Nocardia cyriacigeorgica brain abscess with Pemphigus vulgaris: first report.

Nocardia brain abscess is an uncommon but potentially life threatening opportunistic infection that generally occurs in immunocompromised patients. Nocardia cyriacigeorgica is a recently described species rarely reported as a cause of human disease. Pemphigus vulgaris is managed with immunosuppression. There have been four prior reports of brain abscess caused by Nocardia cyriacigeorgica.

Bilateral vertebral artery occlusion after traumatic complete disruption of the cervical spine associated with ankylosing spondylitis.

BACKGROUND: Bilateral vertebral artery occlusion is an uncommon and mortal injury that could be seen after high-energy traumas. We illustrate an extreme case of bilateral vertebral artery occlusion following traumatic cervical disruption with complete spinal cord injury in a patient with ankylosing spondylitis. A 49-year-old male was admitted to our emergency department after a motor vehicle accident. The American Spinal Injury Association Impairment Scale was a complete A grade. Computed tomography (CT) scan of the cervical region revealed complete disruption between C2 and C3 levels. Magnetic resonance imaging showed apparent compression and narrow calibration of the spinal cord. CT angiography demonstrated occlusion of the bilateral vertebral arteries. Because of the neurological status of the patient, extensive hematoma, and edema at the region, no surgical intervention could be planned. The patient died on the second day of his hospitalization. Only fourteen cases of bilateral vertebral artery occlusion following blunt cervical spine traumas have been reported to date. They have a possibility to cause vertebrobasilar ischemic events with a poor prognosis of morbidity and mortality. The gold standard of diagnosis is the catheter angiography, but also CT angiography has close sensitivity and specificity. The treatment strategies of vertebral artery occlusion are still unclear.

Efficiency of Distraction and Ligamentotaxis in Posterior Spinal Instrumentation of Thoracolumbar Retropulsed Fractures.

AIM: To compare the efficiency of distraction and ligamentotaxis in posterior spinal instrumentation of thoracolumbar retropulsed fractures according to the grade of spinal canal compression and fracture levels. MATERIAL AND METHODS: This study retrospectively reviewed 56 patients diagnosed with thoracolumbar fractures and significant fracture fragments retropulsed into the spinal canal who only underwent posterior instrumentation with distraction and ligamentotaxis, and compared groups according to the grade of spinal canal compression and fracture levels. The pre-and postoperative clinical outcomes were evaluated using Oswestry Disability Index and visual analog scale scores, and neuroimaging studies showed percentage of the spinal canal compression and fractured vertebral unit height. RESULTS: A total of 34 male (60.7%), and 22 female (39.3%) patients with a mean age of 46.25 years was enrolled in study. The percentage of spinal cord compression reduced significantly from 40.2% preoperatively to 26.8% postoperatively (+13.4%). The vertebral unit height increased significantly from 25.20 ± 3.2 mm to 31.85 ± 2.6 mm (+6.65 ± 2.7). The absolute spinal canal compression reduction was higher for grade II fractures (1/3 to 2/3 compression) (+13.3%) than for grade I fractures (up to 1/3) (+7.9%). Greater widening was observed at L1?L2 level (+16.2%) than at T11?T12 level (+10.2%). Statistically significant differences were found between the two groups according to the grade of canal compression and fracture levels in the mean preand postoperative spinal canal compression reduction. CONCLUSION: Indirect decompression techniques reduce retropulsed fragments, effectively improve the degree of spinal canal compression, and ensure safe laminectomy. The efficiency of distraction and ligamentotaxis after posterior spinal instrumentation correlated with the preoperative percentage of spinal canal compression and higher spinal canal area for fractures with a high preoperative stenosis.

A Comparison of the Surgical Outcomes of Laminoplasty and Laminectomy with Fusion in the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Retrospective Cohort Study.

