Two different approaches regarding hydrocephalus treatment in the Islamic World during the Middle Ages.

AIM: This study aimed to present the sections allocated to hydrocephalus in the works of Ibn Hubal al-Baghdadi and Ibn al-Quff, to include them and determine their position in the history of medicine by discussing relevant literature. MATERIAL AND METHODS: A printed copy and a manuscript in Istanbul Süleymaniye Manuscript Library, Fatih Collection, nr. 3632 of Ibn Hubal's Kitab al-Mukhtarat fi al-Tibb, and a facsimile of a printed copy and a manuscript in Istanbul University Rare Works Library, Arabic Manuscripts, A 4749 of Ibn al-Quff's Kitab al-'Umda fi Sina'a al-Jiraha, were used. The chapters on hydrocephalus in both works have been translated to English and obtained knowledge was determined based on relevant literature. RESULTS: Hydrocephalus was discussed under the title "On swellings and water occurring outside the skull and on the 'utash of the child and on water collection in the skull" in the third volume of Ibn Hubal's work and "The sixth chapter on the treatment of water which collects in the heads of children" in the 19th article of Ibn al-Quff's work. Ibn Hubal's and Ibn al-Quff's knowledge and approach to hydrocephalus match the knowledge and approaches of their predecessors. Compared with Ibn Hubal, Ibn al-Quff provided more systematic and detailed information on hydrocephalus. CONCLUSIONS: Like other writers of the Islamic world in the medieval times, Ibn Hubal and Ibn al-Quff accept definitions and classifications of hydrocephalus by Greco-Roman writers.

Posterior Endoscope-Assisted Diskectomy Is an Effective Technique for Cervical Soft Disk Herniation.

OBJECTIVE: To evaluate the clinicoradiologic conditions of patients with a herniated cervical disk who were treated with percutaneous endoscope-assisted cervical diskectomy. MATERIALS AND METHODS: The medical data of 27 patients (16 men and 11 women; mean age: 40.9 years) who were operated on with the posterior endoscope-assisted cervical diskectomy method were reviewed retrospectively. The mean follow-up was 35.1 months, and the patients were assessed with combined preoperative and postoperative visual analog scale (VAS), Prolo Functional Economic Outcome Rating scale, MacNab scale, and clinical imaging. RESULTS: The mean preoperative VAS level was 8.6 (range: 7-10), and mean Prolo score was 2.5 (range: 2-5). A postoperative assessment performed 1 week postsurgery found a mean VAS level of 2.1 (range: 0-4). At the final examination, the mean VAS level was 0.81 (range: 0-3), and the mean Prolo score was 4.5 (range: 3-5). The final MacNab scale scores were 62.9%, excellent; 25.9%, good; 7.4%, moderate; and 3.7%, poor. CONCLUSION: Percutaneous endoscope-assisted cervical diskectomy is a suitable and effective treatment method for soft cervical disk herniation.

An Early Description of Using Oral Route for the Management of Cervical Vertebra Fracture by Ibn al-Quff in the Thirteenth Century.

OBJECTIVE: This study presents information regarding the treatment of fractures and dislocations of the vertebrae, including the use of the oral route for upper cervical fractures, presented in certain chapters of the book titled Kitab al-'Umda fi Sina'a al-Jiraha (Ibn al-Quff, thirteenth century ad). METHODS: A printed copy of the second volume of the book was studied. Chapters 22 ("On treatment of vertebral fractures") and 33 ("On treatment of vertebral dislocation") of the seventeenth treatise of this book were translated from Arabic into English. Each section is presented (in full text) in the Results section of this article. The findings were compared with the relevant literature and discussed to determine whether Ibn al-Quff presented novel information compared with that presented by his predecessors. RESULTS: The writings of Ibn al-Quff regarding vertebral dislocations seem to summarize information derived from his predecessors. Moreover, he modified certain approaches, previously described for vertebral dislocations, and used them for correcting vertebral fractures. Ibn al-Quff introduced the most novel use of a bridlelike instrument for anterior cervical fracture through the oral route. By introducing the device in the mouth, he described a pushing maneuver to the cervical vertebrae from the ventral site and a simultaneous pulling maneuver by cupping on the neck from the dorsal site. CONCLUSIONS: The use of the oral route introduced by Ibn al-Quff may be one of the earliest examples of novel, practical, and advanced treatment for cervical vertebral fracture.

