Mortality Factors in Crush Syndrome.

BACKGROUND: Crush Syndrome is a major cause of morbidity and mortality following large-scale catastrophic earthquakes. Since there are no randomized controlled studies on Crush Syndrome, knowledge on this subject is limited to expert experience. The primary objective is to analyze the epidemiological and demographic characteristics, clinical outcomes, and mortality factors of earthquake victims after the Pazarcik and Elbistan earthquakes on February 6, 2023. METHODS: This cross-sectional and observational retrospective study evaluated 610 earthquake victims who presented to our center between February 6 and April 30, 2023. Among these patients, 128 with Crush Syndrome were included in the study. Patient information was gathered from hospital records during their stay and from national registries upon referral. The primary outcome was to identify risk factors for mortality. Demographic and laboratory data were analyzed by acute kidney injury (AKI) stages; mortality-affecting factors were identified through regression analysis. RESULTS: Of the 128 Crush Syndrome patients (100 adults, 28 children), 64 were female. The AKI rate was 32.8%. Among patients with AKI, the frequency of hemodialysis requirement was 69%, and the mortality rate was 14.2%. The overall mortality rate for patients with Crush Syndrome was 4.6%, compared to 3.9% (19/482) in earthquake victims without Crush Syndrome (p=0.705). Notably, low systolic blood pressure at admission was the only factor significantly affecting mortality in Crush Syndrome patients (Hazard Ratio [HR]: 1.088, p=0.021, 95% Confidence Interval [CI]). CONCLUSION: Our study highlights low systolic blood pressure upon admission as a significant risk factor for increased mortality in Crush Syndrome patients. This finding may contribute to the literature by emphasizing the importance of monitoring blood pressure under rubble and administering more aggressive fluid therapy to patients with low systolic blood pressure.

Malignant congenital orbital teratoma: Glioblastoma multiforme with primitive neuronal pattern and choroid plexus papilloma: A rare diagnosis at an unusual age.

Childhood orbital teratomas are usually congenital lesions that are most often present at birth with progressive, massive unilateral proptosis. During the routine controls of 27-year-old woman between 26-27th weeks of pregnancy her fetal ultrasonography (USG) revealed a mass in the eye of the fetus, and termination was recommended. The family refused the termination option and in the 37th week of pregnancy, vaginal delivery is performed in an external medical center. The mass in the baby's eye was surgically removed. Microscopic examination revealed disorganized ocular tissues, adipose tissue, microcalcification, nerve plexuses as well as areas of neuronal nodules including hypercellular areas, palisatic necrosis, and microvascular proliferation. The immunprofile--patchy GFAP staining in the areas of cellular epithelioid and spindled cells that also show an focal and sparse expression p53 staining and a high proliferation rate in Ki67 staining--confirmed the hematoxylin-eosin (HE) impression of a teratoma with a component of glioblastoma (GBM). In this unique presentation of a malignant orbital teratoma with a GBM, we have identified three tumor components: (1) GBM component, (2) nodules of neuroglial tissue with mature neurons and BRAF mutation, and (3) papillary proliferation possibly representing a choroid plexus papilloma.

Effect of decompressive hemicraniectomy in patients with acute middle cerebral artery infarction

Background/aim: We aimed to determine in which cases this procedure may be more effective based on the data of patients who underwent decompressive hemicraniectomy (DHC). Material and methods: Overall, 47 patients who underwent DHC due to acute middle cerebral artery (MCA) infarction between January 2014 and january 2019 were retrospectively investigated. These patients were divided into two groups: those who died after DHC (Group A) and those who survived DHC (Group B). The groups were compared in terms of various parameters. We investigated whether the patient's modified Rankin scale (mRS) status changed depending on age (> 60 and < 60 years). Results: The median age of all patients was 65 (37­80) years; groups A and B had median ages of 66.5 (37­80) and 61 (44­79) years (p = 0.111), respectively; 55.3% patients were male. The elapsed times until hospitalization after the onset of symptoms were 4.5 and 3 h in groups A and B, respectively (p = 0.014). The median GCS score at the time of admission was 7 (5­12) and 10 (8­14) in groups A and B, respectively (p = 0.0001). At the time of admission, 63.3% patients in group A had anisocoria, whereas no patient in group B had anisocoria (p = 0.0001). In postoperative period, 40% patients in group A and all patients in group B received AC/AA treatment. The survival of patients aged < 60 and > 60 years who underwent DHC for MCA infraction was 61.5% and 26.5%, respectively (p = 0,041). The median mRS of patients < 60 and > 60 years were 4 (1­6) and 6 (1­6), respectively (p = 0.018). Conclusion: Age, DHC timing, and elapsed time until hospitalization or access to treatment directly affect the functional outcome and survival in MCA-infarcted patients who underwent DHC. In patients in whom the medical treatment fails, early DHC administration will increase survival without waiting for neurological worsening once herniation is detected radiologically.

