Pituitary Colloid Cyst.

Colloid cysts appear most commonly in the third ventricle, their occurrence in the sellar region is uncommon. The authors report a female patient with a pituitary colloid cyst. She was diagnosed incidentally with a sellar lesion by a routine paranasal computed tomography examination performed for planning of a dental implant surgery. Radiologic examinations revealed a pituitary lesion that was removed by transnasal transsphenoidal route. Her pathologic examination revealed that the lesion was a colloid cyst. Although rare, colloid cysts should be considered in the differential diagnosis of pituitary lesions.

Intrasellar arachnoid cyst: A case report and review of the literature.

INTRODUCTION: Arachnoid cysts (ACs) are frequently found on intracranial imaging studies but intrasellar arachnoid cysts are rarely encountered. PRESENTATION OF CASE: We present a 49-year old patient who had headaches for 6 months and cystic sellar mass was found in his cranial imaging. We operated him by transnasal transsphenoidal route. Our intraoperative diagnosis was an arachnoid cyst and pathologic studies verified our observation. He did well postoperatively and after a 1year follow-up he was left free from future follow-ups. DISCUSSION: As common cystic lesions occupying the sellar region can simulate ACs both clinically and radiologically, neurosurgeon can fail to include ACs in making the initial diagnosis preoperatively. CONCLUSION: Although a rare entity, arachnoid cysts should be considered in the differential diagnosis of sellar region.

Hyperglycemia is a predictor of prognosis in traumatic brain injury: Tertiary intensive care unit study.

BACKGROUND: Hyperglycemia is frequently encountered in critically ill patients and has been shown to contribute to both morbidity and mortality. We aimed to study the predictive role of blood glucose level in clinical outcomes of mechanically ventilated patients with traumatic brain injury during intensive care unit (ICU) stay and to explore its relationship with Glasgow coma scale (GCS) and acute physiology and chronic health examination (APACHE) II scores that are used in the evaluation of ICU patients as predictor. MATERIALS AND METHODS: A total of 185 patients with craniocerebral trauma who were hospitalized in the ICU were included in the study. Comparisons of mean glucose values (MGVs) and APACHE II scores between survivors and nonsurvivors were made with Student's t-test and chi-square test. Survival analysis was performed with log rank (Mantel-Cox) test and Cox regression was used for mortality risk factors analysis. RESULTS: MGVs at the initial, last, and all measurements were significantly higher for nonsurvivors than for survivors. Hazard rate at any given time point for patients with mean glucose value (MGV) between 150 and 179 was found to be 3.691 times that of patients with MGV values between 110 and 149. The hazard rate at any given time point for patients with MGV values ≥180 was found to be 6.571 times that of patients with MGV values between 110 and 149. CONCLUSION: High glucose level is an independent risk factor for mortality in mechanically ventilated ICU patients with traumatic brain injury.

Obstructive hydrocephalus due to vertebrobasilar dolichoectasia: diagnostic and therapeutic considerations.

BACKGROUND: Obstructive hydrocephalus caused by vertebrobasilar dolichoectasia is an extremely rare entity. Cerebrospinal fluid pathway obstruction may be localized at the level of either the foramina of Monro or the cerebral aqueduct. Radiological imaging can sometimes be misleading in establishing the precise location of the obstruction, which is crucial in determining the optimal surgical strategy. We report such a case with diagnostic challenges and also present a review of previously reported cases with a special focus on diagnostic and therapeutic controversies. CASE DESCRIPTION: We present a patient with an obstructive hydrocephalus associated with a dolichoectatic basilar artery extending to the level of the foramina of Monro. Although computed tomography angiography findings indicate bilateral occlusion of the foramina of Monro by the posterior cerebral arteries, mild but suspicious dilatation of the third ventricle raised concerns about the precise location of the obstruction. Endoscopic exploration of the right foramen of Monro was performed not only to clarify questionable radiological findings but also to be prepared to make a septostomy prior to monoventriculoperitoneal shunting if exploration would confirm occlusion of the foramina of Monro. However, the right foramen of Monro was documented to be patent during surgery and the cerebral aqueduct was considered to be the location of obstruction. The procedure was accomplished with monoventriculoperitoneal shunting, which achieved a full recovery immediately after the operation. CONCLUSIONS: Our current experience and the literature review highlight the usefulness of neuroendoscopy as a diagnostic and therapeutic solution, particularly in cases considered to have obstructive hydrocephalus caused by compression of the foramina of Monro by dolichoectatic basilar artery.

Diagnostic and therapeutic role of CT-guided stereotactic surgery in the management of intracranial tuberculomas.

