Hydatid Cyst of the Cerebellopontine Angle.

Hydatid disease is caused by Echinococcus granulosus. The liver is the first organ of entry, while the central nervous system is affected in about 2% of cases. Primary brain hydatid cyst is extremely rare. The cysts are generally located in cerebral lobes. Here, we reported a 68-year-old Syrian immigrant woman with hydatid cyst in the left cerebellopontine angle. The patient presented gait disturbance, asymmetrical palatal arcs, negative gag reflex, and disturbed cerebellar tests on the left side. The patient was operated via suboccipital craniotomy. The cyst ruptured during manipulation, but it was totally removed.

Aneurysmal Bone Cyst in a Renal Transplant Patient.

Aneurysmal bone cysts constitute 1% to 2% of all primary bone tumors.They are rapidly growing benign bone tumors. Nearly 80% of aneurysmal bone cysts occur in the first 20 years of life, and most are primary tumors. Aneurysmal bone cysts are mostly benign, locally aggressive, and highly vascularized tumors. Generally, the period required for postoperative recovery and new bone formation is long. The relapse rate can be up to 50%. Although computed tomography and magnetic resonance imaging scans are the preferred diagnostic methods, biopsy is the most necessary prerequisite to confirm diagnosis, as aspects of these cysts can show similarity to many other bone lesions. Correct histopathologic diagnosis is important since malignancies may be seen in transplant recipients.

Cervical Spinal Ependymoma With Hemorrhage in a Renal Transplant Patient.

Ependymomas are the most common intramedullary spinal tumors in adults and constitute around 20% of all spinal tumors in adults. There are 3 subgroups of ependymomas according to World Health Organization classification: subependymoma or myxopapillary (grade 1), ependymoma (grade 2), and anaplastic (grade 3). Therapy for patients is aimed at safe and total surgical removal and, in selected cases, postoperative radiotherapy. Bleeding from a spinal ependymoma, with subsequent urgent surgery, is extremely rare. Here, we present a case of a renal transplant patient who had a cervical ependymoma. Although a considerable volume of peritumoral blood was observed during surgery, the patient had no neurologic deficits and no signs of deterioration.

Balloon Kyphoplasty Is a Safe and Effective Option for the Treatment of Vertebral Compression Fractures in Solid-Organ Transplant Recipients.

OBJECTIVES: Solid-organ transplant recipients are at great risk for osteoporotic vertebral compression fractures because of both underlying pretransplant bone diseases and posttransplant immunosuppressive treatments. Balloon kyphoplasty is a minimally invasive procedure that is used to treat painful osteoporotic vertebral compression fractures. It involves injection of polymethylmethacrylate into the vertebral body to stabilize the fracture and to alleviate the pain immediately. In this study, we report the results of balloon kyphoplasty for treatment of vertebral compression fractures in solid-organ transplant recipients. MATERIALS AND METHODS: We retrospectively reviewed 512 liver transplant and 2248 kidney transplant procedures that were performed in our center between 1985 and 2015. Seven transplant recipients with a total of 10 acute, symptomatic vertebral compression fractures who were unresponsive to conservative treatment for 3 weeks underwent balloon kyphoplasty. Clinical outcome was graded using the visual analog scale. Radiographic evaluation included measurement of the segmental kyphosis by the Cobb method. RESULTS: There were 4 female and 3 male patients in our study group. Ages of patients ranged from 56 to 63 years with an average age of 58.8 years. The affected vertebral levels varied from T12 to L4. Mean follow-up after balloon kyphoplasty was 3.4 years, and mean time interval from transplant to balloon kyphoplasty was 8.6 years. Statistically significant difference is evident 3 years after transplant surgery (P < .05). Sagittal alignment improved (> 5 degrees) in 2 of 7 patients (28%). CONCLUSIONS: Transplant recipients are at great risk in terms of vertebral compression fracture development, especially within 1 year after transplant. Although conservative treatment has been the first treatment choice for vertebral compression fracture, long treatment time and high costs may be needed to achieve cure. Experience with our small patient population showed that balloon kyphoplasty was effective and safe for obtaining rapid pain relief and earlier mobilization with fewer complications.

Microsatellite Instability in Glioblastoma: Is It Really Relevant in Tumor Prognosis?