Treatment of Cavernous Sinus Hemangiomas with Gamma Knife Radiosurgery as a Primary and Sole Therapy.

AIM: To evaluate the effectiveness of Gamma Knife radiosurgery (GKRS) as the primary and only therapy for the treatment of cavernous sinus hemangiomas (CSH) and to report the tumor volume dynamics, course of symptoms, and complications after stereotactic radiosurgery. MATERIAL AND METHODS: A total of 10 CSH patients were treated with GKRS using a median margin dose of 14.2Gy (range 13-16Gy). The median follow-up period was 42 months (range 12-85 months). Tumor volumes were calculated from magnetic resonance images before treatment and compared with those after treatment. RESULTS: Prior to the treatment, all patients complained of headache and retro-orbital pain, and six patients complained of diplopia due to abducens nerve paralysis. Within six months of treatment, all patients declared some improvement in headache and retro-orbital pain, and abducens nerve paralysis recovered fully in all six patients. At the first-year follow-up, at least 74% decrease in tumor volume was noted with average tumor volume reduction of 90.2% in all treated patients. Tumors less than 6 cm3 in volume nearly disappeared at 24 months. No tumor progression, re-growth, or radiation-induced adverse effects were noted in our patients. CONCLUSION: Characteristic radiological features that enable identification of CSH avert the need for an open biopsy for diagnosis. Under suitable circumstances, GKRS may be considered as the primary and only therapy for CSH. GKRS has favorable outcomes in the treatment of CSH, demonstrating good tumor shrinkage, symptom recovery, and low incidence of side effects.

The effects of infusion of perineural pregabalin in the experimentally created sciatic nerve anastomosis in rats.

INTRODUCTION AND OBJECT: The aim of our study was to assess the effect of perineural pregabalin administration on the success of coaptation in experimental rat sciatic nerve anastomosis by measuring the expression of anti-inflammatory cytokine TGF-ß. It is thus to provide alternative solutions to this problem which we often see in clinical practice and whose results are not satisfactory. METHODS: In our study, 40 adult, male, Sprague-Dawley rats; 5 groups were randomly assigned. Group 1: This group's sciatic nerves were dissected and the surgical site was sutured. Group 2: Rats whose sciatic nerves are sectioned transversely through the full-thickness and end-to-end anastomosis is performed and no additional procedure is performed. Group 3: Intraperitoneal administration of 30 mg / kg pregabalin for 7 days with anastomosis. Group 4: 30 mg/kg pregabalin given orally for 7 days with anastomosis. Group 5: Given 10 microliters / h pregabalin subcutaneous perineural infusion for 7 days with anastomosis. After 60 days of surgery, the experiment was terminated with high dose thiopental (50 mg/kg). The right sciatic nerves of all animals were taken and sections obtained were examined immunohistopathologically. RESULTS: Inflammation was significantly less in the 5th group than in the other groups. TGF-ß expression in Groups 3, 4, and 5 is significantly higher than Groups 1 and 2, which also supports this situation. Although the expression in group 5 was not statistically significant, the number of TGF-ß expression was higher than Groups 3 and 4. In terms of immunohistochemical properties; 1 to 3, 1 to 4, 1 to 5, 2 to 5 groups were statistically significant (p <0,05). CONCLUSIONS: In conclusion, perinural infusion of pregabalin into the anastomotic region has not been previously tried in the literature and it has been found that immunohistochemistry provides positive contributions to healing of anastomosis. More research is needed to demonstrate that this effect is superior to other methods of administration of the drug. KEY WORDS: Anastomosis, Peripheral nerve, Perineural, Pregabalin, Sciatic nerve.

Effect of gabapentin on primary surgical treatment of experimental sciatic nerve injury in rats.

