Evaluation of cervical sagittal parameters on supine magnetic resonance imaging in patients with Chiari I malformation without syringomyelia.

OBJECTIVE: The current study aimed to assess the effects of tonsillar herniation on cervical alignment in Chiari I patients without syringomyelia using new cervical sagittal alignment parameters, such as C0-2 Cobb angle, C2-7 cobb angle, T1 slope, and C2-7 sagittal vertical axis (SVA). METHODS: Two spinal surgeons independently evaluated midline T2-weighted sagittal magnetic resonance imaging findings of 28 Chiari I patients without syringomyelia and 40 patients without tonsillar herniation but with similar complaints. Thereafter, the measured C0-2 Cobb angle, C2-7 Cobb angle T1 slope, and C2-7 SVA were compared using the t-test. RESULTS: Differences in the mean values for C2-7 Cobb angle, T1 slope, and C2-7 SVA were found between Chiari I patients and those without tonsillar herniation. CONCLUSION: The current study showed that Chiari I patients were less lordotic (kyphotic) compared to subjects without tonsillar herniation.

Surgical removal of spinal mass lesions with open door laminoplasty.

OBJECTIVE: The open door laminoplasty technique has been previously used to treat cervical spondylotic myelopathy. We adapted this technique for the removal of spinal tumors all along the spinal axis. METHODS: Between January 2002 and January 2003, 17 patients with various intraspinal lesions underwent open door laminoplasty. The thoracal level was involved in 10 cases, the cervical level in 3 patients and the lumbar level in 4. Location of the tumor was intradural-intramedullary in 7, intradural-extramedullary in 6 and extradural in 4 patients. The histological diagnoses were 4 astrocytomas, 2 meningiomas, 3 neurinomas, 2 ependymomas and one case each with Ewing's sarcoma, metastasis, abcess, hemangioblastoma, arachnoid cyst and lipoma. RESULTS: All lesions were exposed using the open door laminoplasty technique and were successfully removed for intraspinal mass lesions. An average of 3.7 level laminoplasty was performed. Neither spinal malalignment on the coronal plane nor displacement of bone flap (laminoplasty flap) were observed on postoperative CT and MR examinations. No complications due to laminoplasty were encountered. The mean follow-up was 30 months (range 22-48 months). CONCLUSION: Open door laminoplasty is a simple procedure and has two main advantages over the classical laminectomy procedure; a lower incidence of spinal deformities with or without neurological deficits and an absence of epidural scar tissue. This procedure can be used in all spinal cases with intraspinal mass lesions.

Diffuse villous hyperplasia of choroid plexus.

Diffuse villous hyperplasia of choroid plexus (DVHCP) is a rare condition which is characterized by the presence of diffuse enlargement of the entire choroid plexus throughout the length of the choroidal fissure and overproduction of CSF. The diagnosis of diffuse villous hyperplasia of choroid plexus can be established by the MR demonstration of diffusely large, contrast enhanced choroid plexus in the cases of overproduction hydrocephalus. Although some authors recommend choroid plexus excision or coagulation, ventriculo-atrial shunt insertion is a simple and effective treatment modality in cases of diffuse villous hyperplasia of the choroid plexus. In this report we present a case of diffuse villous hyperplasia of the choroid plexus and a short review of the literature. To our knowledge, in the CT and MRI era only 5 cases of DVHCP cases have been reported.

Non-traumatic intradiploic arachnoid cyst.

In this report, we present a case of non-traumatic intradiploic arachnoid cyst in a 65 year-old woman with a slow growing swelling in the right frontotemporal region without a history of head trauma, which was diagnosed intra-operatively. Extradural intracranial location of non-traumatic arachnoid cyst is a rare clinical entity with a few reported cases in the literature. Characteristic features of non-traumatic intradiploic arachnoid cysts are also described in this mini-review article.

Aspergillus pituitary abscess.

