Brain injury due to air gun shot: report of three adult cases.

Air guns (AGs) are arms that use air or another compressed gas to propel a projectile. Generally, brain injury may occur in children due to their incomplete skull development; however, the less-resistant and thin region of the skull in adults may also be penetrated by an AG shot. In this paper, we present three adult cases treated in our clinic for brain injury caused by an AG. The first case had brain and skull damage related to the high pressure of the compressed gas, and the others additionally had foreign bodies in their brain. All of the patients were operated. Two were discharged without neurological deficit; the third case had a permanent slight hemiparesis. Average follow-up was 11 months and no abscess formation was observed in this period. AGs are known as low-velocity arms; however, they have the potential to cause brain injury, and brain penetration may occur especially in the relatively less resistant and thin sites of the skull such as the orbit and temporal and occipital bones. As cerebrospinal fluid leakage is one of the expected conditions, urgent surgery is usually required.

Microsurgical resection of supratentorial cerebral cavernomas.

AIM: More than two thirds of cerebral cavernomas are located supratentorially. The transsulcal approach without excision of the perilesional gliotic parenchyma and simple lesionectomy are keys to surgery on eloquent areas. MATERIAL AND METHODS: We present 11 supratentorial cerebral cavernomas operated between 2003 and 2007 with signs of seizures in six and focal neurological deficit in four cases. The age ranged from 19 years to 69 years with a mean of 40 years and the male/female ratio was 6:5. The mean follow-up was 26 months. RESULTS: All lesions were lobar and the size ranged between 18 and 48 mm. Four were located in eloquent areas and two were deeply seated. Total lesionectomy was performed in all without major complications. A gliotic hemosiderin ring was noted in 7 and resected in 5 of them. Postoperative outcome was improved in all patients with complete seizure control in four. Seizure control was partial in 2 of the cases without any recurrence or residual mass. CONCLUSION: Asymptomatic cerebral cavernomas should be followed with regular MR scans. Symptomatic ones in noneloquent or accessible areas should be resected. Deeply situated cavernomas in eloquent areas should also be resected with the guidance of fMRI and stereotactic marking if available.

Single-stage posterolateral Corpectomy and circumferential stabilization without laminectomy in the upper thoracic spine: cadaveric study and report of three cases.

AIM: Surgical approach to the upper thoracic spine diseases is challenging since anterior interventions to this region are quite complicated with the presence of major vascular elements or important visceral and soft-tissue structures. MATERIAL AND METHODS: Operative technique was performed initially on eight cadavers and then on three consecutive patients. Costotransvesectomy was performed on the left side and pediculectomy were added on the contralateral side to achieve wide visual angle during corpectomy. A cage was implanted into the field of corpectomy from the left side and the stabilization procedure was completed with posterior instrumentation. RESULTS: Anterior low cervical approach is less invasive than posterior approach for T2 level and above.The area below T3 level includes the heart, aorta, common carotid or brachiocephalic artery and thoracic duct favoring the safety of posterior approach which provides a sufficient surgical window for corpectomy and circumferential stabilization at a single operation. CONCLUSION: The corpectomy procedure could be clearly performed under bilateral visualization of healthy bony margins with this technique. Although preserved laminae and spinous process lose the connection to the involved segment and hanged to adjacent levels only with posterior ligamentous complex, we propose that a chance of interlaminar fusion could further contribute to spinal stabilization rather than posterior instrumentation only.

Spontaneous resolution of calcified cephalhematomas of infancy: report of two cases.

Cephalhematoma (CH) is less commonly encountered problem of infancy with an incidence of 1 % however calcified CHs are seldom. The exact reason of calcification remains unclear. We report two cases of calcified CHs that developed as a complication of vacuum extraction during vaginal delivery. Calcified CHs generally present with cosmetic reasons like skull asymmetry and calvarial mass. Although Doppler ultrasonography is useful in the diagnosis of CHs, computerized tomography or direct X-rays help more in the detection of calcified ones. Follow-up should be considered for cases below 2 years of age since the cranium continues to grow and there appears to be a chance of spontaneous resolution. Surgical intervention should be reserved for cases with neurological deficits or persistent lesions on follow-up.

The revised Acute Physiology and Chronic Health Evaluation System (APACHE II) is more effective than the Glasgow Coma Scale for prediction of mortality in head-injured patients with systemic trauma.

