What is the restorative effect of VEGF inhibitor bevacuzimab against subarachnoid hemorrhage in an experimental model?

BACKGROUND: This study investigated the effect of vascular endothelial growth factor (VEGF) inhibitor bevacuzimab (BVZ) on the rabbit basilar artery using 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+BVZ group (n = 6). 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 10 mg/kg, intravenous BVZ for 2 days after the SAH. Basilar artery diameters were measured with magnetic resonance angiography (MRA) 72 h after the SAH in all groups. After 72 h, whole brains, including the upper cervical region, were obtained from all the animals after perfusion and fixation of the animal. The wall thickness, luminal area, and the apoptosis at the basilar arteries were evaluated in all groups. RESULTS: BVZ significantly prevented SAH-induced vasospasm confirmed in vivo with MRA imaging with additional suppression of apoptosis on basilar artery wall. DISCUSSION: VEGF inhibition with BVZ has shown to have a vasospasm and apoptosis attenuating effect on basilar artery in a SAH model.

Study the effects of zonisamide on fine structure of rabbit basilar artery and hippocampus in rabbit subarachnoid hemorrhage model.

BACKGROUND: In this study, we investigated the effect of a novel antiepileptic drug, zonisamide (ZNS), on the basilar artery and hippocampus in a rabbit subarachnoid hemorrhage (SAH) model. METHODS: Three groups of New Zealand white rabbits were used: a sham (non-SAH) group, an SAH + saline group, and SAH + drug treatment group that received ZNS. In the treatment group, the subjects were given ZNS for 3 days after the SAH. Hippocampal sections were evaluated for neural tissue degeneration. Basilar artery lumen areas and arterial wall thickness were also measured in all groups. RESULTS: The mean luminal area of the SAH + ZNS was significantly greater than the SAH + saline group. In addition, the arterial wall thickness of SAH + ZNS group was significantly thinner than the SAH + saline group. The neuronal degeneration scores of the hippocampal CA1 regions in the SAH + ZNS group were significantly lower than the SAH + saline treatment animals. CONCLUSIONS: These results indicate that ZNS has a vasodilatatory effect on the basilar artery and a neuronal protective effect in the CA1 region of the hippocampus in a rabbit SAH model.

[Seroepidemiology of pertussis in 10-15 years old healthy children in Isparta province, Turkey]. / Isparta ilinde 10-15 yas grubu saglikli çocuklarda bogmaca seroepidemiyolojisi.

Pertussis, a highly contagious respiratory disease, commonly affects infants and young children and can be fatal, especially in babies less than one year of age. Bordetella pertussis continues to circulate even in populations where a high vaccine coverage of infants and children is achieved. Adults are reservoirs for infections in infants, in whom pertussis may be severe and life-threatening. Despite the rising rates of vaccination in our country and all over the world for the past 25 years, the number of pertussis cases among adolescents and adults has been increasing. To decrease the risk of pertussis infection and thus protect adults and adolescents against pertussis, booster doses should be administered to preschool children and adolescents. In order to decide when to administer the booster doses in a country, age-specific seropidemiology of the disease should be known. The aim of this study was to determine the pertussis toxin antibody levels of fully vaccinated healthy children in Isparta, Turkey, aged 10-15 years old. A total of 296 participants, that comprised fully vaccinated 254 healthy elementary-school students aged between 10-15 years (126 male, 128 female) and 42 adults between 18-39 years old (21 male, 21 female) were included in the study with informed consent. The sensitivities of subjects to pertussis were tested by the determination of pertussis toxin IgG levels with the use of commercial ELISA test (Genzyme Virotech, Germany). In our study, the seropositivity rate was found 12.6% (32/254) for 10-15 age group, however all the adult subjects were seronegative. Thus the total seropositivity rate was estimated as 10.8% (32/296). Pertussis toxin IgG seropositivity rate was 12.7% (16/126) for males and 12.5% (16/128) for females, and there was no significant gender difference (p> 0.05). The highest seropositivity rates were detected at 10(th) (23.8%) and 11(th) (19%) years in males, and 12(th) and 14(th) (23.8%) years in females. No seropositivity was detected in individuals over age 15 in our study. Since adults lose their immune protection gained by pertussis vaccination, they start becoming an infection source for infants. Therefore, a booster dose of acellular pertussis vaccine should be considered in preschool period and at ages 14-18. Further studies regarding diagnosis and surveillance of pertussis disease are required, as well as enhancement of vaccination rates.