AIM: To compare the effectiveness of laminoplasty and laminectomy with fusion in the treatment of patients with cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS: This study retrospectively reviewed 52 patients diagnosed with CSM who underwent either laminoplasty (LP group) or laminectomy with fusion (LF group). The preoperative and postoperative clinical outcomes were evaluated using Cobb?s angle of cervical lordosis, visual analogue scale (VAS) and modified Japanese Orthopaedic Association (mJOA) scores, and radiographs showing the antero-posterior diameter and area of the spinal canal. RESULTS: The mean age of the LP group was 60.12 years, while that of the LF group was 63.84 years. The pre- and postoperative mean mJOA scores were 11.46 ± 1.27 and 15.27 ± 0.87, respectively, in the LP group and 10.15 ± 1.89 and 14.92 ± 1.23, respectively, in the LF group. The pre- and postoperative Cobb angles were 16.22 ± 6.36° and 14.45 ± 4.50°, respectively, in the LP group and 14.39 ± 5.34° and 15.10 ± 6.21°, respectively, in the LF group. Recovery rates were 58.26% and 60.76% in the LP and LF groups, respectively. The mJOA scores, antero-posterior diameter and area improved significantly after surgery in both groups, while the Cobb angle increased in the LF group and decreased in the LP group. CONCLUSION: Laminoplasty and laminectomy with fusion improved neurological functions in patients diagnosed with CSM. Laminectomy with fusion should be the preferred choice when treating patients with preoperative axial pain as, despite expanding the spinal canal successfully, laminoplasty can also worsen the pain. However, laminectomy with fusion (except for OPLL) should not be the treatment of choice in a mobile spine as it severely restricts neck movements and impairs the Health-Related Quality of Life (HRQoL) of the patient. In the absence of kyphotic deformity, laminoplasty should be the preffered method for treatment.

Guillain-Barre Syndrome After Craniocerebral Gunshot Injury: First Report.

BACKGROUND: Guillain-Barre syndrome (GBS) is a rare but serious disorder involving peripheral nerve inflammatory demyelination characterized by acute onset tetraparesis and areflexia. Generally, GBS is preceded by a bacterial or viral infection, and post-traumatic or postsurgical GBS is rarely seen. CASE DESCRIPTION: A 41-year-old man with severe craniocerebral gunshot injury and open depressed occipital bone fracture was operated urgently. Two weeks postoperatively, he suffered from sudden quadriparesis. He had flaccid paralysis of his bilateral muscle lower extremities (0/5), along with bilateral upper extremity weakness (2/5). CONCLUSIONS: We report the first case, to our knowledge, with post-traumatic GBS after craniocerebral gunshot injury. We want to indicate the possibility of post-traumatic GBS in cases of unexplained quadriparesis or quadriplegia after trauma or surgery.

Local Tissue Electrical Resistances in Transpedicular Screw Application in the Thoracolumbar Region.

AIM: To determine local tissue electrical resistance differences generated during a screw pass from the pedicle to another tissue rather than determining all individual electrical tissue resistance values. MATERIAL AND METHODS: We attempted to measure electrical resistance values of regional tissues in addition to fluoroscopic imaging during application of fixation via a transpedicular screw. We also attempted to detect local tissue electrical resistance alterations in case of malposition of the screw inside the pedicle. For this purpose, local tissue electrical resistances of 10 transpedicular tracks opened with standard track openers bilaterally in 5 vertebrae, and of spinal cord accessed by puncturing the medial walls of three vertebrae in a cadaver were measured. These resistance differences were not only measured in human cadaveric tissue but also in 36 pedicles belonging to a total of 18 vertebrae between Th 1-S1 vertebrae of a sheep cadaver. Both medial and lateral walls were drilled to measure local tissue resistance differences in a sheep cadaver. RESULTS: Our results indicated that local tissue electrical resistance changes were statistically significant in both human and sheep cadaver. CONCLUSION: It is possible to prevent screw malposition using a simple and cheap electrical resistance measurement. Local tissue electrical resistance measurement during transpedicular screw insertion is a safe, simple, cheap, and practical method.

Surgical management of Juxtafacet cysts in the lumbar spine.

INTRODUCTION: Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic juxta facet cysts in the Neurosurgical Department of our hospital and review of the literature. METHODS: Data from seven patients (age range 58-68 years, mean age 63 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concominant local pathology, treatment and results of treatment were recorded. After surgery there was no case of a recurrent cyst during the follow-up period. The mean follow-up period of patients at the time of this study was 4 years. RESULTS: All patients had back pain, while five also experienced unilateral radicular leg pain and two had bilateral leg pain. Four patients had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. CONCLUSION: Surgery is a safe and effective treatment for lumbar juxtafacet cysts.

A large primary dumbbell hydatid cyst causing neural foraminal widening of the thoracic spine: A case report and literature review.

INTRODUCTION: Spinal hydatid cyst is a rare, but serious condition. PRESENTATION OF THE CASE: Herein, we present a 17-year-old male patient with back pain radiating to the legs and progressive weakness in the lower limbs. CT and MRI showed a spinal-paraspinal hydatid cyst with a dumbbell appearance that caused neural foraminal widening and spinal cord compression. The case was explored via right T3-T4 hemilaminectomy, and the hydatid cyst was completely removed. DISCUSSION: The clinical presentation, diagnosis, and surgical treatment of this rare case of spinal hydatid disease are discussed, and all published cases of primary dumbbell hydatid cyst are reviewed. CONCLUSION: Even if serological test results are negative, hydatid cysts should be considered in the differential diagnosis of cystic lesions of the spine.