AIM: To evaluate the frequency and prognostic significance of microsatellite instability (MSI) in patients with glioblastoma (GBM), an immunohistochemical analysis of mismatch repair (MMR) proteins was performed. MATERIAL AND METHODS: A total of 71 patients with GBM who underwent surgery between 2011 and 2019, were included in the study. MMR protein expression was examined using immunohistochemistical analysis of tumor tissue samples; the association between the MMR status and clinicopathological findings was evaluated. RESULTS: Immunohistochemical analysis revealed expressions of MLH1, MSH2, MSH6, and PMS2 proteins in 67 (94.4%), 65 (91.5%), 67 (94.4%), and 64 (90.1%) patients, respectively. Among the 71 patients, 64 (90.1%) expressing all MMR proteins were considered microsatellite stable (MSS), and 7 (9.9%) patients showing loss of at least one of the MMR proteins were considered to show MSI. Tumor recurrence was noted in 25 (39.1%) patients in the MSS GBM group, and 4 (57.1%) patients in the MSI GBM group (p=0.433). The overall median survival was 30.65 ± 5.1 and 10.71 ± 5.2 months in the MSS GBM and MSI GBM groups, respectively (p=0.059). CONCLUSION: The results of this study showed no significant relationships between MMR protein expression and recurrence rates or overall survival in patients with GBM.

Vertebral Body Lipoma: An Unusual Pathology Treated With Kyphoplasty.

STUDY DESIGN: Case report. OBJECTIVE: This case report is unique since this is the first vertebral lipom case that was treated by kyphoplasty alone. SUMMARY OF BACKGROUND DATA: Vertebral lipoma is extremely rare and our search of the English literature has revealed 20 patients in 16 reports. METHODS: A 32-year-old female patient was admitted to our neurosurgery department with the chief complaint of low back pain that had lasted nearly 1 year. A lumbar MR suggested a hemangioma and the patient was operated on. RESULTS: On microscopic examination, the lesion was seen to have a widely infiltrating appearance of mature fat tissue between bone trabeculae diagnosis was intraosseous lipoma. CONCLUSION: We believe that the management should be surgical total removal of the lesion even in incidentally found cases in order to obtain histologic diagnosis and pain relief. LEVEL OF EVIDENCE: 5.

Intracranial Fungal Infection After Solid-Organ Transplant.

Neurologic complications after solid-organ transplant reveal a great spectrum of pathologies. Intracranial hemorrhages, cerebral ischemic lesions, infarctions, lymphoproliferative disorders, and infections, including aspergillosis, have been observed after liver transplant. Fungi constitute nearly 5% of all central nervous system infections, mainly occurring in immunocompromised patients. The most common causative agent is Aspergillus species. It presents either as maxillary sinusitis or pulmonary infection. Brain involvement of Aspergillus carries a high rate of mortality. Aspergillosis presents in the forms of meningitis, mycotic aneurysms, infarctions, and mass lesions. Aspergillosis does not have a specific radiologic appearance. Parenchymal aspergillosis has heterogenous signal intensity (hypointense on T1-weighted and hyperintense on T2-weighted images). Here, we present 3 patients who underwent solid-organ transplant and developed central nervous system aspergillosis. Different modalities of neurosurgical intervention were performed in combination with chemotherapy as part of their fungal therapy.

Prognostic Impact of Histologic Subtype in Non-Small Cell Lung Cancer Patients Treated with Gamma Knife Radiosurgery: Retrospective Analysis of 104 Patients.

AIM: In this study, factors affecting survival, local failure, distant brain failure, whole brain failure and whole-brain radiation therapy (WBRT) free survival according to histological subtypes were investigated in patients with brain metastases from non-small cell lung cancer (NSCLC). MATERIAL AND METHODS: Patients with positive pathology reports for adenocarcinoma (ACA) and squamous cell carcinoma (SCC) were included in the study. Seventy-eight ACA and 26 SCC patients were included in the study. Patients with previous history of cerebral metastasis surgery and WBRT were excluded from the study. RESULTS: The median survival was calculated as 12.6 months for patients with ACA and 5.9 months for patients with SCC. One-year distant brain failure was calculated as 65.1% in ACA patients and 39.6% in SCC patients. One-year whole brain failure was calculated as 58.1% in ACA patients and 39.6% in SCC patients. The one-year freedom from WBRT rate was calculated as 72.8% in ACA patients and 56.3% in SCC patients. SCC histology was considered as a significant factor in deterioration of overall survival in multivariate analysis. SCC histology, the increase in the number of metastases and RPA class were factors that caused an increase in distant brain failure. Also, SCC histology, the increase in the number of metastases and RPA class were factors that caused an increase in whole brain failure. CONCLUSION: SCC histology may be an important prognostic factor for overall survival. Also, due to high distant brain failure rate in SCC histology, WBRT can be added to treatment early.