BACKGROUND: The Glasgow Coma Scale (GCS) is popular, simple, and reliable, and provides information about the level of consciousness in trauma patients. Nevertheless, the necessity of using a more complex system than GCS has been questioned recently. The revised Acute Physiology and Chronic Health Evaluation system (APACHE II) is a physiologically based system including 12 physiological variables, and it also includes GCS. In addition, it is thought to be superior to GCS due to recognition of increasing age and significant chronic health problems, which adversely affect mortality. METHODS: This retrospective study included 266 patients (195 males, 71 females; mean age 60.5; range 14 to 87 years) with head injury associated with systemic trauma in 2003 and 2004. RESULTS: Mortality increased in the elderly group (p<0.001). Mean survival score in APACHE II was 38.0 and death score was 68.7 (p<0.001); these values in GCS were 10.4 and 6.3, respectively (p<0.001). APACHE II at the cut-off point was better than GCS in the prediction of death and survival in patients (p<0.01). The area under the receiver operating characteristic curve for sensitivity and specificity was larger in APACHE II (0.892+/-0.028) than GCS (0.862+/-0.029). CONCLUSION: For the assessment of mortality, the GCS score still provides simple, less-time consuming and effective information concerning head injury patients, especially in emergencies; however, for the prediction of mortality in multitrauma patients, APACHE II is superior to GCS since it includes the main physiologic parameters of patients.

Choroid plexus papillomas in two siblings: case report.

Choroid plexus papilloma (CPP) is a rare, benign epithelial brain tumor of the nervous system seen particularly in infants. Familial cases are extremely uncommon. Some other form of malignant tumors was noted in the relatives of patients with CPPs, and some genetic defects regarding this coincidence were reported in the literature. These neoplasms are occasionally bilateral and hydrocephalus is an associated sign in most of the cases. We report three lateral ventricle CPPs in two siblings, at the age of 7 month and 2 years respectively. All tumors were resected with parietotemporal craniotomy and a superior temporal sulcus approach to the lateral ventricle. To avoid a concomitant need of ventriculoperitoneal shunt insertion, external ventricular drainage was inserted for a week in the postoperative period relieving symptoms of hydrocephalus. Search for a hereditary defect in the p53 gene of the second infant (7 months old) revealed no mutation. Postoperative courses were uneventful and the patients were followed for three years without any recurrence. Bilateral CPPS are rare and unusual in two siblings. A genetic predisposition such as the p53 mutation should be investigated in bilateral CPPs in particular.

Cerebral leukoencephalopathy with calcifications and cysts operated for signs of increased intracranial pressure: case report.

BACKGROUND: Association of leukoencephalopathy with calcifications and cysts is extremely rare. It should be differentiated from FD or bilateral striopallidodentate calcinosis and astrocytoma. Yet, there are many other clinical syndromes featuring bilateral symmetric cerebral calcifications. Neuroradiologic and histopathologic findings are more helpful than clinical picture in differentiating these 3 entities from each other. CASE DESCRIPTION: We report a sporadic case operated for signs of increased ICP and cerebellar cystic mass. The patient had symmetric bilateral cerebral and cerebellar calcifications, white matter edema, and a secondary thalamic cyst as well. After resection of the cerebellar mass, clinical picture returned to normal and edematous findings on MRI resolved in addition to a decrease in size of the thalamic lesion on follow-up. CONCLUSION: Patients with findings of cystic cerebral calcifications on CT scans should be followed cautiously for acute deterioration because surgery is indicated in cases having signs of increased intracranial pressure.

Cystic olfactory schwannoma of the anterior cranial base.

Olfactory groove schwannomas are extremely uncommon and less than 30 cases are reported in the literature. We report a 21-year-old developmentally-retarded boy who experienced severe headache and aggressive behaviour for 5 months. Imaging showed a cystic mass in the subfrontal region, which was removed by craniotomy. The lesion had a vascular supply from the anterior ethmoidal arteries and it was noted to be attached to the right olfactory nerve. It was removed completely and histology showed it to be a schwannoma. Olfactory groove schwannomas are rare lesions and should be differentiated from meningiomas, neuroblastomas and dural-based metastatic lesions of the anterior cranial base.

Cerebral abscess caused by Nocardia nova.

