The analysis of long-term follow-up screening in patients with surgically treated intracranial aneurysms.

AIM: To understand the late anatomical results of surgically treated intracranial aneurysms (IA's) and to investigate the incidence of recurrent, de novo aneurysms, the natural history of residual aneurysms, and the morphological changes in temporarily clipped vascular segments. MATERIAL AND METHODS: A total of 117 patients underwent screening with digital subtraction angiography (DSA) or computed tomographic angiography (CTA) in a range of 3 - 13 years. Late angiographies were evaluated in terms of recurrence, change in known residua, the presence of de novo aneurysms and the morphological changes in temporarily clipped vessels. We also analysed the cumulative data including previously published results. RESULTS: In the long-term DSA, three residual aneurysms were observed to be enlarged while four remnants showed no morphological change. In one patient, spontaneous obliteration was seen. No recurrent aneurysm was detected. One de novo aneurysm was observed. We did not find any morphological change in 71 temporarily clipped vascular segments. CONCLUSION: Our data demonstrates that completely occluded aneurysms could remain stable even years later. Most of the small neck residues appeared to remain unchanged or even be thrombosed but they should be carefully followed. The incidence of de novo aneurysms might be expected to be lower.

Cerebrospinal fluid cystatin C levels following treatment for aneurysmal subarachnoid hemorrhage.

AIM: To investigate the changes of cerebrospinal fluid (CSF) cystatin C (CC) levels associated with the postoperative ischemic conditions and prognostic outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). MATERIAL AND METHODS: The study group consisted of 40 patients with microsurgically clipped intracranial aneurysms (IA's) and 22 control CSF samples. In patients, CSF samples were taken from the lumbar intrathecal catheter for CC measurement, at the beginning of operation, immediately after the operation (early postoperative), and the first postoperative day (late postoperative). RESULTS: CC levels in three periods were significantly higher in patients with Hunt-Hess scores of 4, 5 than 1, 2, 3. There was a significant difference between the CC concentrations on the first postoperative day and controls. In patients who developed focal cerebral ischemia, CC levels at early and late postoperative periods were significantly higher than the group without ischemia. In addition, patients with poor prognostic outcome (GOS score of 1, 2, 3) had significantly higher levels of CC in all three periods than that of patients with good outcome (GOS score of 4, 5). CONCLUSION: The raised CSF CC concentrations appear to be associated with the severity of bleeding, intraoperative ischemic events and poor prognostic outcome in patients with aneurysmal SAH.

Multiple spinal cavernous malformations in Klippel-Trenaunay-Weber syndrome.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare, congenital vascular disorder characterized by cutaneous haemangiomas, venous varicosities, and hypertrophy of the osseous and soft tissue. Various vascular anomalies of the central nervous system have been described in this syndrome. Two previous associations between KTWS and spinal cord cavernous malformations have been reported in the English literature. In this report, we present a patient in whom multiple cavernous malformations located in the conus medullaris region and cauda equina were associated with KTWS. General physical examination as well as neuroradiological and operative findings are described.

The results of radiological screening in asymptomatic at-risk members of intracranial aneurysm families from the Turkish population.

AIM: To better understand the characteristics of familial intracranial aneurysms (FIA) and to investigate the yield of screening in asymptomatic, at-risk individuals in intracranial aneurysm (IA) families within the Turkish population. MATERIAL AND METHODS: We identified six families in which at least two first-degree relative members had an IA in our database. In five families, we screened 95 first-degree relatives of affected members. RESULTS: As a result of our screening, we identified 9 unruptured aneurysms in 95 individuals for a total yield of 9.4%. There was a prominent female preponderance in affected family members and nearly half of the aneurysms were on the middle cerebral artery (MCA). Most of the affected relatives were siblings. CONCLUSION: Our results support a general recommendation to screen first-degree relatives of IA patients from families with two or more cases of IA. Familial aggregation of IA's is not only useful in identifying asymptomatic individuals harboring unruptured aneurysms but also implicates a genetic contribution to the pathogenesis of this disease in different patient populations.

Multiple middle meningeal artery aneurysms associated with fistulous galenic arteriovenous malformation: a case report.