BACKGROUND: The aim of our study is to minimize the morbidity related to nerve injury by determining the protective effects of gabapentin in experimental sciatic nerve injury and end-to-end anastomosis model in rats and to guide clinical studies on this subject. METHODS: In our study, 40 adult male Sprague-Dawley rats were randomly divided into the following five groups: I: Only surgical intervention was applied; II: The sciatic nerve was cut properly and was repaired by end-to-end anastomosis. No additional procedure was performed; III: A single dose of gabapentin at 30 mg/kg was given after anastomosis; IV: 30 mg/kg gabapentin was given for 3 days after anastomosis; and V: 30 mg/kg gabapentin was given for 7 days after anastomosis. The experiment was terminated with high-dose thiopental (50 mg/kg) 60 days after the surgical intervention. The right sciatic nerve was taken from all animals. The obtained sections were examined immunohistopathologically. RESULTS: Immunohistochemical properties and Schwann cell proliferation were found to be statistically significantly lower in the control group than in the other groups. Schwann cell proliferation was higher in Group 3 than in Group 5. Immunohistochemical changes were significantly lower in Group 4 than in Group 3. Axonal degeneration was also higher in Group 4 than in Group 3. CONCLUSION: Gabapentin promotes neurological recovery histopathologically in peripheral nerve injury due to its neuroprotective properties. Our study results show that gabapentin can be used as an adjunctive therapy to primary surgical treatment after peripheral nerve injury.

Multiple Extraneural Metastases of Anaplastic Oligodendroglioma.

Oligodendrogliomas (ODGs) is a diffuse glial tumor that constitutes 4.2% of all brain tumors. Extraneural metastases, sometimes seen in glioblastoma multiforme, are extremely rare in ODG. In this report, we present a 63-year-old male patient who was diagnosed with Grade 3 ODG and had an intracranial mass resected in our clinic 4 years ago. The subject now presented with low back pain and was found to have widespread metastases. The prolongation of patient survival by current treatment regimens has revealed a growing number of ODG patients with metastases. We believe that back pain complaints in patients with ODG should be viewed as an indicator of metastasis.

Brain Metastasis Of Penile Angiosarcoma.

Angiosarcoma is a rare malignancy originating from vascular endothelial cells. Brain metastasis of aniosarcomas are uncommon up to the literature. Penile angiosarcomas are also seldom among all anjiosarcomas. A case with penile angiosarcoma with confirmed brain metastasis is aimed to be reported and contribute to the literature for similar cases.

Safety and Efficacy of Ventriculostomy Procedures under Dual Antiplatelet Therapy in Patients Treated With Stent Assisted Coiling In Subarachnoid Hemorrhage.

AIM: Stent assisted coilling (SAC) is an alternative in the treatment of ruptured aneurysms. Stenting requires the use of dual antiplatelet agents. Hydrocephaly is a complication of subarachnoid hemorrhage (SAH) requiring ventriculostomy. Antiplatelet treatment reveal a risk of hemorrhage in ventriculostomy. Anti-aggregant effect starts at least four hours after the initial doses of treatment. However, in many studies, ventriculostomy was performed before antiplatelet treatment and the hemorrhagic complications were related to the procedure. The aim of this study was to determine the risk of ventriculostomy related hemorrhage in patients with impaired thrombocyte function and to contribute to the literature. MATERIAL AND METHODS: Between 2011 and 2016, 53 patients treated with SAC due to SAH in our clinic were retrospectively evaluated. Hemorrhagic complication risks due to antiplatelet therapy related to ventriculostomy were retrospectively evaluated Results: All of the ventricular catheter procedures were performed at least 1 day after the dual therapy (in average 4,3 days after SAC). On 5 patients 1 ventriculostomy was performed, on 2 patients 2, and on 1 patient 6 ventriculostomies were performed. Although radiological hemorrhage was present on the catheter tract in 4 patients, no temporary or permanent neruologic deficit was observed. CONCLUSION: Impaired thrombocyte functions pose a risk in ventriculostomy. Also, evaluating the risk of hemorrhage before the antiplatelet treatment reaches its full effect may lead to false results. Studies with small patient groups with antiagregant therapy and impaired thrombocyte functions also contribute to the literature. Larger studies regarding this subject are needed.

Usefulness of End-to-Side Bridging Anastomosis of Sural Nerve to Tibial Nerve: An Experimental Research.