Primary cerebral nocardiosis is very rare and the subgroup of the isolate has usually been defined as Nocardia asteroides. We report an unusual patient with a cerebral abscess whose cultures were typical for N. nova. It was first isolated from an HIV-1 infected individual and has a distinctive antibiotic susceptibility among the species of N. asteroides. Aggressive surgical and medical intervention is a must for these unusual pathogens. Although our surgical strategy was successful, treatment of nocardial cerebral abscess is quite hard and long lasting, and N. nova in particular necessitates a specific antibiotic regimen.

Dural sinus thrombosis following head injury: report of two cases and review of the literature.

Dural sinus thrombosis (DST) usually involves the sagittal, transverse and sigmoid sinuses and is more common in women due to pregnancy, puerperium and oral contraceptive use. Other etiologies include coagulopathies, infection and head injury. We have present two DST cases following head injury. The first case was a 35-year-old man hospitalized because of one-week history of headache and repeated vomiting after a mild head injury. Thrombosis of the superior sagittal sinus, right transverse and sigmoid sinuses and right jugular vein was determined on angiography. The second case was a 25- year-old man operated on for epidural hematoma at the posterior fossa. Meningitis developed and an abducens palsy was determined. Magnetic resonance imaging demonstrated thrombosis of the right transverse and sigmoid sinus. Low molecular weight heparin was administrated for three months. Both cases had good recovery, but one had recanalisation of the thrombosis. Intracranial hematomas, depressed skull fracture or skull fracture that cross the sinus can obstruct the blood flow in the sinus. Moreover, closed head injury may cause to DST. Because of undefinitive pathophysiology, a consensus was not obtained on overall strategy concerning conservative, radiosurgical, or surgical therapy yet.

Delayed chiasmal herniation after transsphenoidal removal of a pituitary adenoma - case report.

We report a 41-year-old woman who experienced visual deterioration after successful removal of a pituitary adenoma. Possible mechanisms of this visual deterioration and contribution of chiasmal herniation into the sella as well as defect in the diaphragma sellae are discussed with emphasis on the regulation of medical treatment for pituitary adenomas. We conclude that medical therapy after pituitary surgery should be carefully managed together with periodic visual examinations.

Late angiographic and clinical follow-up results of 100 consecutive aneurysms treated with Onyx reconstruction: largest single-center experience.

We present the long-term clinical and angiographic follow-up results of 100 consecutive intracranial aneurysms treated with Onyx liquid embolic system (MTI, Irvine, Calif.), either alone or combined with an adjunctive stent, in a single center. A total of 100 aneurysms in 94 patients were treated with endosaccular Onyx packing. Intracranial stenting was used adjunctively in 25 aneurysms including 19 during initial treatment and 6 during retreatment. All aneurysms except two were located in the internal carotid artery. Of the 100 aneurysms, 35 were giant or large/wide-necked, and 65 were small. Follow-up angiography was performed in all 91 surviving patients (96 aneurysms) at 3 and/or 6 months. Follow-up angiography was performed at 1, 2, 3, 4 and 5 years in 90, 41, 26, 6 and 2 patients, respectively. Overall, aneurysm recanalization was observed in 12 of 96 aneurysms with follow-up angiography (12.5%). All 12 were large or giant aneurysms, resulting in a 36% recanalization rate in the large and giant aneurysm group. One aneurysm out of 25 treated with the combination of a stent and Onyx showed recanalization. There was also no recanalization in the follow-up of small internal carotid artery aneurysms treated with balloon assistance only. At final follow-up, procedure- or device-related permanent neurological morbidity was present in eight patients (8.3%). There were two procedure-related and one disease-related (subarachnoid hemorrhage) deaths (mortality 3.2%). Delayed spontaneous asymptomatic occlusion of the parent vessel occurred in two patients, detected on routine follow-up. Onyx provides durable aneurysm occlusion with parent artery reconstruction resulting in perfectly stable 1-year to 5-year follow-up angiography both in small aneurysms treated with balloon assistance only (0% recanalization rate) and large or giant aneurysms treated with stent and Onyx combination (4% recanalization rate). Endosaccular Onyx packing with balloon assistance may not be adequate for stable long-term results in those with a large or giant aneurysm. However, the recanalization rate of 36% in these aneurysms is better than the reported results with other techniques, i.e., coils with or without adjunctive bare stents.

[Global cerebral ischemic findings in a woman who attempted to commit suicide by hanging]. / Asilarak intihar girisiminde bulunan kadin olguda global serebral iskemi bulgulari.