Non-traumatic multiple saccular aneurysms of the middle meningeal artery are extremely rare lesions. In our case the patient was a 51-year-old woman admitted with complaints of progressive headache. Magnetic resonance imaging showed a dilatation of the vein of galen malformation. Cerebral angiography revealed multiple saccular aneurysms of the middle meningeal artery and fistulous type of galenic arteriovenous malformation. Only one case of non-traumatic multiple middle meningeal artery aneurysms has been reported until now and this case of multiple multiple middle meningeal artery aneurysms associated with the fistulous type of galenic arteriovenous malformation is unique.

Assessment of adjacent segment degeneration in and between patients treated with anterior or posterior cervical simple discectomy.

AIM: The authors compared the incidence of radiologically documented and/or symptomatic adjacent segment degeneration in and between patients who underwent anterior or posterior single-level, simple discectomy. MATERIAL AND METHODS: 79 patients were clinically and radiologically examined for adjacent segment degeneration (ASD). The results were compared to evaluate which approach was predominant for adjacent segment disc degeneration. RESULTS: ASD was found in 57 of a total of 79 patients. 24% of the patients demonstrated clinical and radiographic evidence and 48% of the patients demonstrated only radiographic evidence of ASD. Both anterior and posterior single level simple discectomy had similar rates for adjacent segment disease (p>0.05) . ASD was found to appear earlier in patients who had anterior cervical discectomy (4.78 vs 9.85 years, p:0.005). Symptomatic evidence of ASD was found to start earlier than radiological evidence of ASD (4.67 vs 7.63 years p:0.003). Radiographic evidence of adjacent segment degeneration was observed more commonly compared to symptomatic evidence of ASD (38 vs 19 patients p:0.002). CONCLUSION: Although, radiographic and clinical evidence of ASD is inevitable for both simple cervical discectomy procedures, neither anterior nor posterior simple cervical discectomy is the predominant approach for causing ASD.

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury.

AIM: Debate continues as to whether decompressive craniectomy (DC) is an effective treatment for severe traumatic brain injury (STBI). DC is mostly used as a second tier treatment option. The aim of this study was determined whether early bilateral DC is effective as a first tier treatment option in patients with STBI. MATERIAL AND METHODS: The study compared two groups. Group 1 comprised 36 STBI patients for whom control of intracranial pressure (ICP) was not achieved with conservative treatment methods according to radiological and neurological findings. These patients underwent bilateral or unilateral DC as a second tier treatment. Group 2 comprised 40 STBI patients who underwent early bilateral DC as a first tier treatment. RESULTS: Group 2 patients had a mean better outcome than Group 1 patients especially for patients with a GCS 6-8. Postoperative ICP was lower in Group 2 patients than Group 1 patients. CONCLUSION: This study indicates that early bilateral DC can be effective for controlling ICP in STBI patients. It is likely the favorable outcome results for Group 2 patients reflects the relatively short time between trauma and surgery. Therefore, these data indicate early bilateral DC can be considered as a first tier treatment in STBI patients.

Retroclival arachnoid cyst presenting with haemorrhage: a brief report of a special case.

Retroclival arachnoid cysts are rarely reported. A 40-year-old woman had a sudden onset of occipitocervical pain. Magnetic resonance imaging (MRI) revealed a cystic mass lesion located in the retroclival region and complicated with intracystic haemorrhage. At operation, by a right lateral suboccipital approach, an old, intracystic haemorrhage was aspirated and the cyst wall removed totally. This report demonstrated the second case of retroclival cyst presenting with symptomatic spontaneous intracystic haemorrhage.

Intra-operative brain tumor detection using elastic light single-scattering spectroscopy: a feasibility study.