Level I to III craniofacial approaches based on Barrow classification for treatment of skull base meningiomas: surgical technique, microsurgical anatomy, and case illustrations.

OBJECT: Although craniofacial approaches to the midline skull base have been defined and surgical results have been published, clear descriptions of these complex approaches in a step-wise manner are lacking. The objective of this study is to demonstrate the surgical technique of craniofacial approaches based on Barrow classification (Levels I-III) and to study the microsurgical anatomy pertinent to these complex craniofacial approaches. METHODS: Ten adult cadaveric heads perfused with colored silicone and 24 dry human skulls were used to study the microsurgical anatomy and to demonstrate craniofacial approaches in a step-wise manner. In addition to cadaveric studies, case illustrations of anterior skull base meningiomas were presented to demonstrate the clinical application of the first 3 (Levels I-III) approaches. RESULTS: Cadaveric head dissection was performed in 10 heads using craniofacial approaches. Ethmoid and sphenoid sinuses, cribriform plate, orbit, planum sphenoidale, clivus, sellar, and parasellar regions were shown at Levels I, II, and III. In 24 human dry skulls (48 sides), a supraorbital notch (85.4%) was observed more frequently than the supraorbital foramen (14.6%). The mean distance between the supraorbital foramen notch to the midline was 21.9 mm on the right side and 21.8 mm on the left. By accepting the middle point of the nasofrontal suture as a landmark, the mean distances to the anterior ethmoidal foramen from the middle point of this suture were 32 mm on the right side and 34 mm on the left. The mean distance between the anterior and posterior ethmoidal foramina was 12.3 mm on both sides; the mean distance between the posterior ethmoidal foramen and distal opening of the optic canal was 7.1 mm on the right side and 7.3 mm on the left. CONCLUSIONS: Barrow classification is a simple and stepwise system to better understand the surgical anatomy and refine the techniques in performing these complex craniofacial approaches. On the other hand, thorough anatomical knowledge of the midline skull base and variations of the neurovascular structures is crucial to perform successful craniofacial approaches.

Comparison of the effect of mexiletine and methylprednisolone on neural function and histopathological damage after transient spinal cord ischemia in rabbits.

AIM: The purpose of this study was to investigate the effect of mexiletine on the neural function and histopathological changes after ischemic spinal cord injury in rabbits. We also compared the effect of mexiletine to that of methylprednisolone. MATERIAL AND METHODS: Twenty six male New Zealand white rabbits were randomly divided into six groups. Group 1; sham operated group (n=3) underwent only the surgical exposure of infrarenal aorta. Group 2 (n=4) received neither intravenous (iv) nor intraperitoneal medication but the infrarenal aorta was cross-clamped. Group 3 (n=5) received intravenous infusion of 20 ml/kg/h normal saline. Group 4 (n=5) received 30 mg/kg intravenous methylprednisolone. Group 5 (n=3) received intraperitoneal 20mg/kg/h normal saline. Group 6 (n=6) received 50mg/kg mexiletine intraperitoneally. Temporary spinal cord ishemia was induced by infrarenal aortic occlusion for 25 minutes and followed by reperfusion. The neural status was scored using the Tarlov criteria at 24 hours after reperfusion. Immediately after the neurological scoring, the spinal cords of all animals were removed for histopathological study. RESULTS: Histopathological examination scores were significantly higher in group 6 compared to group 2 (p < 0.05). CONCLUSION: Mexiletine can significantly ameloriate the neural function and prevent histopathological damage after transient spinal cord ischemia in rabbits. This is the first research that investigates the neuron=protective effect of mexiletine in a spinal cord ischemia model.

