Growth rate of a giant Tarlov (perineural) cyst with intrapelvic extension.

BACKGROUND AND IMPORTANCE: Giant Tarlov cysts (GTCs) are perineural cysts and their presacral intrapelvic extension are extremely rare entities. We present a case of GTC with intrapelvic extension who has preoperative Magnetic Resonance Imaging (MRI) follow-ups of 12 years, and we demonstrate the annual growth rate and the time-size correlation of a GTC. METHODS: Case report. CLINICAL PRESENTATION: A 37-year-old woman was admitted with left gluteal pain radiating to left foot, left leg numbness, progressed over 12 years. On MRI, starting from the L5-S1 level, a giant Tarlov cyst with an atypical configuration, is observed. The patient had a known sacral Tarlov cyst, first discovered on MRI obtained 12 years before the surgery. She had 6 consecutive MRI follow-ups in 12 years preoperatively. The cysts diameters have been measured and the growth rate was estimated. We showed for the first time that presented GTC grows in in both Sagittal Diagonal (SD) and Sagittal Craniocaudal (SC) diameters over time with overall annual growth rates, 7.671% for RGR_SD and 6.237% for RGR_SC. CONCLUSION: When the time-size correlation is observed, it becomes evident that the GTSs' growing speed increases over the years because of minimal resistance in the intrapelvic cavity. Early surgery may be considered to prevent rapid growth in the intrapelvic cavity and to reduce possible complications of the giant cyst.

Evidence that osteogenic and neurogenic differentiation capability of epidural adipose tissue-derived stem cells was more pronounced than in subcutaneous cells

Background/aim: The management of dura-related complications, such as the repairment of dural tears and reconstruction of large dural defects, remain the most challenging subjects of neurosurgery. Numerous surgical techniques and synthetic or autologous adjuvant materials have emerged as an adjunct to primary dural closure, which may result in further complications or side effects. Therefore, the subcutaneous autologous free adipose tissue graft has been recommended for the protection of the central nervous system and repairment of the meninges. In addition, human adipose tissue is also a source of multipotent stem cells. However, epidural adipose tissue seems more promising than subcutaneous because of the close location and intercellular communication with the spinal cord. Herein, it was aimed to define differentiation capability of both subcutaneous and epidural adipose tissue-derived stem cells (ASCs). Materials and methods: Human subcutaneous and epidural adipose tissue specimens were harvested from the primary incisional site and the lumbar epidural space during lumbar spinal surgery, and ASCs were isolated. Results: The results indicated that both types of ASCs expressed the cell surface markers, which are commonly expressed stem cells; however, epidural ASCs showed lower expression of CD90 than the subcutaneous ASCs. Moreover, it was demonstrated that the osteogenic and neurogenic differentiation capability of epidural adipose tissue-derived ASCs was more pronounced than that of the subcutaneous ASCs. Conclusion: Consequently, the impact of characterization of epidural ASCs will allow for a new understanding for dural as well as central nervous system healing and recovery after an injury.

Stem cell/cellular interventions in human spinal cord injury: Is it time to move from guidelines to regulations and legislations? Literature review and Spinal Cord Society position statement.

PURPOSE: In preclinical studies, many stem cell/cellular interventions demonstrated robust regeneration and/or repair in case of SCI and were considered a promising therapeutic candidate. However, data from clinical studies are not robust. Despite lack of substantial evidence for the efficacy of these interventions in spinal cord injury (SCI), many clinics around the world offer them as "therapy." These "clinics" claim efficacy through patient testimonials and self-advertisement without any scientific evidence to validate their claims. Thus, SCS established a panel of experts to review published preclinical studies, clinical studies and current global guidelines/regulations on usage of cellular transplants and make recommendations for their clinical use. METHODS: The literature review and draft position statement was compiled and circulated among the panel and relevant suggestions incorporated to reach consensus. This was discussed and finalized in an open forum during the SCS Annual Meeting, ISSICON. RESULTS: Preclinical evidence suggests safety and clinical potency of cellular interventions after SCI. However, evidence from clinical studies consisted of mostly case reports or uncontrolled case series/studies. Data from animal studies cannot be generalized to human SCI with regard to toxicity prediction after auto/allograft transplantation. CONCLUSIONS: Currently, cellular/stem cell transplantation for human SCI is experimental and needs to be tested through a valid clinical trial program. It is not ethical to provide unproven transplantation as therapy with commercial implications. To stop the malpractice of marketing such "unproven therapies" to a vulnerable population, it is crucial that all countries unite to form common, well-defined regulations/legislation on their use in SCI. These slides can be retrieved from Electronic Supplementary Material.