Presence of matrix metalloproteinase-2 and tissue inhibitor matrix metalloproteinase-2 gene polymorphisms and immunohistochemical expressions in intracranial meningiomas.

OBJECT: Meningiomas are benign extraaxial tumors with a slow progression. Some of them, in spite of being benign in nature, may show an aggressive progression pattern. To investigate the behavioral characteristics of meningiomas, researchers have studied matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), interstitial collagens, proteins, vascular endothelial growth factors (VEGF), and tumor necrosis factors. METHODS: In this study, the authors investigated MMP2 and TIMP2 gene polymorphisms in formalin-fixed paraffin-embedded tissue samples obtained from meningioma patients who had previously undergone surgery at the authors' institution. In addition, brain invasion, Ki-67 index, and MMP-2 and TIMP-2 expressions were investigated using immunohistochemical methods. MMP2 (735C>T, 1575G>A, 1306C>T) and TIMP2 (418G>C, 303C>T) gene polymorphisms were investigated from paraffin-embedded tissue sections using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: There were statistically significant differences between genotype (p = 0.001) and allele frequencies (p = 0.001 and OR 7.4 [95% CI 1.5-36.2]) in patient and control groups for MMP2 1306C>T polymorphism. The authors did not find a statistically significant difference for other polymorphisms. GA genotype was found to be more frequent when brain invasion was suspected for MMP2 1575G>A polymorphism (p = 0.006). There was not a statistically significant difference for other MMP2 or TIMP2 gene polymorphisms. CONCLUSIONS: The authors' results support the importance of MMPs and their tissue inhibitors in meningioma pathogenesis. In future studies, these gene polymorphisms, especially MMP2 1306C>T and 1575G>A, should be investigated for meningioma or brain invasion susceptibility in larger study groups.

Osteoblastoma of C2 Corpus: 4 Years Follow-up.

Osteoblastomas are rare neoplasms of the spine. The majority of the spinal lesions arise from the posterior elements and involvement of the corpus is usually by extension through the pedicles. An extremely rare case of isolated C2 corpus osteoblastoma is presented herein. A 9-year-old boy who presented with neck pain and spasmodic torticollis was shown to have a lesion within the corpus of C2. He underwent surgery via an anterior cervical approach and the completely-resected mass was reported to be an osteoblastoma. The pain resolved immediately after surgery and he had radiologic assessments on a yearly basis. He was symptom-free 4 years post-operatively with benign radiologic findings. Although rare, an osteoblastoma should be considered in the differential diagnosis of neck pain and torticollis, especially in patients during the first two decades of life. The standard treatment for osteoblastomas is radical surgical excision because the recurrence rate is high following incomplete resection.

Identification of promoter region methylation patterns of MGMT, CDKN2A, GSTP1, and THBS1 genes in intracranial meningioma patients.

BACKGROUND: Cytogenetic, molecular and epigenetic changes are all known to take place in the pathogenesis of meningiomas. In this study, we aimed at investing methylation of MGMT (DNA repair), CDKN2A (cell cycle control), GSTP1 (detoxification), and THBS1 (angiogenesis inhibitor) genes, which are known to be unmethylated in normal tissue, in meningioma samples. MATERIALS AND METHODS: Methylation specific polymerase chain reaction was used to study promoter regions methylation of genes in 36 patient samples. RESULTS: Methylation in promoter regions of MGMT, CDKN2A, GSTP1, and THBS1 genes were found in 11.1%, 8.3%, 2.8%, and 0% of the cases, respectively. About 19.4% of cases revealed promoter methylation of at least a single gene, whereas only 2.8% of cases revealed methylation of more than one gene. Based on their World Health Organization 2007 grade; 6.3% of grade I cases, 35.3% of grade II cases, and 33.3% of grade III cases showed hypermethylation in the promoter regions of the genes studied. No statistically significant relation was found between promoter zone methylation and factors such as age, sex, histopathology, grade, or recurrence. CONCLUSIONS: Further research on promoter zone methylation will help expose the methylation profile and pathogenesis of meningiomas, which will consequently guide to a deeper understanding of the pathogenesis of the disease, thus ensuring a better understanding of the prognosis and considering novel treatment options.