AIM: CT-guided stereotactic methods have long been used for the diagnosis and treatment of intracranial masses. Intracranial tuberculoma is a rare form of extrapulmonary tuberculosis. Histological confirmation is the gold standard for a correct diagnosis. However, histopathological diagnosis and excision of these lesions have advantages over open surgical methods. This study presents our experience on the use of stereotactic biopsy and excision in the management of intracranial tuberculomas. MATERIAL AND METHODS: Thirteen patients with intracranial masses underwent stereotactic procedures for tissue samples to establish histopathological diagnosis. In 6 suitable patients, stereotactic microsurgical excision was performed for both diagnostic and therapeutic purposes, whereas only stereotactic biopsy was conducted in the remaining subjects. RESULTS: The tuberculoma diagnosis was established in 12 out of 13 cases (92%). Seizure control was achieved in all patients admitted with a history of seizures. There was no procedure-related mortality, none of the patients suffered permanent disability and most procedures were uneventful. Total resection without any residual mass was done. All patients responded to antituberculous treatment with complete lesion disappearance. CONCLUSION: These findings suggest that CT-guided stereotactic surgery of intracranial tuberculomas has advantages over other methods, with a potential to become the first-line modality, particularly as a diagnostic tool, in the management of these lesions.

The effects of eicosapentaenoic acid on the endothelium of the carotid artery of rabbits on a high-cholesterol diet.

The preventive and therapeutic effects of eicosapentaenoic acid (EPA) on diet-induced hyperlipidemia in rabbits have been investigated. Eighteen New Zealand rabbits were randomly divided into three groups of 6 subjects each; experimental group-I (EG-I) was administered a cholesterol rich diet, experimental group-II (EG-II) was treated with EPA (300 mg/kg/d) following a cholesterol-rich diet and the control group (CG) had a standard diet. Blood samples were collected at day 0 and at the 4th and 12th weeks of EG-II to obtain serum levels of total cholesterol (TC), high density lipid-cholesterol (HDL-C), low density lipid-cholesterol (LDL-C) and triglyceride (TG). From each group tissue samples were collected from the carotid artery for immunohistochemistry and electron microscopy. Our results showed that EPA could significantly lower (p<0.001) serum TC, LDL-C, HDL-C and TG levels with a reduction of 35%; 55%; 44% and 51%, respectively. Scanning and transmission electron microscopy results revealed that endothelial damage was more prominent in EG-I when compared to EG-II. The ruptured endothelial lining and damaged cellular surface was increased in EG-I when compared to EG-II. Ultrastructural observations showed that after EPA treatment, the degeneration and cellular surface damage on the endothelium were also decreased. These biochemical and ultrastructural results suggest that EPA is a potential drug which significantly lowers the serum lipid profile and partially repairs endothelial dysfunction due to hyperlipidemia.

Spinal dysraphisms of the cervicothoracic region in childhood.

PURPOSE: Spinal dysraphisms are the most common congenital anomalies of the CNS. Spinal dysraphism (SD) of cervical and upper thoracic region are rare, demonstrating distinct clinical and structural configurations compared to lumbar counterparts. METHODS: In Haydarpasa Numune Hospital, a total of 7 cases (3 male and 4 female) ranging between 20 days to 9 years of age with cervicothoracic SD were operated on between 2002 and 2008. The sacs were located in the cervical and thoracic region in 4 and 3 of the cases, respectively. The associated anomalies were diagnosed in 3 cases, including SCM type 2, Chiari type 2, hyrocephalus and hydromyelia. All cases underwent surgical treatment that involves excision of the sac and intradural exploration providing untethering of the spinal cord. Postoperative follow up of these patients was uneventful and neither neurological deficits nor complications were observed. CONCLUSION: Cervicothoracic SD has more favorable outcome in respect to neurological, orthopaedic and urologic problems compared to lumbar counterparts. In order to prevent forthcoming neurological deterioration, surgical treatment consisting of intradural exploration of the lesion, untethering of the spinal cord and excision of potential adhesions should be performed in the early period.

Cysteinyl-leukotriene receptor antagonist montelukast decreases blood-brain barrier permeability but does not prevent oedema formation in traumatic brain injury.