Esophageal perforation after anterior cervical surgery: a review of the literature for over half a century with a demonstrative case and a proposed novel algorithm.

PURPOSE: To review relevant data for the management of esophageal perforation after anterior cervical surgery. METHODS: A case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review. RESULTS: The treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed. CONCLUSION: Following anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.

Neuroprotective effects of propofol, thiopental, etomidate, and midazolam in fetal rat brain in ischemia-reperfusion model.

PURPOSE: The aim of this study was to investigate the neuroprotective effects of propofol, thiopental, etomidate, and midazolam as anesthetic drugs in fetal rat brain in the ischemia-reperfusion (IR) model. METHODS: Pregnant rats of day 19 were randomly allocated into eight groups. Fetal brain ischemia was induced by clamping the utero-ovarian artery bilaterally for 30 min and reperfusion was achieved by removing the clamps for 60 min. In the control group, fetal rat brains were obtained immediately after laparotomy. In the sham group, fetal rat brains were obtained 90 min after laparotomy. In the IR group, IR procedure was performed. No treatment was given in the IR group. One milliliter intralipid solution, 40 mg/kg propofol, 3 mg/kg thiopental, 0.1 mg/kg etomidate, and 3 mg/kg midazolam was administered intraperitoneally in the vehicle group, propofol group, thiopental group, etomidate group, and midazolam group, respectively, 20 min before IR procedure. At the end of the reperfusion period, the whole brains of the fetal rats were removed for evaluation of thiobarbituric acid reactive substances and for examination by electron microscopy. RESULTS: According to lipid peroxidation data, all the anesthetic drugs provide neuroprotection; however, ultrastructural findings and mitochondrial scoring confirms that only propofol and midazolam provides a strong neuroprotective effect. CONCLUSIONS: Propofol and midazolam may be used to protect fetal brain in case of acute fetal distress and hypoxic injury as a first choice anesthetic drug in cesarean delivery.

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells.

BACKGROUND AIMS: Spinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limited. METHODS: The study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinic. RESULTS: At the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cells. CONCLUSIONS: The results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.

Cranial ossifying fibroma causing visual disorder.

Fibrous lesions of the head and the maxillofacial region are generally slow-developing benign tumors that may aggressively take course in clinical terms. These locally destructive lesions show a high recurrence rates unless they are removed gross totally. Sarcomatoid degeneration is also reported to develop in recurring lesions. Difficulties in the diagnosis, classification, and treatment make this entity complex for several years. These tumors are frequently seen among children and young adults. The maxilla and the mandibula are the 2 most common sites that the tumor originates. In our article, we discuss a 59-year-old man whose condition was diagnosed as an ossified fibroma revealing craniofacial extension. Accompanied by literature findings, it has been underlined that, as well as with the pathologic criteria, clinical features and radiologic images should be evaluated together for a specific diagnosis in fibrous lesions.

Anatomical study of axis for odontoid screw thickness, length, and angle.