Treatment of aneurysms arising from the proximal (A1) segment of the anterior cerebral artery.

The aim of our study was to report a series of 15 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery. In 15 patients with diagnosed A1 aneurysms, representing 2.1% of 720 aneurysm patients treated at a University Clinical Center between October 1999 and August 2012, clinical presentation, neuroradiological findings, surgical treatment methods and outcome were retrospectively analyzed. Mean patient age was 53.06 (range 32 to 75) years. Ten saccular aneurysms were treated with micro neurosurgical approach via standard pterional craniotomy, four fusiform aneurysms with coiling, and one fusiform aneurysm with stent. No patients died during the operation. The mean follow-up period was 32 months (range 5 months to 7 years). Clinical outcomes revealed good recovery in all patients. Despite the general opinion that A1 aneurysms are benign lesions, an increasing number of reports have demonstrated their potential complications. To date, due to the rarity of A1 aneurysms, only a few consecutive series have been reported. Conduct of multicenter studies are required in order to understand clinical features of A1 aneurysms and devise a proper treatment plan.

Ruptured distal middle cerebral artery aneurysm: Case report.

INTRODUCTION: This report describes a rare case of a distal middle cerebral artery (dMCA) aneurysm. PRESENTATION OF CASE: That developed a right intracerebral haematoma and subarachnoid haemorrhage. It was treated by surgical exploration and clipping via pterional approach. DISCUSSION: Clinical findings and surgical approaches of dMCA aneurysm are different from proximal middle cerebral artery (MCA) aneurysms. Microneurosurgical clipping is the most effective treatment of dMCA aneurysm. CONCLUSION: We comprehensively review the literature related to these rare aneurysms within the temporal lobe, surgical anatomy of the dMCA aneurysm.

Breast metastasis of anaplastic oligodendroglioma: a case report.

Extracranial metastasis of primary brain tumors is rarely observed. Of all brain malignancies, glioblastomas, medulloblastomas and astrocytomas metastasize most frequently. Metastasis of oligondendroglioma is rare. We present a case of breast metastasis in a 58-year-old man with an anaplastic oligodendroglioma.

Large primary intraorbital hydatid cyst.

The authors report a rare case of a large primary intraorbital hydatid cyst diagnosed in 3-year-old children who had presented with unilateral progressive nonpulsatile proptosis of the left eye, explored by computed tomography and magnetic resonance imaging.

Effect of systemic parameters following experimental subarachnoid hemorrhage and cerebral vasospasm in rabbits by injection of blood into the subarachnoidal space.

OBJECTIVES: To investigate acute changes of systemic parameters following experimental subarachnoid hemorrhage (SAH) and cerebral vasospasm conditions created by intracisternal injection of fresh autologous blood in a rabbit model. METHODS: The study was carried out at the Neurosurgery Clinic, Izmir Training and Research Hospital, Izmir, Turkey between April 2002 and March 2005. Thirty-two male rabbits were divided into the following 4 groups: group one with mild hemorrhage received 0.5 cc of blood, group 2 with moderate hemorrhage received 0.7 cc of blood, group 3 with severe hemorrhage received 1 cc of blood, and the sham-operated group 4 with no blood. The clinical parameters of all animals were monitored 2 hours after the operation, and blood analysis was performed just after hemorrhage. A series of systemic parameters such as rectal temperature, systolic and diastolic blood pressure, and blood gas analysis were measured before and after administration of blood injection. Results were compared by analysis of variance and paired t-tests, and p-values less than 0.05 were considered significant. RESULTS: The systolic blood pressures were significantly different in groups 1, 2, and 3 before and after the bleeding period. The diastolic blood pressures were also considerably different. CONCLUSIONS: This study suggests that the presence of a blood clot and different amounts of blood in the subarachnoid space can evoke a series of changes in both local and systemic states in experimental models.

Biomarkers of connective tissue disease in patients with intracranial aneurysms.

Connective tissue defects may play a significant role in the development of intracranial aneurysms (IAs). Multiorgan connective tissue disorders may, therefore, indicate a risk of IA development. We investigated biomarkers of connective tissue disease in patients with IAs. A series of 62 patients with IAs was studied by physical examination, echocardiography, ultrasound examination of the kidneys and abdomen, and microscopic examination of skin tissue (temporal area) and superficial temporal artery taken at operation. Patients with IAs had a higher incidence of biomarkers of systemic connective tissue disease than controls and identification of these markers may be important for screening for IAs. Microscopic investigation of biopsies of the skin and superficial temporal artery from patients and their relatives may become valuable for clinical diagnosis, identification of people at risk and basic studies of the pathogenesis of this vascular disease.

