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.

Punica granatum L. Juice Attenuates Experimental Cerebral Vasospasm in the Rabbit Subarachnoid Hemorrhage Model: A Basilar Artery Morphometric Study and Apoptosis.

Background This study investigated the effect of Punica granatum L. (pomegranate) juice on the rabbit basilar artery in an experimental subarachnoid hemorrhage (SAH) model. Methods Eighteen adult male New Zealand white rabbits were randomly divided into three groups: a control group (n = 6), SAH group (n = 6), and SAH + treatment group (n = 6). Basilar artery diameter was measured with magnetic resonance angiography (MRA) in all groups at the beginning of the study. Experimental SAH was created by injecting autologous arterial blood into the cisterna magna. In the treatment group, the subjects were administered a daily dose of 30 ml/kg pomegranate juice via gastric gavage for 4 days after the SAH. The SAH group and SAH + treatment group underwent cerebral MRA after 72 hours. After a neurologic score assessment, all the animals were killed. The wall thickness and lumen area of the basilar artery were measured histometrically in all groups, and the apoptotic cell percentage in the artery was identified. The mean diameter of the basilar artery during MRA was measured. Results Pomegranate improved neurologic functions compared with the SAH group (p < 0.01). The mean basilar artery diameter on MRA in the SAH + treatment group was larger than in the SAH group and smaller than in the control group (p < 0.01 and p < 0.05, respectively). The mean vessel wall thickness value in the SAH + treatment group was lower than in the SAH group (p < 0.01), whereas there was no difference between the control and the SAH + treatment group (p > 0.05). The apoptotic cell rate in the SAH + treatment group was significantly lower than in the SAH group (p < 0.001). Evaluation of the basilar artery luminal area showed no difference between the three groups (p > 0.05). Discussion Pomegranate was shown to have a vasospasm- attenuating effect on the basilar artery in the rabbit SAH model for the first time in our study.

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.

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.

Faun tail nevus and spinal dysraphism: cosmetic improvement with alexandrite laser epilation.

Faun-tail presents as an abnormal lumbosacral hypertrischosis and may be associated with spinal dysrasphism. In addition to the problems due to spinal anomalies, patient's physico-social life may also be affected. Here, we report a case of 13 years old female patient with Faun-tail in association with sypinal dysraphism, in which cosmetic improvement was achieved with the help of Alexandrite laser. Alexandrite laser can be the method of choice for permanent hair removal method due to its safe, effective and easy to apply properties.

Effect of granulocyte-colony stimulating factor on spinal cord tissue after experimental contusion injury.

The purpose of this study was to investigate the early effects of granulocyte-colony stimulating factor (G-CSF) on myeloperoxidase (MPO) activity, lipid peroxidation (LPO) and ultrastructural findings in rats after spinal cord injury (SCI). We also compared the effects of G-CSF and methylprednisolone sodium succinate (MPSS). Wistar rats were divided into four groups: control, SCI alone (50 g/cm weight drop trauma), SCI+MPSS (30 mg/kg), and SCI+G-CSF (50 µg/kg). Administration of G-CSF and MPSS significantly decreased LPO (p < 0.05) and MPO activity (p < 0.05) in the first 24 hours. MPSS was more effective than G-CSF in reducing LPO (p < 0.05) and in minimizing ultrastructure changes. The results of this study indicate that G-CSF exerts a beneficial effect by decreasing MPO activity and LPO and may reduce tissue damage in the first 24 hours after SCI. Our findings do not exclude the possibility that G-CSF has a protective effect on spinal cord ultrastructure after the first 24 hours following SCI.

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.

Paraplegia associated with spinal hydatid cyst: a case report.

STUDY DESIGN: Case report. OBJECTIVES: To report a case with paraplegia caused by spinal hydatid cyst. SUMMARY OF BACKGROUND DATA: Hydatid cyst is a disease caused by larval Echinococcus granulosus tapeworm. Spinal hydatid cyst rarely leads to severe neurologic problems. METHODS: A 34-year-old male patient was referred to our outpatient clinic due to back and low back pain, progressive weakness and numbness in both lower extremities, and a prediagnosis of lumbar disc hernia. He had spastic paraplegia, and thorax magnetic resonance imaging revealed a lobulated cystic lesion with extradural intraspinal localization. RESULTS: After surgery and following 2 months of rehabilitation program, the patient showed a dramatic clinical improvement. CONCLUSION: By this case, it is emphasized that spinal hydatid cyst should come to mind in the differential diagnosis of spinal cord compression, and the importance of prevention, early diagnosis, and treatment is highlighted because of high mortality and morbidity.

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.

Use of pimecrolimus to prevent epidural fibrosis in a postlaminectomy rat model.

OBJECT: Epidural fibrosis is the scar tissue formed over the dura mater after a laminectomy. Extensive epidural fibrosis may be an important underlying cause of failed back syndrome. Pimecrolimus, an ascomycin derivative, is one of the new classes of immunomodulating macrolactams and was specifically developed for the treatment of inflammatory diseases. This study examined the preventive effects of the local application of pimecrolimus in minimizing spinal epidural fibrosis in a rat laminectomy model. METHODS: Thirty Wistar rats were divided into 3 equal groups: control, mitomycin C (MMC), and pimecrolimus groups. Each rat underwent a laminectomy at the L-3 lumbar level. In the experimental groups, a cotton pad soaked with MMC (0.5 mg/ml) or 5 mg pimecrolimus was placed on the exposed dura mater. No treatment was performed in the control group rats. Thirty days after surgery, the rats were killed and the dura mater thickness, epidural fibrosis, and arachnoidal involvement were quantified. RESULTS: The mean dura thickness was measured at 9.28 +/- 3.39 microm in the MMC group and at 8.69 +/- 2.32 microm in the pimecrolimus group, compared with 14.70 +/- 4.14 microm in the control group. In addition, the epidural fibrosis and arachnoidal involvement were reduced significantly in the treatment groups compared with the control group. CONCLUSIONS: In this animal model, it was shown that locally applied pimecrolimus effectively reduces epidural fibrosis and dural adherence in rats that underwent lumbar laminectomy. Mitomycin C was equally effective as pimecrolimus in reducing epidural fibrosis and dural adherence in this study.

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.

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.

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.

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.

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.