Anterior odontoid screw fixation is a safe and effective method for treatment of odontoid fractures. The screw treads should fit into the odontoid medulla, should pass the fracture line, and should pull fractured odontoid tip against body of axis in order to achieve optimum screw placement and treatment. This study has demonstrated optimal anterior odontoid screw thickness, length, and optimal angle for safe and strong anterior odontoid screw placement. Dry bone axis vertebrae were evaluated by direct measurements, X-ray measurements, and computerized tomography (CT) measurements. The screw thickness (inner diameter of the odontoid) was measured as well as screw length (distance between anterior-inferior point body of axis and tip of odontoid), and screw angle (the angle between basis of axis and tip of odontoid). The inner diameter of odontoid bone was measured as 6.5+/-1.9 mm, the screw length was 37.6+/-3.3 mm, and the screw angle was 62.4+/-4.7 on CT. There was no statistical difference between X-ray and CT in the measurements of screw thickness and angle. X-ray and CT measurements are both safe methods to determine the inner odontoid diameter and angle preoperatively. Screw length should be measured on CT only. To provide safe and strong anterior odontoid screw fixation, screw thickness, length, and angle should be known preoperatively, and these can be measured on X-ray and CT.

Cranial epidural hydatid cysts: clinical report and review of the literature.

BACKGROUND: Cerebral hydatidosis accounts for approximately 1-3% of all cases of hydatid disease. METHOD: In this report, 32-year-old female with epidural multilocular hydatid cysts in the midline posterior parietal region is reported. FINDINGS: Most commonly, cerebral hydatid cysts are single lesions and locate in the watershed of the middle cerebral artery. CONCLUSIONS: However, cerebral epidural hydatid cysts seem to have a tendency occurring around in the highly vascularized venous sinus.

The importance of vertebral artery proximity to the odontoid process during anterior odontoid approaches.

The proximity of the vertebral artery (VA) to the odontoid process makes it vulnerable to injury during surgery. Knowledge of the quantitative anatomy of the VA groove is therefore necessary. In this study we assessed the spatial relationship between the VA and the odontoid process on cadavers by direct measurement and in patients by CT angiography. Our goal was to measure the distances from the VA and vertebrobasilar junction to the odontoid tip. The VA and odontoid process of 10 craniocervical cadavers ("cadavers") and of 20 patients were evaluated and average measurements obtained. The measured parameters were: (i) distance from the right VA to the odontoid tip (right VA-odontoid tip); (ii) distance from the left VA to the odontoid tip (left VA-odontoid tip), and (iii) distance from the vertebrobasilar junction to the odontoid tip (vertebrobasilar-odontoid tip). On the cadavers, the right VA-odontoid tip distance was 11.55mm, the left VA-odontoid tip was 11.02mm, and the vertebrobasilar junction-odontoid tip distance was 24.55mm. In patients, using CT angiography, the right VA-odontoid tip distance was 11.47mm and the left VA-odontoid tip distance was 11.50mm. The VA-odontoid tip distance is important in anterior odontoid approaches. Since the odontoid process may be in close contact with the VA, the relationship between them should be evaluated preoperatively in all candidates for odontoid surgery using three-dimensional CT angiography.

The effect of mitomycin C as fibrosis preventive agent during craniectomies.

OBJECT: The authors conducted a study to determine the effectiveness of mitomycin C (MMC) in preventing epidural fibrosis in rats which underwent craniectomy. METHODS: Craniectomies were performed in the right frontoparietal region; after the procedure the animals had been divided in 2 groups of 10 each. Cotton pads soaked with 0.1 mg/ml MMC or saline (control) were applied to the operative sites. Four weeks after craniectomy the rats were sacrificed, and epidural fibrosis was evaluated histologically. The dura mater thickness, the density of epidural fibrosis, arachnoidal involvement, and bone regeneration were determined. RESULTS: No obvious adhesion formed in the rats in the MMC group, but severe epidural adhesions were found in control group. The duramater thickness, the density of epidural fibrosis, and arachnoidal involved rat number in the MMC group were significantly lower than in control groups. CONCLUSIONS: Epidural fibrosis can be a devastating condition that forms after craniectomy. Topical application of mitomycin C may be a successful method of preventing epidural fibrosis following craniectomy.

Morphometric characteristics of the inner and outer diameter of lumbar pedicles on computed tomography.