OBJECTIVE: Repair of sensorial nerve defect is an important issue on peripheric nerve surgery. The aim of the present study was to determine the effects of sensory-motor nerve bridging on the denervated dermatomal area, in rats with sensory nerve defects, using a neural cell adhesion molecule (NCAM). METHODS: We compared the efficacy of end-to-side (ETS) coaptation of the tibial nerve for sural nerve defect repair, in 32 Sprague-Dawley rats. Rats were assigned to 1 of 4 groups: group A was the sham operated group, group B rats had sural nerves sectioned and buried in neighboring muscles, group C experienced nerve sectioning and end-to-end (ETE) anastomosis, and group D had sural nerves sectioned and ETS anastomosis was performed using atibial nerve bridge. Neurological evaluation included the skin pinch test and histological evaluation was performed by assessing NCAM expression in nerve terminals. RESULTS: Rats in the denervated group yielded negative results for the skin pinch tests, while animals in the surgical intervention groups (group C and D) demonstrated positive results. As predicted, there were no positively stained skin specimens in the denervated group (group B); however, the surgery groups demonstrated significant staining. NCAM expression was also significantly higher in the surgery groups. However, the mean NCAM values were not significantly different between group C and group D. CONCLUSION: Previous research indicates that ETE nerve repair is the gold standard for peripheral nerve defect repair. However, ETS repair is an effective alternative method in cases of sensorial nerve defect when ETE repair is not possible.

Stubborn hiccups as a sign of massive apoplexy in a naive acromegaly patient with pituitary macroadenoma.

Pituitary apoplexy (PA) may very rarely present with hiccups. A 32-year-old man with classical acromegaloid features was admitted with headache, nausea, vomiting and stubborn hiccups. Pituitary magnetic resonance imaging (MRI) demonstrated apoplexy of a macroadenoma with suprasellar extension abutting the optic chiasm. Plasma growth hormone (GH) levels exhibited suppression (below <1 ng/mL) at all time points during GH suppression test with 75 g oral glucose. After treatment with corticosteroid agents, he underwent transsphenoidal pituitary surgery and hiccups disappeared postoperatively. The GH secretion potential of the tumor was clearly demonstrated immunohistochemically. We conclude that stubborn hiccups in a patient with a pituitary macroadenoma may be a sign of massive apoplexy that may result in hormonal remission. LEARNING POINTS: Patients with pituitary apoplexy may rarely present with hiccups.Stubborn hiccupping may be a sign of generalized infarction of a large tumor irritating the midbrain.Infarction can be so massive that it may cause cessation of hormonal overproduction and result in remission.

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.

Effects of Atorvastatin on Experimental Spinal Cord Ischemia-Reperfusion Injury in Rabbits.

AIM: Extent of secondary injury is the determinant of tissue destruction and functional worsening after primary spinal cord injury (SCI). Data have accumulated on alleviation of secondary injury in SCI from many studies on the subject. Besides its cholesterol lowering effects, statins are known to have anti-inflammatory and anti-oxidant effects which are the main targets of spinal cord research. This study aims to evaluate the effects of atorvastatin on experimental spinal cord ischemia-reperfusion injury. MATERIAL AND METHODS: Thirty adult male New Zealand rabbits were allocated into control, ischemia-reperfusion (I/R) and treatment groups. Treatment group received 5 mg/kg of atorvastatin via lavage for the preceding 14 days. Other groups received placebo during the same time period. After two weeks, animals in the I/R and treatment groups underwent abdominal temporary aorta occlusion for 30 minutes. Neurological condition of the animals was recorded during the 48 hours of observation. Afterwards, animals were sacrificed and levels of malondialdehyde, glutathione and nitric oxide in spinal cord tissue and plasma and the histopathological tissue changes were determined. RESULTS: Animals in the treatment groups demonstrated significantly better results than the I/R group regarding biochemical markers. Neurological evaluation using the Tarlov scale demonstrated significantly better results at the 48th hour in treatment group. Histopathological results were also better in the treatment groups. CONCLUSION: Results of this study demonstrate the neuroprotective effects of atorvastatin. Atorvastatin has favorable effects on biochemical markers of oxidative stress in SCI. Further studies with larger cohorts and different time periods are also needed.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

BACKGROUND AND PURPOSE: Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. MATERIALS AND METHODS: Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. RESULTS: 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3-51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. CONCLUSIONS: Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.

Efficacy of endovascular treatment and feasibility of stent-assisted coiling in the presence of severe and symptomatic vasospasm.