Percutaneous CT-guided treatment of recurrent spinal cyst hydatid.

The involvement of spinal column in cyst hydatid disease is rare and hard to treat. The gold standard treatment is total removal of the cysts without rupture. However, recurrence after surgery is almost inevitable and reoperations carries technical difficulties and higher morbidity. We present a 69-year-old woman with two cystic masses at the T12 level, which compress the spinal cord causing severe paresis in her left leg. Under local anestesia, the cysts were aspirated and irrigated with 20% hypertonic saline solution via bilateral T12 transpedicular route. We aimed to report that percutaneous CT guided treatment should be considered as an alternative therapeutic option in case of recurrent spinal cyst hydatid.

Simple decompression of the ulnar nerve at the elbow via proximal and distal mini skin incisions.

The purpose of the present study was to describe a new minimally invasive surgical technique for decompression of the ulnar nerve at the elbow for treatment of cubital tunnel syndrome. Four patients underwent surgical treatment for cubital tunnel syndrome. Preoperative clinical states were classified by using the McGowan grading system and the postoperative states were recorded by using the Wilson and Krout grading system. Preoperative and last follow-up electromyographic results were also recorded. At the last follow-up, three patients were recorded as excellent and one patient was recorded as good according to Wilson and Krout grading system. One patient showed improvement in sensory nerve conduction velocity another showed improvement in motor nerve conduction velocity at the last follow-up. We conclude that simple decompression of the ulnar nerve at elbow via proximal and distal mini skin incisions is an effective, technically simple and safe surgical method in the treatment of cubital tunnel syndrome.

Extraabdominal desmoid tumor appearing following resection of thoracolumbar schwannoma.

The authors report the case of an adult female patient who developed a thoracic paraspinous desmoid tumor (aggressive fibromatosis) located just cranially to the incision scar of the previous surgery for resection of a spinal schwannoma. To the best of the authors' knowledge, this is the first report of an extraabdominal desmoid tumor occurring after resection of a spinal schwannoma. Desmoid tumors develop from muscle connective tissue, fasciae and aponeuroses. They are known to occur in association with surgical scars or implants. Incidence of this tumor is low. The etiology is still uncertain. Although rare, this distinctive tumor should be kept in mind in the differential diagnosis of palpable masses and especially those occurring around the previous skin incisions.

Spontaneous supratentorial intracerebral hemorrhage: Does surgery benefit comatose patients?

INTRODUCTION: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is still controversial. We therefore analyzed the comatose patients diagnosed as having spontaneous SICH and treated by surgery. MATERIALS AND METHODS: We retrospectively analyzed the collected data of 25 comatose patients with initial Glasgow Coma Scale (GCS) ≤ 8 diagnosed as having spontaneous SICH and they had been treated by surgical evacuation between 1996 and 2008. The outcome was assessed using Glasgow outcome scale (GOS). The side and location of the hematoma and ventricular extension of the hematoma were recorded. The hematoma volume was graded as mild (<30 cc), moderate (30-60 cc) and massive (>60 cc). RESULTS: Age of the patients ranged from 25 to 78 years (mean: 59.6 ± 15.14 years). Among the 25 patients studied, 11 (44%) were females and 14 (56%) were males. GCS before surgery was <5 in 8 (32%) patients and between 5 and 8 in 17 (68%) patients. The hematoma volume was less than 30 cc in 2 patients, between 30 and 60 cc in 9 patients and more than 60 cc in 14 patients. Fourteen of the patients had no ventricular connection and 11 of the hematomas were connected to ventricle. All the 25 patients were treated with craniotomy and evacuation of the hematoma was done within an average of 2 hours on admission to the emergency department. Postoperatively, no rebleeding occurred in our patients. The most important complication was infection in 14 of the patients. The mortality of our surgical series was 56%. GCS before surgery was one of the strongest factors affecting outcome GCS (oGCS) (P = 0.017). Income GCS (iGCS), however, did not affect GOS (P = 0.64). The volume of the hematoma also affected the outcome (P = 0.037). Ventricular extension of the hematoma did affect the oGCS and GOS (P = 0.002), but not the iGCS of the patients (P = 0.139). CONCLUSION: Our data suggest that being surgically oriented is very important to achieve successful outcomes in a select group of patients with SICH.

Rapid Development of Brain Abscess Caused by Streptococcus Pyogenes Following Penetrating Skull Injury via the Ethmoidal Sinus and Lamina Cribrosa.