BACKGROUND AND PURPOSE: The inner pedicle diameter is very important in pedicle screw placement in order to achieve safe and strong posterior stabilization. The optimal pull-out strength can be achieved by a screw which fits into the pedicle medulla. The aim of the present study was to compare the inner and outer pedicle diameters of lumbar pedicles, to determine the inner/outer pedicle diameter ratios, and to develop a simple measure for estimating optimal pedicular screw size. MATERIAL AND METHODS: 178 lumbar pedicles of 20 patients were evaluated. Inner and outer pedicle diameters of lumbar vertebrae were measured in computed tomography (CT). A simple linear regression analysis was performed to assess the relationship between the inner and outer pedicle diameters. RESULTS: The widest pedicle outer diameter was seen at L5, with a mean of 16.538 +/- 1.899 mm. The narrowest pedicle outer diameter was seen at L1, with a mean of 8.310 +/- 1.870 mm. The maximum inner pedicle diameter was at the L5 level, with a mean of 11.416 +/- 2.664 mm, whereas the minimum was at the L1 level, with a mean of 5.510 +/- 1.887 mm. The regression coefficient between the inner and outer pedicle diameter was 0.68 for all pedicles combined. CONCLUSIONS: We have demonstrated the relation of the inner and outer pedicle diameter of lumbar pedicles and described an easy and reliable method to estimate the inner pedicle diameter from the outer diameter on CT.

Attempted suicide with screw penetration into the cranium.

Intracranial foreign bodies are usually secondary to penetrating injuries. Nails, knives, screwdrivers, sewing needles, bullets, and shrapnel have been described related to penetrating brain injury. In this report, we present a 34-year-old prisoner with an intracranial screw located in the right parietal lobe. The screw was used by prisoner in an attempted suicide. A right parietal craniectomy was performed, and the screw was removed successfully. It is important to know the type of penetrating brain injury preoperatively in order to determine the best surgical approach to remove the foreign body settled in the brain. A long-term radiological assessment should be performed to detect any future complications, such as a cerebral abscess.

Glioblastoma multiforme mimicking arteriovenous malformation.

Glioblastoma multiforme is the most common intracranial neoplasm of all primary central nervous system tumors. Glial tumors can present in different forms. Intracranial hemorrhage may occur in all central nervous system tumors to a varying degree and extent and may even be massive. A 58-year-old man presented with intraparenchymal hemorrhage manifesting as severe headache and vomiting. Cranial computed tomographic scans revealed a right posterior temporoparietal intraparenchymal hemorrhage. Cerebral angiography revealed a 3 x 2 cm right inferior parietal arteriovenous malformation. The patient underwent surgical treatment with a diagnosis of arteriovenous malformation. Postoperatively, the histological diagnosis was glioblastoma. Glioblastoma may mimic an arteriovenous malformation. Close follow-up of such patients is essential.

A neurosurgical view of anatomical evaluation of anterior C1-C2 for safer transoral odontoidectomy.

An anatomical study for evaluation of anterior C1-C2. To provide essential anatomic data for safer transoral odontoidectomy. The surface dimensions of the atlas vertebra and the transoral approach for odontoidectomy have been described in detail. Anterior arcus of C1 must be drilled out to reach odontoid process for transoral odontoidectomy. The thickness of anterior ring of C1 has not been studied before. Sixty, dried adult atlas and 60 axis vertebrae and ten cadaveric craniocervical specimens were measured for the following: (1) bony drilling depth (BDD), the distance from the anterior wall of anterior ring of C1 to anterior wall of odontoid; (2) minimum drilling diameter (MDD), distance of minimum C1 anterior ring removal for odontoid resection on horizontal plane; (3) maximum bony drilling diameter (MBDD), distance of maximum C1 anterior ring removal for odontoid resection on horizontal plane. Lateral border of this diameter is limited by medial borders of the lateral mass; (4) the widest odontoid diameters (WOD) on coronal sections were measured. On 60 atlas and axis vertebrae, the BDD was 7.0 +/- 1.2 mm on dry bones, the distance between the medial borders of the lateral mass (MBDD) was 16.1 +/- 1.5 mm, and the WOD on coronal sections (WOD) was 9.8 +/- 0.8 mm. On cadavers, the distance between the two edges of C1 anterior ring removal for odontoid resection (MDD) was 10.8 +/- 1.1 mm and the WOD on coronal sections (WOD) was 10.1 +/- 1.4 mm. An odontoid surgery through transoral approach is safe and feasible. A quantitative understanding of the anterior anatomy of C-1 and C-2 is necessary when considering transoral odontoid resection. In this study the authors define safe zones for anterior atlas and axis.