We have investigated the potential application of elastic light single-scattering spectroscopy (ELSSS) as an adjunctive tool for intraoperative rapid detection of brain tumors and demarcation of the tumor from the surrounding normal tissue. Measurements were performed on 29 excised tumor specimens from 29 patients. There were 21 instances of low-grade tumors and eight instances of high-grade tumors. Normal gray matter and white matter brain tissue specimens of four epilepsy patients were used as a control group. One low-grade and one high-grade tumor were misclassified as normal brain tissue. Of the low- and high-grade tumors, 20 out of 21 and 7 out of 8 were correctly classified by the ELSSS system, respectively. One normal white matter tissue margin was detected in a high-grade tumor, and three normal tissue margins were detected in three low-grade tumors using spectroscopic data analysis and confirmed by histopathology. The spectral slopes were shown to be positive for normal white matter brain tissue and negative for normal gray matter and tumor tissues. Our results indicate that signs of spectral slopes may enable the discrimination of brain tumors from surrounding normal white matter brain tissue with a sensitivity of 93% and specificity of 100%.

CT angiography and perfusion imaging in patients with subarachnoid hemorrhage: correlation of vasospasm to perfusion abnormality.

INTRODUCTION: We retrospectively evaluated computed tomography angiography (CTA) and perfusion imaging (CTP) of patients with aneurysmal subarachnoid hemorrhage (SAH) for any correlation between degree of vasospasm and perfusion deficit. MATERIALS AND METHODS: Sequentially performed CTP and CTA of 41 patients at least at the third day of postbleeding were reviewed for vasospasm and perfusion deficit throughout the anterior and middle cerebral arteries and corresponding territories. Vasospasm was noted comparing the contralateral normal ones or extradural components of the vessel itself and graded to negative, mild, moderate, and severe as luminal narrowing none, <25%, between 25% and 50%, and >or=50%, respectively. CTP abnormality was noted using cerebral blood flow and volume and mean transit time maps. RESULTS: Of 41 patients, 20 had no vasospasm; 15 had mild to moderate and six had severe vasospasm. Three of 20 patients with no vasospasm (15%), four of 15 patients with mild to moderate vasospasm (26%), and five of six patients with severe vasospasm (83%) had perfusion abnormality. Perfusion abnormalities noted were ischemia, infarction, and hyperperfusion. Perfusion abnormality without vasospasm was observed in the watershed areas and adjacent to sulcal clots. CONCLUSION: In SAH patients, if there is a macrovascular vasospasm with luminal narrowing >or=50%, there is a high likelihood (83%) of perfusion abnormality in the territory of the vasospastic vessel. There may also be perfusion abnormality without macrovascular vasospasm in the watershed areas or in the vicinity of sulcal clots.

CSF rhinorrhea from a transclival meningocele: a case report.

The most common site of cerebrospinal fluid (CSF) leakage is through the floor of the anterior fossa, which communicates with the ethmoid or frontal sinuses or with the nasal fossa. The sphenoid sinus is rarely implicated as a source of spontaneous CSF fistula. Transclival meningocele is an extremely rare lesion. A 36-year-old woman with a 1-year history of intermittent CSF rhinorrhea was found to have a transclival meningocele. The diagnosis of transclival meningocele was made by magnetic resonance (MR), 3-dimension-computerized tomography (CT). At operation, by a transsphenoidal approach, the transclival meningocele was packed with fasia lata graft, fat tissue, and bio-glue. This is the third case of transsphenoidal transclival meningocele producing rhinorrhea in an adult. Transclival meningocele should be taken into consideration in patients with spontaneous CSF rhinorrhea.

A case of extraventricular neurocytoma of the spinal cord.

Central neurocytoma is a rare neuroectodermal tumor generally found in young adults. It mainly originates from lateral ventricles. Extraventricular location of this kind of tumor, especially spinal cord involvement, is extremely rare. This article is the ninth case of central neurocytoma derived from the spinal region, and includes a review of the literature. The patient in this case is a 49-year-old woman presenting with C3-C5 spinal mass with typical histopathologic findings and low MIB-1 index.

Epithelioid hemangioendothelioma derived from the spine region: case report and review of the literature.

Epithelioid hemangioendotheliomas (EHE) are rare vascular tumors which generally originate from soft tissues and visceral organs. Primary bone EHEs, especially those occurring in the spine region, are extremely rare. Our case is that of a 30-year-old man who was admitted to hospital with low back pain, difficulty in walking, post-voiding urinary incontinence and numbness in the caudal area. X-ray showed a lytic process affecting the vertebra L2 and collapse of L1. Vertebrectomy of L1 and gross total tumor resection were performed. Histopathological and immunohistochemical findings of the tumor tissue supported the diagnosis of EHE. The case, which to the best of our knowledge is only the fifth such reported case, is presented with its clinicopathological findings and a review of the literature.