Bioresorbable Vascular Scaffolds in Interventional Neuroradiology.

PURPOSE: Bioresorbable vascular scaffolds (BVS) have changed practice patterns in cardiology. These resorbable stents have not yet been utilized in the cerebrovascular circulation. We report the initial experiences with these devices in interventional neuroradiology. METHODS: A retrospective review of clinical presentations, imaging findings and follow-up results of all patients treated using a BVS by our neurovascular team was carried out using hospital electronic charts and the hospital radiographic archive system. Treatment was performed only if patients had a non-tortuous cerebrovascular anatomy suitable for navigation by the bulky BVS. RESULTS: In this study 9 patients (5 women, mean age 51.3 years) were treated with Absorb or DeSolve scaffolds without permanent morbidity or mortality, 5 had intracranial or vertebral artery stenosis and in 4 patients with cerebral aneurysms scaffold-assisted coiling was performed. At a mean follow-up of 22.3 months, 1 parent artery in the aneurysm group was occluded and the remaining BVSs showed no significant restenosis. Fusiform luminal enlargement was demonstrated in one aneurysm patient. In two patients treated for stenosis, transient intra-arterial filling defects resembling BVS struts (scaffold silhouette) was demonstrated on early follow-up angiograms. In the patient with parent artery occlusion (who was judged to have unjailed the internal carotid bifurcation) and in the patient with luminal remodeling, we were able to discontinue all antiplatelet medications at 3 years without any consequences. CONCLUSION: Absorbable stent technology has potential applications in interventional neuroradiology. We suggest that BVS should be optimized for cerebral circulation if prospective studies are to be undertaken for cerebrovascular applications of BVS.

How Cranial Shapes Led to Contemporary Ethnic Classification: A Historical View.

In the medical literature, various ethnic terms such as Caucasian or Mongolian,are sporadically cited to indicate the relationship between certain disorders and the geographical origin of individuals. Few scientists recognize that those definitions stem from a medical thesis written by the German physician Johann Friedrich Blumenbach in 1775. Through considering cranial shapes, Blumenbach proposed five race varieties including the Caucasian, the Mongolian, the Malayan, the Ethiopian, and the American. While he favored only beauty, his contemporaries reclaimed an intellectuality arrangement among those race types and gave the highest credibility to Caucasian, which therefore, besides defining an ethnicity, has conveyed a discriminatory meaning. The term had been widely used in the medical literature without knowledge of its historical background. Although not commonly used any longer, the Caucasian and similar terms that reflect racial preference should be abandoned in medical text and replaced by more favorable definitions.

One of the Earliest Accounts of Head Wounds in Firdaws al-Hikma by al-Tabari from the 9th Century.

OBJECTIVE: To present the first Arabic text on suturing scalp wounds. METHODS: A related section entitled "On the wounds in the head" from the book Firdaws al-Hikma (Paradise of the Wisdom) written by al-Tabari in the 9th century was identified and analyzed. This work was one of the earliest medical compendiums in the Islamic world during the medieval period. A printed copy of Firdaws al-Hikma edited by Muhammad Zubayr al-Siddiqi was examined, and findings were compared with relevant knowledge in the literature. RESULTS: A notable part of this text is based on appropriate closure of scalp wounds using sutures. Before this work, only the well-known Indian medical book Susruta-Samhita had mentioned closure of scalp wounds using sutures. In his work, al-Tabari recommended using materials made of silk or linen for suturing. He additionally proposed some recipes that have a coating feature that prevents bleeding from the wound after it was closed properly. He also dealt with persistent swelling and provided formulas for solving the problem with special compositions. CONCLUSIONS: Firdaws al-Hikma is a noteworthy work in the history of medicine, and it includes a unique chapter on head wounds. To the best of our knowledge, this is the first mention of suturing scalp cuts in Arabic literature and the second reference in medical literature after the Indian work Susruta-Samhita.