Dual-Ionomer-Based Device: Acetylcholine Transport and Nonenzymatic Sensing.

The malfunctioning in the release of acetylcholine (ACh+), leading to consequential damages in the neural system, has become an impulsion for the development of numerous progressive transport and detection gadgets. However, several challenges, such as laterality and complexity of transport devices, low precision of amperometric detection systems, and sumptuous, multistaged enzymatic quantification methods, have not yet been overcome. Herein, ionomers, because of their selective ion transporting nature, are chosen as suitable candidates for being implemented into both targeted ACh+ delivery and sensing systems. Based on these two approaches, for the very first time in the literature, the disulfonated poly(arylene ether sulfone) membrane is concurrently (i) used in the mimicry of transduction of the electrical-to-ionic signal in a neural network as "Acetylcholine Pen" (ACh+ Pen) and (ii) operated as a highly sensitive, conductivity-based ACh+ quantifier. Our dual device, being able to operate under an actual action potential of 55 mVbias, shows a strong potential of future applicability in real-time ionic delivery-and-sensing systems.

Topiramate attenuates hippocampal injury after experimental subarachnoid hemorrhage in rabbits.

OBJECTIVE: The aim of this study was to investigate the ability of topiramate (TPM) to prevent neural injury in a rabbit model of subarachnoid hemorrhage (SAH). The effect of TPM on cerebral vasospasm was also evaluated. METHODS: Fifty-three New Zealand white rabbits were allocated into three groups randomly. SAH was induced by injecting autologous blood into the cisterna magna. The treatment groups were as follows: (1) sham operated (no SAH (n=18); (2) SAH only (n=17); (3) SAH + TPM (n=18). Hippocampal sections were evaluated for neural tissue degeneration, using the previously described neural degeneration scoring system. The ApopTag peroxidase in situ apoptosis detection kit (Serologicals Corp., former Intergen) was used to assess apoptosis in the hippocampal sections and the effect of TPM on the apoptotic response. Basilar artery lumen areas and arterial wall thickness were also measured in all groups. RESULTS: There was a statistically significant difference between the mean degeneration scores of the control and SAH only groups (p<0.05). The level of neural degeneration in TPM treated group was significantly lower compared with SAH only group (p<0.05), but not significantly higher than the control group (p>0.05). There were no statistically significant differences between arterial cross-sectional area and arterial wall thickness measurements of the SAH group and SAH + TPM group. CONCLUSION: These findings demonstrate that TPM has marked neuroprotective effect in an experimental model of SAH in rabbits. This observation may have clinical implications suggesting that this antiepileptic drug could be used as a possible neuroprotective agent in patients without major adverse effects.

Ideal screw entry point and projection angles for posterior lateral mass fixation of the atlas: an anatomical study.

Although various posterior insertion angles for screw insertion have been proposed for C1 lateral mass, substantial conclusions have not been reached regarding ideal angles and average length of the screw yet. We aimed to re-consider the morphometry and the ideal trajections of the C1 screw. Morphometric analysis was performed on 40 Turkish dried atlas vertebrae obtained from the Department of Anatomy at the Medical School of Ankara University. The quantitative anatomy of the screw entry zone, trajectories, and the ideal lengths of the screws were calculated to evaluate the feasibility of posterior screw fixation of the lateral mass of the atlas. The entry point into the lateral mass of the atlas is the intersection of the posterior arch and the C1 lateral mass. The optimum medial angle is 13.5 +/- 1.9 degrees and maximal angle of medialization is 29.4 +/- 3.0 degrees . The ideal cephalic angle is 15.2 +/- 2.6 degrees , and the maximum cephalic angle is 29.6 +/- 2.6 degrees . The optimum screw length was found to be 19.59 +/- 2.20 mm. With more than 30 degrees of medial trajections and cephalic trajections the screw penetrates into the spinal canal and atlantooccipital joint, respectively. Strikingly, in 52% of our specimens, the height of the inferior articular process was under 3.5 mm, and in 70% was under 4 mm, which increases the importance of the preparation of the screw entry site. For accommodation of screws of 3.5-mm in diameter, the starting point should be taken as the insertion of the posterior arch at the superior end of the inferior articular process with a cephalic trajection. This study may aid many surgeons in their attempts to place C1 lateral mass screws.

