Posttraumatic locked-in syndrome from combined brainstem and upper cervical injury in childhood: A case report.

Locked in syndrome (LIS) is a condition characterized by quadriplegia, lower cranial nerve palsies and mutism in which only vertical eye movements and upper eyelid movements are preserved while the patient's state of consciousness is intact. The most common cause of LIS is pontine infarction after vertebrobasilar system occlusion. We hereby present a case report of LIS secondary to cervicomedullary contusion after head trauma. Due to the possibility of neurological recovery, early and accurate diagnosis is important in posttraumatic nonvascular LIS cases and aggressive neurological and other systemic treatment and early neurological rehabilitaion options should also be eveluated. Neurological rehabilitaion of these ventilator dependent patients is difficult and should be improved.

Intradural migration of a bullet following spinal gunshot injury.

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

Atypical intradural spinal tuberculosis: report of three cases.

OBJECTIVE: To report three cases of intradural spinal tuberculosis (TB) by calling attention to atypical forms of spinal TB. SETTING: A University Hospital, Istanbul, Turkey. METHODS: Histopathological, radiological, surgical and physical examination findings of three patients with spinal TB were retrospectively reviewed. RESULTS: Based on histopathological, surgical and radiological findings, diagnosis of intramedullary abscess had been made in the first case and early and late phases of arachnoiditis in the other two patients, respectively. The clinical outcome was evaluated as satisfactory for the patient with intramedullary abscess who had been treated with medical and surgical interventions. The remaining two patients with arachnoiditis, who had been treated by shunting or simple decompression, had a relatively less favorable clinical outcome. CONCLUSION: Spinal TB, in its atypical forms, is a rare clinical entity and low index of suspicion on the part of the surgeon may result in misdiagnosis such as neoplasm. In cases presenting with an intraspinal mass lesion, possibility of a tuberculous abscess and/or a granuloma should be considered in the differential diagnosis.

Capillary haemangiomas of the spinal cord: report of two cases.

The clinicopathological features of two cases of capillary haemangioma of the spinal cord are described. The presenting symptoms were similar to those of common intradural, intramedullary tumours or tumour-like mass lesions. Radiological features of these two lesions resembled other vascular lesions of the spinal cord. The patients underwent surgery, and recoveries were good. Histologically, the lesions resembled capillary haemangioma of superficial tissues that are composed of lobules of small capillaries with feeding vessels. A fibrous capsule enveloped the lesions. Capillary haemangiomas of the central nervous system are rare. Awareness of their existence may help the surgeon to avoid misdiagnosis and overtreatment of these benign tumour-like lesions.

Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury.

OBJECTIVES: To determine whether proton magnetic resonance spectroscopy (MRS), a newer radiographic technology, would be useful in the evaluation of the thalamus of patients in vegetative states resulting from traumatic brain injury. METHODS: 14 victims of severe traumatic brain injury who were in the vegetative state and whose magnetic resonance images of the thalamus were normal underwent bilateral thalamic proton (MRS) studies. The N-acetyl aspartate to creatine (NAA:Cr) and choline to creatine (Cho:Cr) ratios were obtained for each patient. The proton thalamic MRS findings of patients who were in a persistent vegetative state (n = 8) and in patients who had regained awareness after being in the vegetative state (n = 6) were compared with proton thalamic MRS findings in five healthy volunteers. RESULTS: While conventional magnetic resonance imaging suggested that each patient had a normal thalamus, proton MRS indicated that the thalamus of each patient in the series was damaged. The NAA:Cr ratio was significantly lower in the thalami of both the patients who remained in a persistent vegetative state for the duration of the study and in those who regained awareness after being in the vegetative state (p < 0.001). In addition, NAA:Cr ratios were lower in the group of patients who remained in a persistent vegetative state than in the group of patients who regained awareness after being in the vegetative state (p < 0.001). CONCLUSIONS: Results suggest that the NAA:Cr ratio within the thalamus is significant and that thalamic MRS may be helpful when attempting to determine the degree of severity of neuronal and axonal injury in patients in the vegetative state.

A great misfortune: second traumatic spinal cord injury.

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

Spinal cord injury caused by gunshot wound during pregnancy.