OBJECTIVE: Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS). There have been five reported case in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury. We present a patient who suffered from penetrating skull injury that resulted in a brain abscess caused by Streptococcus pyogenes. METHODS: The patient was a 12-year-old boy who fell down from his bicycle while cycling and ran into a tree. A wooden stick penetrated his skin below the right lower eyelid and advanced to the cranium. He lost consciousness on the fifth day of the incident and his body temperature was measured as 40. While being admitted to our hospital, a cranial computed tomography revealed a frontal cystic mass with a perilesional hypodense zone of edema. There was no capsule formation around the lesion after intravenous contrast injection. Paranasal CT showed a bone defect located between the ethmoidal sinus and lamina cribrosa. RESULTS: Bifrontal craniotomy was performed. The abscess located at the left frontal lobe was drained and the bone defect was repaired. CONCLUSION: Any penetrating lesion showing a connection between the lamina cribrosa and ethmoidal sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism.

Rare lesions of the cerebellopontine angle.

Vestibular schwannomas, meningiomas and epidermoids account for a vast majority of the lesions occurring in the cerebellopontine angle (CPA). Neoplastic and non-neoplastic pathologies other than these tumors constitute 1% of all lesions located in the CPA. The aim of this study was to reveal our experience in the treatment of the rare lesions of the CPA. We have retrospectively reviewed the medical files and radiological data of all patients who underwent surgery involving any kind of pathology in the CPA. We have excluded those patients with a histopathological diagnosis of meningioma, schwannoma and epidermoids. Our research revealed a case of craniopharyngioma, a case of chloroma, a case of solitary fibrous tumor, a case of pinealoblastoma, a case of atypical teratoid rhabdoid tumor, a case of an aneurysm, a case of hemorrhage and a case of abscess.

Ruptured intradiploic dermoid cyst overlying the torcular herophili.

We present a 22-month-old boy with a ruptured dermoid cyst overlying the torcular herophili. The cyst had caused scalp erosion and a lytic bone lesion and was successfully excised surgically. The general features of these cysts are discussed, along with the surgical procedure and implications of cyst rupture.

Cerebellar mutism syndrome and its relation to cerebellar cognitive and affective function: Review of the literature.

Tumors of the cerebellum and brainstem account for half of all brain tumors in children. The realization that cerebellar lesions produce clinically relevant intellectual disability makes it important to determine whether neuropsychological abnormalities occur in long-term survivors of pediatric cerebellar tumors. Little is known about the neurobehavioral sequale resulting specifically from the resection of these tumors in this population. We therefore reviewed neuropsychological findings associated with postoperative cerebellar mutism syndrome and discuss the further implications for cerebellar cognitive function.

Topical use of colchicine to prevent spinal epidural fibrosis in rats.

OBJECTIVES: Epidural fibrosis after spinal surgery may be the cause in most cases of recurrent pain. Numerous pharmacological agents and anti-adhesive barriers have been used to prevent epidural fibrosis, but the success rates are variable. Colchicine is an historical drug extracted from the flowers of Colchium autumnale widely used in arthritic conditions in the past. Currently, it is used in acute gout attacks, familial mediterranean fever for its anti-inflammatory and antifibrotic effects. Also, colchicine is used locally in the cutaneous diseases (e.g. actinic keratoses, psoriasis) for its similar effects. In present study, we investigated the effect of topical colchicine on spinal epidural fibrosis in the rats. METHODS: The rats were randomly divided to three groups of six animals each. Total L4-5 laminectomy was performed, and ligamentum flavum and epidural fat were removed gently. Meticulous hemostasis was achieved by using cotton pad when necessary, and no bone wax and cauterization were used. Dura was left clean with no hemorrhages. In treatment group cotton pads (5 × 5 mm) soaked with 0.005 mg/ml colchicine and applied on laminectomy sites for 10 minutes and removed, in sham group only saline irrigation was done. In control group no medication or irrigation was applied. The wound was closed in layers using the same material in each group. Four weeks later, the rats were killed, and the spinal column, including surrounding muscle tissue, was removed en bloc, decalcified, and fixed in formaldehyde. Epidural fibrosis was evaluated histologically. RESULTS: In colchicine-treated group, epidural fibrosis was significantly reduced compared with control and sham groups. CONCLUSIONS: Epidural fibrosis is a well-known complication following lumbar disc surgery. Topical application of colchicine is very effective in preventing epidural fibrosis.