Tapered Flow Diverters in the Treatment of Intracranial Aneurysms.

AIM: To report the initial experience of cerebral aneurysm treatment with Tapered flow diverters (TFDs). MATERIAL AND METHODS: Thirty patients with 34 aneurysms underwent cerebral aneurysm treatment with TFD (Silk, Balt, Montmorency, France) between March 2011 and March 2016. Procedural findings, complications, clinical and imaging follow-up were assessed retrospectively. RESULTS: The patients" mean age was 48±14.5 years (range, 16-74; 25 females). Aneurysms size ranged from 3 to 35 mm with an average diameter of 13.9±8.8 mm and a median diameter of 10.5 mm. Technical success rate was 96.6%. Technically, deployment of the device was similar to the non-tapered version and subjectively, it appeared to be easier in the paraophthalmic segment. Permanent morbidity and mortality rates secondary to the procedure were 0%. On clinical follow-up (29 patients, mean 9.3±9.1 months) there were no clinical untoward events. Imaging follow-up was at or after 6 months (20 patients, mean 12.3±10 months). Angiographic occlusion rate was 80%. CONCLUSION: TFD is safe to use and effective for the treatment of intracranial aneurysms in this series. The occlusion rate is higher with respect to the previous reports and experience using the non-tapered version. Maintenance of porosity at the transition zone may be the factor underlying the higher occlusion rate. TFD may be preferred especially for arterial segments aneurysms where there is considerable discrepancy in size between the distal and proximal parent artery.

Silk Device for the Treatment of Intracranial Aneurysms. Part 1: Peri-Procedural Results, Technical Aspects and Learning Curve.

AIM: We evaluated the procedural outcomes of intracranial aneurysm treatment with the Silk device and its relation with operator experience. We also detailed some technical points we learned throughout our experience. MATERIAL AND METHODS: One hundred and six consecutive patients with intracranial aneurysms treated using Silk (BaltExtrusion, Montmorency, France) stent between October 2010 and November 2013 were included. Patients were evaluated in terms of age, sex, aneurysm size, location, technical success, and adverse events. RESULTS: There were 106 patients (71 female) undergoing 116 procedures with a mean age of 49.8 (range: 3-78 years). Mean aneurysm size was 10.7±8.0 (range, 2-40 mm). Technical success of the procedures was 96.5%. Adverse event rate was 11.2%. Among adverse events, there were 4 adverse events without complications, 2 mild complications, 7 severe complications, 4 of which resulted with death. The adverse event rate was significantly higher during the first half of the operator's experience. The rate of adverse events seemed to stabilize after around 50 patients. Adverse events, regardless of the presence or absence of a clinical complication, were more frequent in aneurysms larger than 18.5 mm. CONCLUSION: Safety of flow-diverter (FD) placement for intracranial aneurysms increases with operator experience. Training programs in endovascular management of cerebrovascular diseases and relevant fellowship curricula must be adapted to include sufficient flow diverter experience. The learning curve needs to be kept in mind when studies comparing different FD devices or those comparing other treatments to FDS are planned.

Silk Device for the Treatment of Intracranial Aneurysms, Part 2: Factors Related to Clinical and Angiographic Outcome.