Magnetic resonance spectroscopic imaging associated with analysis of fluid in cystic brain tumors.

OBJECTIVE: There is a growing interest in cystic lesions of the brain. Examining the cyst content of brain tumors may contribute in determining the malignancy of the given tumor accompanied by a cyst. METHODS: In this work, samples of cyst fluid from 18 patients with brain tumor were collected and studied biochemically regarding their protein, lactate contents and pH values; magnetic resonance spectroscopic images of these patients were also compared. We investigated the relation between the grade of malignancy and the lactate concentration and the discrepancy between the high levels of lactate in cysts and their alkaline environment. RESULTS: There appears to be a positive relation between the grade of malignancy and the concentration of lactate in the cysts' fluid. A significant two-fold increase in lactate concentration in malignant tumors cysts has been found as compared with the more benign tumor cysts (p<0.001). This increase in lactate level is probably because of aerobic glycolysis, which causes lactate production by the tumor. DISCUSSION: High lactate levels found through magnetic resonance spectroscopy are positively related to the grade of tumor malignancy. The pH values in the cyst fluids were above normal, resulting to a discrepancy in high levels of lactate in the cyst and the alkaline environment. This suggests efflux of H+ ions by a Na/H exchange mechanism to compensate for the change of pH.

Ruptured distal anterior choroidal artery aneurysm.

This report describes a patient with a rare distal anterior choroidal artery (AChoA) aneurysm that developed a right intracerebral haematoma and intraventricular haemorrhage and was treated by surgical exploration and clipping via a transtemporal/ventricular approach. The patient was discharged neurologically intact. We review the literature related to these rare aneurysms within the temporal horn, and the surgical anatomy of the AChoA.

Developmental venous anomaly (DVA) with arterial component: a rare cause of intracranial haemorrhage.

INTRODUCTION: To examine the clinical and radiologic findings of patients with developmental venous anomaly (DVA) associated with intracranial haemorrhage but unrelated to cavernoma. METHODS: Computed tomography (CT) was used to obtain intracranial images from seven patients ranging in age from 6 to 51 years. Magnetic resonance imaging (MRI) was then performed on six patients, and two patients were further examined via CT angiography. Finally, digital subtraction angiography (DSA) was performed to confirm the initial diagnosis. RESULTS: CT showed intraparenchymal supratentorial haemorrhage in all patients. The combined imaging modalities eventually confirmed a diagnosis of arterialized DVA in four patients and arterialized DVA associated with arteriovenus malformation (AVM) in three. Two patients were managed symptomatically, two underwent radiosurgery, one underwent surgery, one underwent combined embolisation plus radiosurgery and the remaining patient underwent combined embolisation plus surgery. Two patients died, one as a result of re-bleeding, and the other due to radiation necrosis. The mean follow-up period was 33 months (6 months to 6 years) for the remaining five patients with favourable outcome. CONCLUSION: DVA associated with intraparenchymal haemorrhage, but not related to cavernoma, was confirmed. Though very rare, DVA may present with non-cavernoma-related haemorrhage in the form of arterialized DVA or DVA with AVM.

Total removal of cervicothoracic intramedullary 160-mm-long spinal cord ependymoma: a rare case report.

Ependymomas are neuroectodermal tumours arising from ependymal cells of the ventricular system, choroid plexus, filum terminale, or central canal of the spinal cord. We report on a 160-mm-long cervicothoracic intramedullary spinal cord ependymoma. The tumour was totally removed; no radiotherapy was used as an adjunctive therapy. Postoperative magnetic resonance imaging confirmed that the tumour had been totally removed.

A rare embryologic variation: anterior communicating artery aneurysm associated with carotid-anterior cerebral artery anastomosis or infraoptic course of the anterior cerebral artery.

Aneurysms of the complex of the anterior cerebral artery are frequently associated with anatomic variations of the circle of Willis. We describe a case of aneurysmal rupture of the anterior communicating artery, a variant of the anterior cerebral artery. The aneurysm appeared to be situated on this vessel proximal to the infered site of the AcoA. Surgery was performed at the 6th day after hemorrhage. The anterior communicating artery aneurysm was clipped. The post operative course was unventful, with complete recovery. In our case, an extremely rare variation of the proximal tract of the anterior cerebral artery, i.e. an infraoptic course of the proximal precommunicating tract under the optic nerve, with the distal A1 tract anterior to the chiasm and positioned between the optic nerves, is presented.