INTRODUCTION: Traumatic brain injury is highly associated with the over-production of reactive oxygen species. The aim of this study was to investigate the putative neuroprotective effect of montelukast, a cysteinyl-leukotriene receptor antagonist, in a rat model of traumatic brain injury (TBI). METHODS: Sprague Dawley rats were subjected to TBI with a weight-drop device using 300 g-1 m weight-height impact. The groups were: control (saline), montelukast (10 mg kg(-1) per day, ip), trauma and trauma + montelukast. Two days post-trauma, neurological examination scores were measured and animals were decapitated and the brain tissues were taken for the histologic and biochemical [malondialdehyde (MDA)-an index for lipid peroxidation, reduced glutathione (GSH), myeloperoxidase (MPO)-an index for neutrophil infiltration and Na+/K+-ATPase activity] evaluations. Brain oedema and blood-brain barrier (BBB) permeability were also evaluated. RESULTS: The neurological examination scores mildly increased in trauma groups at 48 hours. Although the scores were decreased in the montelukast treated group, they were still significantly higher than the control. The trauma caused a significant increase in brain water content and Evans blue (EB) extravasation. Montelukast treatment reduced BBB permeability. It also decreased lipid peroxidation and MPO activity. CONCLUSION: The present study suggests that montelukast may have beneficial effects against TBI-induced oxidative stress of the brain.

The pressure angle of the median nerve as a new magnetic resonance imaging parameter for the evaluation of carpal tunnel.

OBJECTIVES: The purpose of this study was to compare the MRI findings of the wrists of patients with carpal tunnel syndrome (CTS) and controls. We present a new MRI parameter, the pressure angle of the median nerve, in CTS patients. PATIENTS AND METHODS: The study included 55 wrists, 36 of which were diagnosed with CTS and 19 healthy controls. All subjects underwent clinical, electrophysiological, and MRI evaluation. Clinical and electrophysiological findings were staged according to the degree of deficit. MRI parameters including median nerve diameter (MR1) and width (MR2) at the pisiform bone level; median nerve diameter (MR3) and width (MR4) at the hamate bone level; carpal arch width (MR5); carpal arch height (MR6); pressure angle of the median nerve (MR7); carpal tunnel diameter at the pisiform bone level (MR8); carpal tunnel diameter at the hamate bone level (MR9) and median nerve-flattening ratio were investigated. Eighteen operated wrists were evaluated 8 weeks after surgery. Correlation between the MRI parameters, EMG and clinical signs were evaluated. RESULTS: Among the 36 wrists with CTS, 5.6% were mild cases, 55.6% were moderate, and 38.9% were severe. Electromyography staging was as follows: 5.6% mild, 52.8% moderate, and 41.7% severe. A good correlation between the clinical and electrophysiological staging of the wrists with CTS was demonstrated (P=0.0001). Median nerve width and carpal tunnel diameter at the pisiform bone level were found to be significantly increased whereas median nerve diameter at the hamate bone level and pressure angle of the median nerve (PAMN) were significantly lower in CTS group in comparison to controls. After surgery, median nerve diameter and width at the pisiform bone level decreased whereas median nerve diameter at the hamate bone level increased. In addition, carpal arch height and PAMN were also found to be significantly increased (P=0.0001). The carpal tunnel diameter and median nerve-flattening ratio increased at the hamate bone level post-operatively (P=0.0001) with no change at the pisiform bone level. CONCLUSION: The pressure angle of the median nerve may prove useful in the assessment of idiopathic CTS, both before and after surgery.

Agenesis of the left internal carotid artery associated with anterior communicating artery aneurysm: case report.

We present a rare case of agenesis of the left internal carotid artery in a 43-year old woman, associated with an aneurysm of the anterior communicating artery and presenting with subarachnoid hemorrhage. The left internal carotid artery was not visualized on the left carotid angiogram. The left middle cerebral artery was perfused from the basilar artery via the dilated posterior communicating artery on vertebral angiogram. Absence of the left carotid canal was proven on temporal bone computed tomography. Absence of the left internal carotid artery was verified at operation. Absence of internal carotid artery is discussed in relation to aneurysm formation.

Post-traumatic early epilepsy in pediatric age group with emphasis on influential factors.

OBJECTIVE: Posttraumatic epilepsy in the pediatric age group is mostly seen within the first week. An acute posttraumatic epileptic fit, which may induce secondary insults, should be hindered. The aim of the study is to define the risk factors for posttraumatic early epilepsy (PTEE) and the indications for prophylactic therapy. METHODS: In this survey, a total of 1,785 pediatric patients--under the age of 16--are studied. The majority of the patients (1,655) were treated in Haydarpasa Numune Hospital within the years 1993-1999. The rest, which consists of 130 patients, were treated in Inönü University Turgut Ozal Medical Center between the years 2001 and 2003. The patients were categorized according to age, gender, neurological manifestations, type of trauma, cranial pathology, number and type of epileptic fits, the interval between trauma and convulsion, electroencephalogram findings, and antiepileptic therapy. All these factors were challenged due to their effect on the evolution of PTEE. RESULTS: Only 149 cases had PTEE (8.4%). There was no correlation between gender and the incidence of PTEE. The data showed that 11.7% of the patients at or under the age of 3 (p=0.00072), 30.8% of the patients with severe head injury (Glasgow Coma Scale=3-8; Children's Coma Scale = 3-8; p=0.00000), 19.3% of the patients with depressed skull fractures (p=0.00038), 13.7% of the patients with intraparenchymal hemorrhage (p=0.0000072), and 21.6% of the patients with cerebral edema (p=0.000008) had PTEE. Only 20% of the patients with PTEE had a Glasgow Outcome Scale (GOS) of 3 or less (p=0.0000075). CONCLUSION: Those patients at or under the age of 3, with severe head injury, cerebral edema, intraparenchymal hemorrhage, or depressed skull fracture, have a higher incidence of PTEE. Moreover, because the GOS of these patients are prone to be worse, antiepileptic therapy in acute stage may be effective in preventing the secondary brain damage.