AIM: To report patient and procedure-related factors affecting the angiographic and clinical outcome in patients treated with the Silk device. MATERIAL AND METHODS: All patients with intracranial aneurysms in whom treatment was attempted with the Silk flow diverter by our neurovascular team between October 2010 and November 2013 were included consecutively. The data was analyzed by an independent stroke neurologist not involved in the treatment of the patients. RESULTS: A total of 96 patients (64 female) with ages range from 3 to 78 were included in this study. We found that 54 of the patients were asymptomatic and 42 of them symptomatic, while 21 had a prior history of subarachnoid hemorrhage (SAH). Mean aneurysm size was 10.2 mm (range 2 to 40 mm). 2 patients died due to consequences of SAH. 3 patients developed visual decline on the follow-up, 2 of these were procedure-related. Symptomatic thromboembolic events were noted in 7 cases. Patients with aneurysms smaller than 13 mm had significantly less complications and higher occlusion rates. The complication rate was significantly high in patients admitted with symptoms. Adjunctive coiling had no impact on outcome. CONCLUSION: Safety and efficacy of flow diversion in this series was closely related to aneurysm size and presenting symptoms. A size cut-off for safety and efficacy has not been reported before and will be useful not only for future studies but also for patient counseling in daily practice. The futility of adjunctive coiling in this series calls for reappraisal of the current recommendations for this specific device.

Initial Discectomy Associated with Aging Leading to Adjacent Disc Disease and Recurrence.

AIM: Failure of surgery for lumbar disc herniation (LDH) can be commonly caused by recurrence. There are many debates regarding the risk factors of recurrent LDH (rLDH) and it is very difficult to define them because many clinical and complicated biomechanical parameters are involved. The purpose of study was to evaluate the long term result of re-discectomy for LDH at the same level and adjacent segments. MATERIAL AND METHODS: Between 1999 and 2009, 1898 cases were operated and 142 (6.4%) patients underwent re-discectomy following initial operation. The study included 65 patients who were operated for single level discectomy, and their charts were analyzed retrospectively. RESULTS: There were 33 (50.8%) women and mean age was 45.5 years (24-73 years). rLDH was diagnosed at the initial level in 40 (61.5%) but adjacent and/or opposite level herniation (with or without the first level) was found in the remaining 25 cases (39.1%). Recurrence at the same level (SLG) and adjacent level groups (ALG) were similar according to the clinical outcomes in follow-up (mean 34.1 months). Admission period after initial operation was also parallel in SLG and ALG (54.7 and 53.1 months, respectively). However, the mean age of ALG (49.4 years) was significantly higher (p≤0.05) than SLG (42.8 years). CONCLUSION: After discectomy, collapsed discs are biomechanically more stable than those with preserved disc heights, and responses to axial compression on intervertebral disc pressure produced deformations of adjacent levels despite limitations. Altered biomechanical loading next to a fusion resulted in ongoing degeneration with aging at the affected entire lumbar spine.

Metamizole Sodium Induces Neural Tube Defects in a Chick Embryo Model.

AIM: The aim of this study was to investigate the effects of metamizole sodium on neural tube development in the early stage chick embryo model that complies with the first month of embryonic development in mammals. MATERIAL AND METHODS: A total of 40 fertilized chicken eggs were divided into 4 equal groups. The eggs were incubated in the incubator at a temperature of 37.8±2°C with 60±5% humidity. Group A was the control, Group B was administered physiological saline, Group C was administered 30 mg/kg metamizole sodium (based on the therapeutic index range of it used in humans) and Group D was administered 90 mg/kg metamizole sodium. All embryos were removed from the egg at the 48th hour and morphologically and histologically examined. RESULTS: Normal development was seen and the neural tube was closed in 17 embryos in Groups A and B. A neural tube defect was seen in 2 embryos in group A and in 1 embryo in group B. A neural tube closure defect was seen in all embryos in group C and 9 embryos in group D. There was 1 dead embryo in Group D. CONCLUSION: Metamizole sodium was seen to produce a neural tube defect in the chicken embyro model.

Neuroprotective effects of adalimumab on rats with experimental peripheral nerve injury: An electron microscopic and biochemical study.