We report a case of a pregnant woman with acute spinal cord injury (C5) caused by gunshot wound and discuss the respective maternal and fetal considerations. Neither decompressive surgery nor corticosteroid protocols were used. At 37 weeks, the patient delivered a normal female infant after induction of labor and epidural anesthesia, with no medical or obstetrical complications. With conservative management and rehabilitation, this patient had significant recovery of function.

Finite element model of the Jefferson fracture: comparison with a cadaver model.

This study tries to explain the reason why the Jefferson fracture is a burst fracture, using two different biomechanical models: a finite element model (FEM) and a cadaver model used to determine strain distribution in C1 during axial static compressive loading. For the FEM model, a three-dimensional model of C1 was obtained from a 29-year-old healthy human, using axial CT scans with intervals of 1.0 mm. The mesh model was composed of 8200 four-noded isoparametric tetrahedrons and 37,400 solid elements. The material properties of the cortical bone of the vertebra were assessed according to the previous literature and were assumed to be linear isotropic and homogeneous for all elements. Axial static compressive loads were applied at between 200 and 1200 N. The strain and stress (maximum shear and von Mises) analyses were determined on the clinically relevant fracture lines of anterior and posterior arches. The results of the FEM were compared with a cadaver model. The latter comprised the C1 bone of a cadaver placed in a methylmethacrylate foam. Axial static compressive loads between 200 and 1200 N were applied by an electrohydraulic testing machine. Strain values were measured using strain gauges, which were cemented to the bone where the clinically relevant fracture lines of the anterior and posterior arches were located. As a result, compressive strain was observed on the outer surface of the anterior arch and inferior surface of the posterior arch. In addition, there was tensile strain on the inner surface of the anterior arch and superior surface of the posterior arch. The strain values obtained from the two experimental models showed similar trends. The FEM analysis revealed that maximum strain changes occurred where the maximum shear and von Mises stresses were concentrated. The changes in the C1 strain and stress values during static axial loading biomechanically prove that the Jefferson fracture is a burst fracture.

Late onset Pott's paraplegia.

BACKGROUND: Pott's disease may cause late neurological involvement due to development of sharp kyphosis. Anterior decompression and fusion is the treatment of choice for this disorder. OBJECTIVE: To determine the mid-term clinical results of patients with late onset Pott's paraplegia, who underwent anterior decompression and grafting after neurological deterioration. SETTING: A university hospital in Istanbul, Turkey. METHODS: Eight patients who developed late onset paraplegia with a mean period of 24.6 years (range, 9-46 years) after the active disease were treated with anterior decompression and grafting. The mean age at surgery was 36.1 years (range, 18-63 years) and the mean duration of neurological deterioration before surgery was 7.4 weeks (range, 2-13 weeks). The mean kyphosis angle of the patients was 105.63 degrees (range, 80 degrees- 135 degrees). No attempt to correct the curve was made in any operation. All but two patients' neurological status were evaluated according to the International Standards for Neurological and Functional Classification of Spinal Cord Injury determined by ASIA-IMSOP on admission. RESULTS: Neurological status of all patients showed progression either in Frankel scale or in motor scores in the early postoperative period. One patient needed to be reoperated on because of a deterioration of neurological status 26 months after surgery. The mean length of time since the operations is 75.9 months (range, 48 173 months) and all the patients are carrying out their lives independently with a mean motor score of 97.5 and full pin-prick and light touch scores. CONCLUSIONS: Anterior decompression and grafting is an effective procedure for the treatment of late onset paraplegia in Pott's disease.

Syringomyelia--as a late complication of tuberculous meningitis.

The aim of this paper is to demonstrate the unusual MR features of thoracic syringomyelia following TB meningitis and to discuss the neurosurgical aspect of the treatment of this rare entity. Four years after a TB meningitis episode, a 30 year-old female patient developed a progressive spastic paraparesis. MR studies revealed multiloculated syrinxes throughout the thoracic cord. She had a syringo-subarachnoid shunt with a silastic "T" tube inserted. On the first postoperative day, she showed a dramatic neurological improvement, but unfortunately her paraparesis progressed to the preoperative level within a month despite diminished size of the syrinxes on the control MRI examination. Two and a half years after the operation the patient complained of having a burning type of central pain, and further deterioration in neurological function. Thoracic spinal MRI examination demonstrated enlarged syringomyelic cavities. At the second operation syringo-peritoneal shunt insertion was performed via right T10-11 hemilaminectomy using a "T" tube. At present, 4 months after the second operation, the patient's neurological examination demonstrated decreased spasticity, and improved strength in the legs compared to the preoperative level. MRI is the first choice of investigation in detecting TB related myelopathy as it provides a greater detail of pathological changes within and around the spinal cord such as syrinx formation and arachnoiditis. The MR findings are also helpful in deciding the management and predicting the outcome. Presence of multifocal loculations and arachnoid adhesions is the likely cause of treatment failures and poor prognosis.