BACKGROUND AND PURPOSE: In patients with aneurysmal subarachnoid hemorrhage, deciding the optimal treatment strategy is challenging in the presence of severe and symptomatic vasospasm and the existing literature is limited. The purpose of this study was to evaluate the safety and effectiveness of endovascular treatment of intracranial aneurysms and the feasibility of stent-assisted coiling during severe and symptomatic vasospasm. MATERIALS AND METHODS: Fifteen consecutive patients with 18 aneurysms who underwent endovascular treatment during severe and symptomatic vasospasm were included in the study. Patient and aneurysm characteristics, treatment technique, and clinical and angiographic outcomes were retrospectively evaluated. RESULTS: Aneurysms were treated by the following techniques: single catheter coiling in 9, stent-assisted coiling in 8 (3 aneurysms with Y-configuration double stents), and balloon-assisted coiling in 1. All patients showed angiographic improvement of vasospasm after treatment including a noticeable dilation of the spastic parent arteries following deployment of the stents. According to the immediate post-treatment angiography results, 14 aneurysms (77.8%) had class I occlusion and 4 (22.2%) had class II occlusion. Three patients died during the course of subarachnoid hemorrhage. Mortality was related to the poor grade (Hunt and Hess grade V) and cardiovascular complications in two and refractory vasospasm one patient. The remaining patients had favorable clinical outcomes at follow-up (modified Rankin Scale 0-2). CONCLUSIONS: Endovascular treatment of intracranial aneurysms during severe and symptomatic vasospasm is safe and effective. Stent-assisted coiling in the presence of severe vasospasm is also feasible in wide-necked aneurysms with the additional benefits of mechanical vasodilation.

Massive Calcified Cerebellar Pilocytic Astrocytoma with Rapid Recurrence : A Rare Case.

Pilocytic astrocytomas (PAs) are World Heath Organization Grade I tumors and are most common in children. PA calcification is not a common finding and has been reported more frequently in the optic nerve, hypothalamic/thalamus and superficially located cerebral tumors. We present a cerebellar PA in a 3-year-old male patient with cystic components and massive calcification areas. The residual tumor grew rapidly after the first operation, and the patient was operated on again. A histopathological examination revealed polar spongioblastoma-like cells. Massive calcification is not a common feature in PAs and can lead to difficulties in radiological and pathological differential diagnoses.

Rapid Spontaneous Resolution of Acute Epidural Hematoma: A Case Report and Review of the Literature.

BACKGROUND: Epidural hematomas (EDH) are pathologies in which the early diagnosis and treatment are important. Resolution under 24 hours is very rare. CASE REPORT: An 11-month-old male patient was brought to the emergency department with head trauma from falling out of bed onto his back. There were no neurological deficits, except for the patient being somnolent. Computed tomography (CT) of the patient revealed subgaleal edema in the right parietal region, linear fracture and image consistent with EDH with a thickness of about 9 mm underneath fracture. A control CT was performed after 3 hours as somnolence continued in follow-up of the patient. Hematoma in the epidural region was observed to completely resolve and edema in the subgaleal region was observed to gain hemorrhagic characteristics. CONCLUSION: In total, 15 cases have been reported, including our case, in the literature with resolution less than 24 hours. Our case has the fourth fastest resolution ever reported in the English literature. We think that the most important factor in the rapid spontaneous resolution is the presence of a connection between the epidural and epicranial space, either through a fracture or cranial sutures.

A Rare Case of Concomitant Intramedullary Gangliocytoma at the Cervicomedullary Junction in Patient with Neuroendocrine Tumor of Lung.

Ganglion cell tumors (GCT) are divided into two subtypes : gangliocytoma and ganglioglioma. Intramedullary gangliocytomas are extremely rare. A 20-year-old male patient with pain of neck, who also had a previously known neuroendocrine tumor of lung, was operated for mass found in the cervicomedullary junction with a presumptive diagnosis of metastases. Only partial resection could be performed. Pathological diagnosis had been reported as gangliocytoma. Only ten cases of intramedullary gangliocytoma have been reported in the literature. Although association with scoliosis and Von Recklinghausen's disease were previously reported in the literature, no gangliocytoma case concomitant with endocrine tumor of lung have been published. Pathological study is the most important diagnostic method for gangliocytomas. Surgical excision is the primary treatment, but difficulty in total surgical tumor resection is the most important problem.

A extremely rare case of cervical intramedullary granuloma due to Brucella accompanied by Chiari Type-1 malformation.

Chiari Type-1 malformation is displacement of the cerebellar tonsils through the foramen magnum into the cervical spine and usually does not exceed the level of C2. It is 50-70% associated with syringomyelia. Nervous system involvement due to brucellosis is called neurobrucellosis, and neurological involvement rate has been reported an average of 3-5%, ranging between 3% and 25% at different series. Intramedullary abscess or granuloma due to Brucella is extremely rare. Hence far, six cases have been reported in the literature and only two of these cases were reported as intramedullary granuloma. This case is presented in order to remind the importance of the cervical cord granuloma which was presented once before in the literature and to emphasize the importance of evaluation of patient history, clinical and radiological findings together in the evaluation of a patient.