BACKGROUND: Adalimumab, a new-generation anti-inflammatory agent, exerts its effect through tumor necrosis factor α (TNF-α), secreted from immune response cells such as macrophages and lymphocytes. TNF-α has been shown to play an important role in the processes of apoptosis and demyelination, and blockage of its activity may improve neural healing. Investigated in the present study is the probable neuroprotective influence of adalimumab in rats using a peripheral nerve injury model with biochemical and electron microscopic methods. METHODS: Forty adult Wistar albino rats were randomly divided into control, sciatic nerve trauma, low-dose adalimumab, and high-dose adalimumab groups. Six rats from each group were assigned biochemical microscopy, and 4 were assigned electron microscopy. Neural injury was induced with clip compression following dissection of sciatic nerves. Adalimumab was simultaneously injected. The rats were sacrificed after 2 weeks of adalimumab treatment. RESULTS: Nerve tissue lipid peroxidation values were found to be significantly decreased in both the low- and high-dose adalimumab treatment groups, compared to the group subjected only to sciatic nerve trauma. CONCLUSION: Results demonstrate that adalimumab is an effective neuroprotective agent for neural healing, particularly in the early phase.

Experimental Endoscopic Cordotomy in the Sheep Model.

AIM: Interventional pain therapies are usually based on destruction of the related pain-conducting pathways. Current procedures targeting pain have replaced conventional pain treatment modalities while being less invasive. In this study, we investigated the feasibility of the endoscopic percutaneous cordotomy process on the sheep cervical spinal cord. MATERIAL AND METHODS: Seven male sheep, Akkaraman® genus, were operated on in the study. The guide was introduced at C1 to C2 vertebrae. The interlaminar area was exposed by a dilator, the dura was identified, and then the working cannula was inserted into the subarachnoid space. The target point of cordotomy was defined by endoscopic visualization as the midpoint between the dentate ligament and ventral root entry zone. After determination of the target point, a carbon dioxide laser (CDL) probe was introduced through the cannula. Ablative lesioning was performed by CDL. Hindlimb withdrawal thresholds were measured using the "Sample Pain Scale". The lesion was demonstrated by magnetic resonance imaging and histopathological examination. RESULTS: Three sheep had ipsilateral hemiparesis and the response to firm pressure test was not performed on them. Among the remaining four sheep, the pain tolerance test showed that one sheep was at stage 0, two at stage 1, and the last one at stage 3. CONCLUSION: Cordotomy might be successfully performed with the endoscopic technique in the sheep model and this should encourage future studies regarding minimal invasive procedures for intractable pain.

Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment?

BACKGROUND AND OBJECTIVE: The outcome of flow diversion for middle cerebral artery (MCA) aneurysms, one of the most common sites for intracranial aneurysms, has not been defined thoroughly. We assessed our outcomes in MCA aneurysms (MCAAs) treated by flow diversion, i.e., with either dedicated flow diverters or telescopic stents. METHODS: Patients with MCAAs were treated by flow diversion if surgical or other endovascular treatment modalities had failed or were deemed likely to fail. Angiographic and clinical outcome of these patients was assessed retrospectively. Aneurysm location on MCA was defined as M1 segment, "true bifurcation" (classical bifurcation of MCA into superior and inferior trunks), "variant bifurcation" (bifurcation of early frontal or early/distal temporal branches), or M2 segment. Aneurysm morphology was classified as saccular versus dissecting/fusiform. RESULTS: Treatment was attempted in 29 MCAAs. Technical failure rate was 3.4% (1/29). Thirteen of aneurysms were fusiform. Of the bifurcation aneurysms, most (10/16) were the variant type. Overall and procedure-related mortality/permanent morbidity rates were 10.3% (3/29) and 3.5% (1/29). Total occlusion rates (mean angiographic follow-up 10.3 months) for saccular and fusiform aneurysms were 40% and 75%, respectively. In bifurcation aneurysms, occlusion was strongly associated with side-branch occlusion (P < 0.005). CONCLUSIONS: In this series, flow diversion for the treatment of MCAAs was safe, was effective in the treatment of fusiform MCAAs, and was not as effective at mid-term for MCA bifurcation aneurysms. Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent.

Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics.

STUDY DESIGN: The study retrospectively investigated 15 cases with multilevel noncontiguous spinal fractures (MNSF). PURPOSE: To clarify the evaluation of true diagnosis and to plane the surgical treatment. OVERVIEW OF LITERATURE: MNSF are defined as fractures of the vertebral column at more than one level. High-energy injuries caused MNSF, with an incidence ranging from 1.6% to 16.7%. MNSF may be misdiagnosed due to lack of detailed neurological and radiological examinations. METHODS: Patients with metabolic, rheumatologic diseases and neoplasms were excluded. Despite the presence of a spinal fracture associated clearly with the clinical picture, all patients were scanned within spinal column by direct X-rays, computed tomography and magnetic resonance imaging. When there were ≥5 intact vertebrae between two fractured vertebral segments, each fracture region was managed with a separated stabilization. In cases with ≤4 intact segments between two fractured levels, both fractures were fixed with the same rod and screw system. RESULTS: There were 32 vertebra fractures in 15 patients. Eleven (73.3%) patients were male and age ranged from 20 to 64 years (35.9±13.7 years). Eleven cases were the American Spinal Injury Association (ASIA) E, 3 were ASIA A, and one was ASIA D. Ten of the 15 (66.7%) patients returned to previous social status without additional deficit or morbidity. The remaining 5 (33.3%) patients had mild or moderate improvement after surgery. CONCLUSIONS: The spinal column should always be scanned to rule out a secondary or tertiary vertebra fracture in vertebral fractures associated with high-energy trauma. In MNSF, each fracture should be separately evaluated for decision of surgery and planned approach needs particular care. In MNSF with ≤4 intact vertebra in between, stabilization of one segment should prompt the involvement of the secondary fracture into the system.

Biomechanical comparison of unilateral semi-rigid and dynamic stabilization on ovine vertebrae.

Using the unilateral pedicle screw fixation was thought to decrease the stiffness of the fixed segments. Various prospective, randomized studies were performed to determine whether unilateral pedicle screw fixation provides the necessities of bilateral fixation in one- or two-segment lumbar spinal fusion. In this study, four different unilateral pedicle screw fixation systems were evaluated to determine which one best approximated an intact spine with respect to biomechanics and kinematics. The four groups included an intact group, a unilateral facetectomy group with no fixation, a unilateral semi-rigid pedicle screw fixation group with a poly-ether-ether-ketone rod, and a unilateral dynamic pedicle screw fixation group. The bone mineral densities of all specimens were measured and specimens were matched with groups randomly. Flexion, lateral bending, and axial rotation tests were performed to compare the groups. For the flexion, lateral bending, and axial rotation tests, the best biomechanical outcomes were in the control group. The unilateral facetectomy group had the poorest performance and was not stable enough, compared with the control group. The dynamic and semi-rigid groups showed performance closer to that of the control group. The biomechanical responses of these two groups were also in good agreement, showing no significant statistical differences. Based on these test results, it is concluded that the unilateral dynamic and semi-rigid pedicle screw fixations can be used to provide stability to the vertebrae.

An uncommon intramedullary tumor: primary spinal cord melanoma.

A 47-year-old woman was admitted with complaints of progressive weakness in the lower extremities and pain in the back and left leg. Thoracic magnetic resonance imaging (MRI) revealed a spinal intramedullary tumor between the T9 and L1 levels, which were iso- to hypointense on T2 and slightly hyperintense on T1-weighted images. The tumor was resected as total, and the diagnosis was malignant melanoma confirmed with histopathology. Neurological findings improved at the postoperative period and no residual or recurrence was noted on postoperative MRI at the 9-month follow-up. Primary melanoma of the spinal cord, particularly intramedullar localization, is seldomly reported in the literature. We report a primary malignant melanoma of the spinal cord and emphasize the diagnostic and prognostic challenges.