upper quadrant. An emergency exploratory laparotomy with left nephrectomy and transverse colon repair were performed. He had complete spinal cord injury below the level of L1. Lumbar magnetic resonance imaging (MRI) revealed hemorrhagic areas in conus medullaris and L1 corpus. The bullet was lodged at the S2 level. S1-S2 laminectomies were performed for the removal of the bullet. The antibiotic therapy was given for 17 days. RESULTS: No meningitis or wound infection was observed after the operation. At discharge his neurological status was improved. CONCLUSIONS: The present case presented the movement of an intraspinal bullet after a spinal gunshot injury. No signs of infection were detected postoperatively. Lumbar MRI was used safely without any change in neurological status or patient discomfort.

Association between interleukin-1 beta (IL-1beta) gene polymorphism and outcome after head injury: an early report.

BACKGROUND: Recent studies focusing on the genetic influences on outcome after head injury (HI) have suggested that different alleles of certain genes are associated with different outcomes. Interleukin-1 beta (IL-1beta) gene, especially beta2 polymorphism, is frequently observed in Alzheimer's disease, a remarkable degenerative state in which HI is among the known risk factors. Therefore, the aim of this paper was to search for the possible association between the outcome and IL-1beta gene polymorphism in human HI. METHODS: The study group was composed of the 69 patients admitted to the neurosurgery department after HI. The severity of the initial injury was evaluated by means of the Glasgow Coma Scale and outcome six months later was assessed by means of the Glasgow Outcome Scale. IL-1beta genotypes were determined from blood samples by standard methods. FINDINGS: Fourteen of 25 (56%) patients with IL-1beta +3953 allele 2 had an unfavourable outcome (dead, vegetative state or severe disability) compared with eight of 44 (18.1%) patients without IL-1beta +3953 (p = 0.0004). Similarly, 20 of 28 (71.4%) patients with IL-1beta -511 allele 2 had an unfavourable outcome compared with two of 41 (4.8%) patients without IL-1beta -511 (p = 0.005). Patients who had a composite of IL-1beta 2/2 or 1/2 genotype from both -511 and +3953 region of the chromosome 2 were more prone to have bad prognosis. CONCLUSION: Results of our study demonstrated that there might be a significant association between IL-1beta gene polymorphism and outcome after HI, supporting the hypothesis of a genetically determined influence.

A great misfortune: second traumatic spinal cord injury.

OBJECTIVE: A second and a separate traumatic spinal cord injury, which results in neurological deterioration, is very rare. In this report we describe a patient who became tetraplegic after sustaining a second spinal trauma. CASE REPORT: A 27-year-old female had a C(7)-T(1) dislocation after a motor vehicle accident. She was neurologically intact and she had undergone a posterior fusion between C(6)-T(2). She made a complete recovery. Eight months after her initial trauma, she sustained a second motor vehicle accident causing a C(5) burst fracture. CONCLUSION: Second traumatic spinal cord injury is a rare entity. Motor vehicle accidents are the most common cause of this type of injury. Whatever the treatment strategy is, the best treatment modality for traumatic spinal cord injury is prevention.

Rotational compression of the vertebral artery at the point of dural penetration. Case report.

Vertebrobasilar insufficiency (VBI) due to vertebral artery (VA) compression occurs in a significant number of patients. Rotational compression of the VA usually occurs below C-2, where the artery is pinched during head rotation, leading to thrombus formation and subsequent cerebellar infarction. Although this problem has been reported to occur at the atlantooccipital levels, a review of the literature revealed no published cases of VA compression at the point of dural penetration, which is located above the atlantooccipital membrane. The authors report the case of a 30-year-old woman who presented with signs and symptoms of VBI. Dynamic angiography demonstrated left-sided VA compression at the site at which dural penetration had occurred, proximal to the posterior inferior cerebellar artery. Surgical decompression of the left VA at the point of dural penetration relieved the symptoms, and postoperative dynamic angiography demonstrated complete resolution of the positional compression of the left VA. Because of these findings, an additional possible location for rotational compression of the VA is described, namely, the point of dural penetration. The authors suggest a method of surgically treating rotational VA compression at this site.

Chiasmatic low-grade glioma presenting with sacral intradural spinal metastasis.