Microsurgical anatomy of the posterior spinal artery via a far-lateral transcondylar approach.

OBJECT: The posterior spinal artery (PSA) is a clinically significant vessel that may frequently be encountered during the far-lateral transcondylar approach. There have been a limited number of reports on the specific origin of the PSA in the literature. The aim of this study was to demonstrate the origin of the PSA. METHODS: Thirteen cadaveric heads (26 sides) were injected with colored silicon. A bilateral far-lateral transcondylar approach was performed on each side. In every specimen the site of the origin of the PSAs, as well as their course, branching pattern and anastomoses, external diameters, and neighboring vascular and nervous structures were recorded. Microanatomical dissections were performed using the surgical microscope. In addition, 8 surgical cases in which the far-lateral approach was used were collected prospectively to record the course and origin of the PSA. Altogether, a total of 34 sides were analyzed for their PSA origin and course. RESULTS: In the cadaveric specimens, the PSA was found to originate from the vertebral artery (VA) in 25 sides (96%). In 13 specimens (50%) the PSA originated from the V(4) segment of the VA intradurally. In 12 specimens (46%) the PSA originated from the V(3) segment of the VA extradurally. In 1 specimen (4%), in whom the posterior inferior cerebellar artery (PICA) had an early origin from the VA extradurally at the C-1 level, the PSA originated from the PICA. Of the 8 surgical cases, 2 patients had extradural origin of the PSA from the V(3) segment of the VA, whereas 6 patients had intradural origin of the PSA from the V(4) segment. CONCLUSIONS: Although the usual origin of the PSA is from the VA either intra- or extradurally, its origin is closely related to the origin of the PICA. The PSA originates from the PICA in cases in which the PICA originates extradurally from the VA. In the far-lateral transcondylar approach, the dura is opened in close proximity to the VA. Knowledge of the origin and course of the PSA is critically important when executing the far-lateral approach to avoid its injury.

Sulcal and gyral anatomy of the orbitofrontal cortex in relation to the recurrent artery of Heubner: an anatomical study.

The aim of this study is to investigate the sulcal and the gyral anatomy of the orbitofrontal cortex with its arterial supply. Ten gross formaline fixed adult brains (20 hemispheres) were used to show the gyral and sulcal anatomy of the inferior frontal lobe, and its arterial supply. The arteries were investigated with special attention to the relationship between the recurrent artery of Heubner (RAH) and the gyrus rectus (GR). Medial and lateral orbital sulci were connected in 4 right hemispheres, and in 7 of the left. The orbital sulci were connected with olfactory sulcus in one right hemispheres, but not in the left. In the right hemispheres, the RAH traveled across the GR in 7 hemispheres and looped over the posterior aspect of the GR in 3 hemispheres. In the left hemispheres, RAH crossed the GR in 8 and looped over the posterior aspect of the GR before entering the anterior perforating substance in 2 hemispheres. There are considerable variations among the gyri and sulci of the orbitofrontal cortex and it is difficult to describe a precise architectural pattern. The RAH demands special attention during GR resection in aneurysm surgery.

Crossed Wernicke's aphasia after aneurysmal subarachnoid hemorrhage: a case report.