We will discuss clinical and radiological findings of a woman who attempted suicide by hanging. We report a 19-year-old women attempted suicide by hanging herself. There was no known period of global brain ischemia. She had a score of 7 on the Glasgow coma scale. CT scan showed bitemporal hippocampal atrophy and SPECT showed non-activated area on right temporal and temporo-occipital regions. There has been few reports relating to the involvement of the brain as documented on CT and SPECT. Hanging leads to global hypoxic damage resulting in hypo-perfusion changes mainly cerebral in temporal lobes and atrophy.

Treatment of internal carotid artery aneurysms with a covered stent: experience in 24 patients with mid-term follow-up results.

BACKGROUND AND PURPOSE: We present our preliminary experience, including mid-term angiographic and clinical follow-up results, with an alternative technique for the endovascular treatment of intracranial aneurysms in a series of patients. This new method, previously described in anecdotal case reports, consists of endovascular deployment of an artificial vessel graft (stent graft or covered stent) in the parent vessel to exclude the intracranial aneurysm sac from circulation. METHODS: Twenty-five internal carotid artery (ICA) aneurysms in 24 patients were successfully treated by using a Jostent coronary stent graft deployed in the parent artery across the aneurysm neck. All except four aneurysms were extradural, located in the petrous or cavernous portion of the ICA. The four intradural aneurysms were located in the carotico-ophthalmic region. Seventeen aneurysms in 16 patients occurred posttraumatically, secondary to motor vehicle accidents or surgical injury. RESULTS: Twenty-three aneurysms were immediately excluded from circulation after stent graft placement. In two aneurysms, a slow contrast material filling (endoleak) into the aneurysm cavity was observed immediately after treatment. One was thrombosed, as shown by late control angiography; in the other one, a second larger bare stent was used to appose the stent graft's distal end to the ICA wall, thus sealing the endoleak into the distal graft. No technical adverse event, including vessel dissection, vessel perforation, or thromboembolism, occurred with or without clinical consequence. No mortality or morbidity developed during or after the procedure, including the follow-up period. Two-year control angiography in one patient, 1.5-year control angiography in two patients, 1-year control angiography in six patients, and 6-month control angiography in 12 patients were performed, revealing reconstruction of the ICA with no aneurysm recanalization. All symptoms resolved after treatment in the patients who had initially presented with mass effect. CONCLUSION: Initial anatomic, clinical and mid-term follow-up results in this small series of patients are encouraging. This technique has been proved to have potential in the reconstructive treatment of intracranial aneurysms. Further research and development are needed to optimize the stent graft technology for the cerebrovascular system.

Cerebellar abscess caused by Shewanella putrefaciens.

We report a case of cerebellar abscess secondary to chronic otitis by caused by Shewanella putrefaciens and localized in the cerebellar hemisphere, in a paediatric patient.

Prognostic value of interleukin-1 beta levels after acute brain injury.

Traumatic injury to central nervous system results in the production of inflammatory cytokines via intrinsic mechanisms by neurons, astrocytes and microglia, and extrinsic mechanisms by infiltrating macrophages, lymphocytes and other leukocytes. Interleukin-1 beta is the key mediator of the acute inflammatory host response. While this response is necessary for resolution of the pathologic event, the toxic nature of many of its products can cause significant tissue damage. We analyzed serum interleukin-1 beta levels by enzyme-linked immunosorbent assay in 48 patients with solitary head injury who were transported to our clinic immediately after trauma. We categorized the patients according to their initial Glasgow coma scores in three groups, and compared their serum interleukin-1 beta values both with their Glasgow coma initial and outcome scores. This study helped to provide quantitative data to estimate clinical impressions and prognosis after head injury.

Neuroprotective effects of propofol following global cerebral ischemia in rats.

Propofol has cerebral vascular and metabolic effects similar to those of barbiturates, and it is used to maintain neurosurgical anesthesia because it reduces cerebral metabolic rate, cerebral blood flow, and intracranial pressure. Although the use of propofol as a cerebral protectant during certain neurosurgical procedures has been advocated, consensus has not been reached as to a protective effect of propofol on cerebral ischemia. In this study we observed the neuroprotective effects of propofol during global cerebral ischemia-reperfusion injury by the use of four-vessel occlusion method in a rat model. We measured the levels of malondialdehyde as a marker of lipid peroxidation in ischemic tissue, and the results indicate that propofol plays a role in the inhibition of neuronal death induced by brain ischemia.