Leptomeningeal metastasis of low-grade gliomas in children has been documented in several series, both at the time of diagnosis and at relapse. The authors report a unique case of chiasmatic low-grade astrocytoma presenting with signs and symptoms related to the metastatic site rather than the primary site. In this respect, the possibility of appearance of symptoms and signs related to leptomeningeal dissemination preceding the signs and symptoms belonging to the primary site should be considered in this type of benign tumours.

Idiopathic granulomatous hypophysitis: are there reliable, constant radiological and clinical diagnostic criterias?

Idiopathic granulomatous hypophysitis is a rare inflammatory disease of unknown aetiology; few cases are reported. We review the clinical presentation and radiological characteristics of these cases and our own experience with three new surgical cases, to determine diagnostic criteria. MRI of three cases revealed sellar lesions extending into the chiasmatic cistern. Their shape varied, from dumbbell to spherical and elliptical. All were isointense with the brain on T1-weighted images and gave heterogeneously high signal on T2-weighted images. Contrast enhancement was homogeneous in one case and heterogeneous in another. The pituitary stalk could not be identified. There was no dural enhancement. The sphenoid sinus mucosa was thickened in two cases and normal in one.

Is it possible to recover from uncal herniation? Analysis of 71 head injured cases.

BACKGROUND: Uncal herniation (UH) caused by head trauma may become a fatal process if not treated rapidly. METHODS: We analysed the factors affecting the outcome in 71 surgically treated patients who had intracranial haematoma diagnosed by computerized tomography (CT), between January 1987 and June 1994 with the symptoms of UH. Age, incident-treatment interval, Glasgow Coma Scale (GCS), type of the lesion and the presence of polytrauma were correlated with Glasgow Outcome Scales (GOS) using SPSS PC+ statistical software. RESULTS: 49.3% of our patients were referred because of a fall from a height and 46.5% because of a motor vehicle accident. 12.7% of the patients were polytraumatized. The mean GCS of the series was 5.662. The mean GCS of the patients expired and who were in good recovery state were 4.8 and 6.9 respectively. Age, presence of polytrauma, type of the lesion and time interval between the incident and the treatment was found to be statistically insignificant when correlated with GOS. The correlation value between the GCS values and GOS was found to be highly significant (p < 0.00001). CONCLUSIONS: The findings showed that the degree of the herniation is the most important factor that affects the prognosis of the patients with UH. The reversibility of UH becomes more difficult if there are complications added during the grades of its progression but it may not be necessarily fatal and be reversible if appropriate interventions are rapidly performed.

The effect of duration of compression on lipid peroxidation after experimental spinal cord injury.

The present study was performed to evaluate the effect of duration of acute spinal cord compression on tissue lipid peroxidation in rats. A clip compression method (1) was used to produce acute spinal cord injury. Rats were divided into 3 groups, each consisting of 10. At 1 hour after trauma all rats were sacrificed, and MDA content of the injured spinal cord segment was measured. The tissue MDA contents were 3.922 mumolMDA/gww in group 1 (control), 10.192 mumol MDA/gww in group 2 (30 seconds compression), and 12.147 mumolMDA/gww in group 3 (60 seconds compression). These results demonstrate that the length of duration of compression significantly enhances lipid peroxidation. Our study supported the view that persisting compression may cause progression of secondary mechanisms which may irreversibly eliminate any potential for recovery.

Cerebral candidiasis presenting as a mass lesion.

The authors report of a case of pseudotumour caused by Candida species without evidence of any underlying disease. No portal of entry of the infection was found. Total removal followed by treatment with flucanazole resulted in a favorable outcome. We discuss the differential diagnosis of a huge calcified intracranial mass lesion without any soft tissue component.

Unilateral hemilaminectomy for the removal of the spinal space-occupying lesions.

In this study we have evaluated 40 patients with spinal lesions with respect to the value of unilateral hemilaminectomy. Our case study group included 29 intradural extramedullary, 6 intramedullary, and 5 extradural tumors. The thoracic spinal cord was involved in 17, the lumbar region in 13, and the cervical spinal cord in 10 cases. The mean age of the 20 males and 20 females was 35 (range 6-71). The rationale for choosing a unilateral approach is to preserve musculoligamentous attachments and bony posterior elements as much as possible. We did not observe any complication relating to unilateral hemilaminectomy. The patients were mobilized the following day after surgery or given rehabilitation therapy beginning on the second postoperative day without the use of any external support. At follow-up evaluation, a mean of 32 months postoperatively, none of the patients showed spinal deformity or spinal instability.