Crossed aphasia (CA) refers to aphasia occurring after right brain damage in right handers. In the literature, numerous CA cases following cerebral ischemia have been reported, but few met the criteria for a prompt diagnosis. The authors present the case of a 52-year-old woman with SAH caused by a right middle cerebral artery (MCA) saccular aneurysm who developed non-fluent aphasia characterized by reduced verbal output, word-finding disturbances and phonemic paraphasias in both oral and written language. 99mTc-HMPAO SPECT was also consistent with right parieto-temporal and frontoparietal ischemia with crossed cerebellar diaschisis on the right cerebellum. A diagnosis of CA was made. One year follow-up showed improvement in communication skills but persistent right fronto-temporo-parietal ischemia. Cerebral vasospasm after aneurysmal SAH symptomatology may vary from motor and sensory disturbances to cognitive disabilities. Aphasia developing after cerebral ischemia of the right hemisphere in a right-hand dominant patient following vasospasm may be a misleading symptom for the localization of the insult. Keeping a high index of suspicion may help in making the correct diagnosis. The changes in the perfusion patterns of cerebellum as assessed by SPECT study during the acute and recovery phases suggests the involvement of cerebellum in language functions.

Metabolic changes during successful medical therapy for brain hydatid cyst: case report.

BACKGROUND: Medical therapy for hydatid disease of the brain has been reported with encouraging results especially in small or medium-sized cysts. To date, no other case correlating the metabolite levels of the cyst with albendazole treatment has been reported. CASE DESCRIPTION: A 52-year-old woman presented with left hemiparesis and seizure. Cranial magnetic resonance revealed a right frontal cystic mass lesion. A diagnosis of hydatid cyst was made, and she was put on medical therapy with albendazole. An MRS before the medical therapy was begun revealed the typical findings of a hydatid cyst with resonance of alanine, acetate, and succinate that were specific for hydatid disease, and additional nonspecific lactate peaks with an additional small peak of choline. Comparison between the multiple MRS examinations was made by comparing the metabolite ratios specific for hydatid disease to choline, which seemed stable from the beginning. Two sequential MRS imaging revealed a prominent decrease of the succinate and acetate resonance, accompanied by a smaller decline of the alanine resonance progressively, correlated with the conventional MRI findings of the cyst, which had a smaller size with blurred margins in the meantime. After 5 months of medical treatment, the cyst had completely disappeared. The patient has been monitored for 5 years and remains well without recurrence. CONCLUSIONS: This case provides additional proof that the brain hydatid cyst is a medically treatable disease in appropriate cases. Furthermore, the changes in the metabolic profile of the cyst, especially those regarding succinate and acetate may represent the efficacy of the medical treatment.

Lamotrigine attenuates cerebral vasospasm after experimental subarachnoid hemorrhage in rabbits.

BACKGROUND: Increasing evidence implicates voltage-dependent sodium and potassium channels, in addition to calcium channels of various types, in the pathophysiological development of cerebral vasospasm. This study investigated the ability of LTG, an antiepileptic drug with multi-ion channel inhibition properties, to prevent cerebral vasospasm and subsequent neural ischemia in a rabbit model of SAH. METHODS: Thirty-five New Zealand white rabbits were assigned to 1 of 3 groups: (1) control (no SAH, saline injection); (2) SAH alone; (3) SAH + LTG, 20 mg/kg daily. Animals were killed 72 hours after SAH, then basilar artery lumen areas and arterial wall thickness were measured in all groups. The histological sections of the CA1 and CA3 regions and dentate gyri of the hippocampi were evaluated semiquantitatively for neural tissue degeneration. RESULTS: In the SAH group, the mean luminal cross-sectional area of the basilar artery was reduced by 62% after SAH as compared with the non-SAH controls (P < .0001). After SAH, the vasospastic response was attenuated by 36% in animals treated with 20 mg/kg of LTG compared with the SAH group (P < .005). The mean luminal cross-sectional areas of the basilar artery were 279000 +/- 27000 microm(2) in the control group, 173000 +/- 17600 microm(2) in the SAH group, and 236000 +/- 10000 microm(2) in the SAH + LTG group. The differences between the SAH group and the LTG-treated group were statistically significant (P < .0001). Histological examination was done in 12 control, 12 SAH, and 9 SAH + LTG-treated animals. The mean degeneration score for the control group and SAH + LTG group was statistically significant (P = .012). The difference between the SAH group and SAH+ LTG group was also statistically significant (P = .006). CONCLUSIONS: These findings demonstrate that oral administration of LTG has marked neuroprotective effect and significantly attenuates cerebral vasospasm after SAH, thus providing additional support for the role of non-L-type calcium channels and voltage-dependent sodium channels in vasospasm.