Primary intracranial low-grade fibromyxoid sarcoma (Evans tumor).

Low-grade fibromyxoid sarcoma was first described in 1987 as a rare soft tissue neoplasm characterized by a bland and deceptively benign histological appearance but with aggressive behavior. A 20-year-old male patient presented with a recent history of headache and seizure. A right frontal mass was detected on MRI and he was operated upon to remove the intracranial mass. Histological examination revealed mildly atypical fibroblastic cells embedded within a myxoid matrix. Nuclear atypia and pleomorphism were minimal, and necrosis was not present. The lesion was diagnosed as a low-grade fibromyxoid sarcoma. Although primary intracranial low-grade fibromyxoid sarcoma has characteristic histological features, clinical and radiological correlation is necessary to make the correct diagnosis.

Meningeal extramedullary haematopoiesis mimicking subdural hematoma.

Extramedullary haematopoiesis is a compensatory phenomenon in diseases where erythrocyte production is diminished or destruction is accelerated. The authors describe a rare case of meningeal extramedullary haematopoiesis mimicking subdural hematoma. CT scan revealed a hyperdense subdural lesion at the right frontal region following head injury. The patient was operated on and the pathological examination of the subdural lesion showed extramedullary haematopoiesis.

Venous outflow of the brain after bilateral complete jugular ligation.

A case of a patient with bilateral internal, external, posterior external and anterior jugular vein ligations and excisions performed in the neck due to a larynx tumor is presented. Radical neck dissection is a standard otorhinolaryngological procedure in the management of head and neck cancer patients with bilateral lymph node metastasis to the neck. Sacrifice of both internal and external jugular veins bilaterally has been recognized as a dangerous approach leading to intracranial hypertension with subsequent neurological sequela and death. In this report, we aimed to demonstrate how venous outflow from the brain diverts after jugular venous system obliteration. After bilateral jugular vein ligations, digital subtraction angiography (DSA) showed that the venous drainage route of the brain had been diverted from the jugular veins to the vertebral venous plexus.

Unusual imaging characteristics of complicated hydatid disease.

Hydatid disease, a worldwide zoonosis, is caused by the larval stage of the Echinococcus tapeworm. Although the liver and the lungs are the most frequently involved organs in the body, hydatid cysts of other organs are unusual. Radiologically, they usually demonstrate typical imaging findings, but unusual imaging characteristics of complicated cyst of hydatid disease, associated with high morbidity and mortality, are rarely described in the literature. The purpose of this study is to review the general features of hydatidosis and to discuss atypical imaging characteristics of the complicated hydatid disease in the human, with an emphasis on structure and rupture of the cystic lesion as well as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) features of the disease. In our study, the available literature and images of the cases with complicated hydatidosis involving liver, lung, brain, spine and orbit were reviewed retrospectively. In hydatid disease, there are many potential local and systemic complications due to secondary involvement in almost any anatomic location in humans. Radiologically, in addition to the presence of atypical findings such as perifocal edema, non-homogenous contrast enhancement, multiplicity or septations and calcification, various unusual manifestations due to rupture or infection of the cyst have been observed in our cases with complicated hydatid disease. To prevent subsequent acute catastrophic results and the development of recurrences in various organs, it should be kept in mind that complicated hydatid cysts can cause unusual USG, CT, and MRI findings, in addition to typical ones, in endemic areas. Therefore, familiarity with atypical radiological appearances of complicated hydatid disease may be valuable in making a correct diagnosis and treatment.