Pineal germinoma associated with multiple congenital melanocytic nevi: a unique presentation.

Intracranial germ cell tumors are rarely seen and typically localize in the pineal or suprasellar region. The largest category of germ cell tumors is the germinoma. There have been reported associations of malignant tumors and chromosomal abnormalities in germ cell tumors. In this study, we present a 22-year-old man with multiple congenital melanocytic nevi in association with pineal tumor. Congenital melanocytic lesions greater than 2 cm were counted to be 54 in number, and those smaller than 1 cm in diameter were found to be 25 in number. The pathological diagnosis of the pineal tumors was germinoma, and the lesions located in the occipital region and trunk were compound congenital nevi. To our knowledge, a relationship between multiple congenital melanocytic nevi and germ cell tumors has not been reported before. The connection between them remains to be clarified.

Bilateral internal carotid to anterior cerebral artery anastomosis with anterior communicating artery aneurysm: technical case report.

OBJECTIVE AND IMPORTANCE: The present case report is the first one to report a bilateral anastomotic artery between the internal carotid artery and the anterior communicating artery in the presence of a bilateral A1 segment, fenestrated anterior communicating artery (AComA), and associated aneurysm of the AComA, which was discovered by magnetic resonance angiography and treated surgically. CLINICAL PRESENTATION: A 38-year-old man who was previously in good health experienced a sudden onset of nuchal headache, vomiting, and confusion. Computed tomography revealed a subarachnoid hemorrhage. Magnetic resonance angiography and four-vessel angiography documented an aneurysm of the AComA and two anastomotic vessels of common origin with the ophthalmic artery, between the internal carotid artery and AComA. INTERVENTION: A fenestrated clip, introduced by a left pterional craniotomy, leaving in its loop the left A1 segment, sparing the perforating and hypothalamic arteries, excluded the aneurysm. CONCLUSION: The postoperative course was uneventful, with complete recovery. Follow-up angiograms documented the successful exclusion of the aneurysm. Defining this particular internal carotid-anterior cerebral artery anastomosis as an infraoptic anterior cerebral artery is not appropriate because there is already an A1 segment in its habitual localization. Therefore, it is also thought that, embryologically, this anomaly is not a misplaced A1 segment but the persistence of an embryological vessel such as the variation of the primitive prechiasmatic arterial anastomosis. The favorable outcome for our patient suggests that surgical treatment may be appropriate for many patients with this anomaly because it provides a complete and definitive occlusion of the aneurysm.

Primary cerebellar glioblastoma multiforme.

Primary glioblastoma multiforme of cerebellar hemispheres in adults is a rare condition. Most of them result from dedifferentiation of astrocytoma to glioblastoma. We present two cases of unusual de novo cerebellar glioblastomas, one of which is the giant-cell variant. We review their clinical behaviour with conventional MR imaging features and discuss the key findings that can lead to the correct diagnosis in sight of new MR imaging technologies.

Intraparenchymal meningioma in a child. Case report and review of the literature.

The authors reported a rare case of temporal intraparenchymal meningioma without dural attachment. A 14-year-old boy presented with a 4-month history of generalized tonic-clonic seizures. Neurological examination showed no abnormality. Magnetic resonance (MR) imaging revealed an anteromedial temporal mass, which appeared to be totally intraaxial and caused peritumoral white matter edema. The tumor was hypointense on T1-weighted and hyperintense on T2-weighted MR images, and enhanced heterogeneously after Gd-diethylenetriamine pentaacetic acid administration. Gross-total excision of the tumor was accomplished. Histopathological examinations indicated that the lesion was a meningioma. The outcome was favorable. The patient has returned to baseline activities without sequelae or epilepsy. Magnetic resonance images revealed no residual tumor during a 3-year follow-up period. In this report, the authors review the literature and discuss intraparenchymal meningiomas in the differential diagnosis of intraaxial lesions.