The work horse of skull base surgery: orbitozygomatic approach. Technique, modifications, and applications.

OBJECT: The aim of this study was to describe the microsurgical anatomy of the orbitozygomatic craniotomy and its modifications, and detail the stepwise dissection of the temporalis fascia and muscle and explain the craniotomy techniques involved in these approaches. METHODS: Nine cadaveric embalmed heads injected with colored silicone were used to demonstrate a stepwise dissection of the 3 variations of orbitozygomatic craniotomy. The craniotomies and dissections were performed with standard surgical instruments, and the microsurgical anatomy was studied under microscopic magnification and illumination. RESULTS: The authors performed 2-piece, 1-piece, and supraorbital orbitozygomatic craniotomies in 3 cadaveric heads each. Stepwise dissection of the temporalis fascia and muscle, and osteotomy cuts were shown and the relevant microsurgical anatomy of the anterior and middle fossae was demonstrated in cadaveric heads. Surgical case examples were also presented to demonstrate the application of and indications for the orbitozygomatic approach. CONCLUSIONS: The orbitozygomatic approach provides access to the anterior and middle cranial fossae as well as the deep sellar and basilar apex regions. Increased bone removal from the skull base obviates the need for vigorous brain retraction and offers an improved multiangled trajectory and shallower operative field. Modifications to the orbitozygomatic approach provide alternatives that can be tailored to particular lesions, enabling the surgeon to use the best technique in each individual case rather than a "one size fits all" approach.

Spinal subdural abscess: a rare cause of low back pain.

Spinal subdural abscess (SSA) is a rare but well-described entity. It may occur secondary to a systemic infectious focus or following a surgical procedure. There are only two SSA cases in the literature that are unrelated to such conditions and without any well-documented etiology. SSA is a neurosurgical emergency and diagnosis may be difficult. Progressive neurological deficits and severe pain with fever suggest the diagnosis. Surgical drainage and subsequent prompt antimicrobial therapy should be performed without delay. We report a patient with SSA unrelated to any predisposing condition and discuss underlying mechanisms of this disease.

Posterior osseous bridging of C1.

The sulcus of the vertebral artery is located behind the lateral mass of the atlas and in some cases is converted into a foramen by anomalous ossification known as the posterior ponticulus (osseous bridge). This study involved anatomical observations of 158 isolated anatomical specimens of dry C1 vertebrae. The incidence and types of posterior osseous bridging were identified for the 158 dry samples of atlas vertebrae. In nine (5.6%) dry C1 vertebrae, partial osseous bridging was detected (bilaterally in eight vertebrae and unilaterally on the left in one). Complete osseous bridging (arcuate foramen) was observed in six (3.8%) dry C1 vertebrae (bilaterally in one vertebra, unilaterally on the left in three, and on the right in two). Awareness of the types of posterior osseous bridging of C1 in craniocervical junction surgery is essential, and may be helpful in surgical interventions in this region.

Posttraumatic infarction in the basal ganglia after a minor head injury in a child: case report.

We present a case of posttraumatic infarction in the territory supplied by the lateral lenticulostriate artery after a minor head injury in a child. A 2.5-year-old child was admited to our emergency room after a head-on fall from a height of 50cm. He developed a right hemiparesis and he could not speak properly for about half an hour. An initial computerized tomography of the head taken two hours after the accident was normal. A follow-up CT obtained two days later revealed a hypodense lesion at the left basal ganglia and a diffusion-weighted magnetic resonance imaging disclosed an area of infarction. The patient was conservatively medicated and full recovery was made in three weeks. Hospital admission, careful observation and early diffusion-weighted MR examination should be considered for patients with persistent neurological deficits.