Sylvian fissure lipomas: case reports and review of the literature.

Two patients with Sylvian fissure lipoma are reported. One of them was operated on because of an increased frequency of epileptic seizures in spite of high dose carbamazepine treatment. A review of the literature regarding the surgical experience with Sylvian lipomas revealed only four cases, and in none of them was the lipoma removed totally. One of ours is the first case in which total removal of the lipoma was achieved. The postoperative course was uneventful and carbamazepine dose was gradually lowered without further epileptic activity. If these exceedingly rare lesions cause symptoms then surgical intervention is indicated. With microsurgical techniques, Sylvian fissure lipomas can be removed totally without complication and symptomatic improvement may result.

Intraspinal schwannoma of the accessory nerve.

The second example of a schwannoma originating from the cervical portion of the accessory nerve is reported. The tumour was diagnosed by MRI and confirmed by surgery. The tumour was small and was located entirely within the cervical subarachnoid space without causing any detectable neurological deficit.

Traumatic intracranial carotid tree aneurysms.

OBJECTIVE: This study was designed to elucidate the requirements for angiographic evaluation in blunt head injuries, the timing of angiography, and the selection of appropriate therapeutic approaches. METHODS: Twelve cases of traumatic aneurysms (TAs) in the intracranial carotid tree were analyzed in this study. Neurological examination results, computed tomographic scans, pre- and postembolization cerebral angiograms, and follow-up data were included. RESULTS: In 11 of 12 cases, TAs were of cranial base origin; in 1 case, the aneurysm was located in the distal anterior cerebral artery. In seven of the cases with cranial base lesions, aneurysms were located in the intracavernous segment of the internal carotid artery; all of the computed tomographic scans for these cases demonstrated sphenoid sinus wall fractures and hematoma in the sphenoid sinus. In two cases, although the initial angiograms revealed no lesions, a second study performed 2 weeks later demonstrated the presence of aneurysms. Nine of the aneurysms were treated with endovascular techniques, two were managed conservatively, and the remaining one patient died with massive epistaxis while awaiting surgical treatment. No morbidity or additional permanent neurological deficits occurred in the endovascularly treated patient group. CONCLUSION: Patients with head trauma who present with sphenoid sinus fractures and massive epistaxis should be evaluated for the development of TAs as soon as possible. If the patients exhibit fractures without epistaxis, angiography should be deferred for 2 to 3 weeks; if the first angiographic evaluation reveals normal findings, repeated epistaxis should prompt a second angiographic evaluation. Current treatment of TAs involves occlusion of the main artery through the use of endovascular techniques. Cases involving internal carotid artery TAs of cranial base origin and patients who do not tolerate test occlusion require extracranial-to-intracranial bypass surgery.

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

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

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

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

Cerebral candidiasis presenting as a mass lesion.

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

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

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

Successful outcome of aspergillus brain abscess in a patient who underwent bone marrow transplantation for aplastic anemia.

We report the course of an aspergillus brain abscess in an 18-year-old female patient who underwent bone marrow transplantation for aplastic anemia. The abscess was discovered on day 35 post-transplant, in a cranial computerized tomography (CT) scan performed for the evaluation of an unexplained headache. Meanwhile, she was receiving broad-spectrum antibacterials and liposomal amphotericin B for a right upper pulmonary lobe infiltrate. A percutaneous puncture of the cerebral lesion was performed; fungal elements were seen in the pus obtained and its culture yielded A. fumigatus. The dose of amphotericin B was increased, intraconazole was added and two more punctures were done. With these antifungals, the abscess regressed significantly; so, amphotericin B was discontinued after a cumulative dose of 6775 mg but intraconazole was maintained at 400 mg/day. At the last follow-up, seventeen months after detection of the abscess, the patient was well, without symptoms and the cerebral lesion diminished to a very small, thick-walled CT image.