Tongue tremor in brainstem pilocytic astrocytoma.

An isolated tremor of the tongue developed in a 22-year-old female patient in a minimally conscious state. The patient was diagnosed with brainstem pilocytic astrocytoma. A widespread lesion of the brainstem and cerebellum was evident on cranial magnetic resonance imaging. The pathophysiology of isolated tongue tremor is discussed with the magnetic resonance findings and the relevant literature.

Multiple anterior inferior cerebellar artery aneurysms associated with an arteriovenous malformation: case report.

BACKGROUND: Multiple aneurysms of the proximal part of the anterior inferior cerebellar artery (AICA) associated with a distal arteriovenous malformation (AVM) are extremely rare lesions. METHODS: A 52-year-old man was admitted because of sudden headache. Neurological examination revealed ataxia. Computed tomography scan showed a right cerebellar and subarachnoid hemorrhage. Vertebral angiograms demonstrated 3 small aneurysms at the proximal part of the AICA and distal AVM. RESULTS: A right-sided lateral retromastoid suboccipital craniectomy was performed. We observed strangulation and obliteration at the AICA due to multiple clipping for aneurysms. Thus, aneurysms could not be clipped. At 11 years after bleeding, vertebral angiograms showed that 3 aneurysms had slightly enlarged but the AVM remained unchanged. To date, the patient is still doing well except for dizziness. CONCLUSION: This association is very rare at the AICA level, and definitive treatment of this association is sometimes complex.

Role of decompressive surgery in the management of severe head injuries: prognostic factors and patient selection.

Decompressive surgery or craniectomy (DC) is a treatment option, which should be considered when the intracranial pressure (ICP) cannot be treated by conservative methods. The purpose of this study was to evaluate the benefits of decompressive craniectomy in patients with intractable posttraumatic intracranial hypertension and to evaluate the patient selection criteria for this management protocol. In this study, 100 patients with severe head injuries were involved. All patients were treated according to the European Brain Injury Consortium (EBIC) guidelines for severe head injuries and were assessed based on individual initial Glasgow Coma Scores (GCS), age, Glasgow Outcome Score (GOS), presence of systemic injury, changes in ICP, presence of mass lesion and the right timing for DC. All patients presented with a GCS of 8 or below. Based on their initial GCS, the patients were divided in two groups of 60 (group I with GCS 4-5) and 40 (group II with GCS 6-8) in each, respectively. Prognosis was evaluated according to the (GOS). After treatment with DC, 84 of the patients (84%) showed unfavorable and 16 (16%) showed favorable outcomes. In group I, 58 patients (96.6%) showed unfavorable and two (3.4%) showed favorable outcomes. In group II, 26 (65%) patients showed unfavorable and 14 (25%) showed favorable outcomes. The importance of initial GCS and age in patient outcomes were statistically significant. The presence of systemic injuries or mass lesions in outcomes were not statistically significant. Based on our findings, we conclude that patients with Glasgow Coma Scores of 6-8 are the best candidates for DC treatment.

Spontaneous decrease in the size of a residual thoracic intradural lipoma.

Intradural spinal lipomas of thoracic cord are quite rare. It is known that lipomas are hamartomas, which change their size with alterations of body fat. An 18-year-old male patient, with a thoracic intradural lipoma showing spontaneous decrease in the size of a residual lipoma and tethering of the cord 4 years after surgery, is presented in this report.

Aneurysmal bone cyst of the orbit.

Aneurysmal bone cysts of the skull are rare, and orbital involvement of these cysts is even less frequent. We present CT, MR imaging, and histopathologic findings of an aneurysmal bone cyst of the orbit in a 13-year-old female adolescent. The tumor mainly involved the frontal bone. MR imaging findings of the aneurysmal bone cyst of the skull were highly suggestive of the diagnosis.