Cervical compression myelopathy: is fusion the main prognostic indicator?

OBJECT: A variety of factors may affect the neurological improvement in patients with cervical compression myelopathy (CCM) after surgery. The aim of this study was to report and discuss the prognostic factors in a group of patients with insufficient decompression of the spinal canal. METHODS: A prospective follow up and analysis of 20 consecutive patients with CCM treated between 2000 and 2002 was performed. All patients were surgically treated via an anterior approach, either by anterior cervical discectomy and fusion with instrumentation or by cervical corpectomy and fusion with instrumentation. The surgical results were examined using the modified Japanese Orthopaedic Asssociation disability scale, with reference to the findings of magnetic resonance imaging, computed tomography, and radiography. Seventeen patients (85%) experienced a 50% or more recovery rate as calculated using the Hirabayashi formula during the follow-up period (mean 32.5 months), despite a persistently narrow spinal canal and permanent or increased intramedullary high-intensity signal after surgery. CONCLUSIONS: Results of the study showed that patients with CCM benefited from anterior cervical discectomy and fusion with instrumentation or cervical corpectomy and fusion with instrumentation procedures despite insufficient decompression of the spinal canal. Fusion of the affected level(s) might be the reason for the acquired high recovery rates. The authors also conclude that the neurological improvement is not correlated with the reversal of or decrease in the intramedullary high-intensity signal change after surgery.

Is every chronic low back pain benign? Case report.

BACKGROUND: There is a well-recognized association between chronic back pain and the existence of an AAA. In literature, there are few reported AAA cases that describe patients with extensive pressure erosion of the vertebral body. CASE DESCRIPTION: The authors present the case of a 38-year-old woman with chronic low back pain for the last 2 years in whom an AAA was formed during the follow-up period. The patient presented with an episode of low back pain following hard work 2 years ago. MR imaging of the lumbar spine was reported as disc degeneration at the L4-5 and L5-S1 levels. She was given medical treatment and was doing well with occasional back pain for a year. One year later, she suffered another disabling pain attack, and MR imaging revealed an additional focal disc protrusion at the L4-5 level. She was again medically treated. In August 2004, she presented with severe low back pain, and this time, MR imaging showed edema and erosion at the anterior part of L3 vertebra body. MR imaging studies (2- and 3-dimensional) depicted AAA as the cause. She was operated on, and the aneurysm was resected with graft repair of the site. She was pain-free in the postoperative period. CONCLUSIONS: The evaluation of a patient with chronic back pain needs a thorough clinical and radiological workup. Limited evaluation of the bony and nervous structures of the spinal canal radiologically is insufficient. Pre- and paravertebral structures as well as vertebral body should carefully be evaluated to diagnose other causes of pain.

Chronic subdural hematoma in patients with idiopathic thrombocytopenic purpura: A case report and review of the literature.

BACKGROUND: cSDH is a rare form of bleeding in patients with ITP. Intracerebral hematoma or subarachnoid hemorrhage is more frequently reported in these patients. Spontaneous resolution of cSDH in patients with idiopathic subdural hematoma is uncommon. CASE DESCRIPTION: We report a case of spontaneous cSDH in a patient with ITP, and we review the related cases in the literature. In our patient, the hematoma resolved spontaneously despite very low platelet levels. There also was an incidental left parietal convexity meningioma. A review of the literature is presented, and the management of the patients is discussed. CONCLUSION: In patients with ITP, cSDHs may resolve spontaneously or with medical treatment, and surgery might be deferred except in emergency conditions or in patients with normal neurological findings. Close neurological and radiological observation along with the medical treatment may be appropriate in the management of patients with normal neurological findings.