BACKGROUND: Pituitary abscess is rare and most of the cases are of bacterial origin. True fungal pituitary abscess is extremely rare only five cases have been reported. In this report, we present a case of aspergillus pituitary abscess. Mortality rate in intracranial aspergillosis is close to 100% especially in immunsuppressed patients when undiagnosed and untreated. In focal CNS aspergillosis total cure can be achieved in approximately 30% of the cases by surgical drainage and intensive antifungal therapy. Although this is the first reported case with magnetic resonance imaging examination the definitive diagnosis was established only by histopathological examination. CLINICAL PRESENTATION: A 42 year-old man was referred to our hospital with the diagnosis of sellar suprasellar mass accompanied by frontal headache and decreased visual acuity. His medical history was insignificant. Physical examination was normal and the patient was afebrile. The neurological examination revealed bilateral papilledema and bitemporal hemianopsia but no stiff neck and motor or sensory deficit. In the light of MRI examination, the preoperative diagnosis was pituitary abscess secondary to paranasal sinus infection or hemorrhagic pituitary adenoma. INTERVENTION: The patient was successfully treated by transsphenoidal surgery. Histopathological examination of sphenoid sinus mucosa revealed normal mucosal appearance with inflammation and histopathological examination of the intrasellar mass resulted in the diagnosis of aspergillosis. All cultures obtained from sphenoid sinus were reported as having no growth. However in the second week after the operation fungal culture of the intrasellar mass grew aspergillus. After 8 weeks of amphothericine-B treatment, the patient was discharged. At the last follow up examination two years after the operation, the patient was symptom free with normal pituitary function. CONCLUSION: Aspergillus pituitary abscess should be considered in the differential diagnosis of a pituitary mass. The correct diagnosis of pituitary aspergillosis can only be achieved by histopathological examination because clinical and radiological findings including MRI are not specific and culture results are obtained later. Immediately after the diagnosis, intensive antifungal therapy should be started for a successful treatment.

Phenytoin penetration into chronic subdural haematomas.

The pathophysiology of chronic subdural haematomas (CSH) is still unclear. In the light of recent ultrastructural examination, exudation from the macrocapillaries in the outer membrane of CSH may play an important role in the enlargement of CSH. In this study, exudation from the macrocapillaries was assessed by the measurement of phenytoin, a protein-bound antiepileptic agent used in cases of CSH. In 22 patients, 1 h after the administration of 250 mg of phenytoin intravenously, blood and subdural haematoma samples were taken and phenytoin levels were measured. The ratio of subdural haematoma level to the blood phenytoin level was determined and defined as the phenytoin penetration ratio (PPR). The correlation between the phenytoin penetration ratio and clinical neurological grades (Markwalder and Glasgow Coma Scale), age of the patients and the CT appearance of CSH were investigated. The mean phenytoin penetration ratio was 19.5%. As the neurological grades of patients increased, average PPR also increased. The average PPR values were 17.64 and 20.84% in the patients younger than 60 years (nine patients) and older patients (13 patients), respectively. Mean PPRs in the groups according to the CT appearance were as follows: low density 11.21% (seven patients), isodensity in 15.88% (10 patients), high density in 38.5% (five patients). A subdural reaccumulation was detected in nine patients with a mean PPR of 27.72%, while mean PPR was 14.56% in the others. Exudation from macrocapillaries in the outer membrane of chronic subdural haematomas probably plays an important role in the enlargement of chronic subdural haematoma, and measuring phenytoin levels in the chronic subdural haematoma is a simple method for the quantitative estimation of the exudation in CSH.

The effect of tizanidine on chronic vasospasm in rats.

BACKGROUND: Cerebral vasospasm after subarachnoid hemorrhage (SAH) has remained a major cause of morbidity and mortality in patients with SAH. Excitatory neurotransmitters are gathered in the extracellular space during ischemia due to cerebral vasospasm and initiate or stimulate a series of pathophysiological biochemical processes which consequently lead to neuronal death. Tizanidine (Sandoz compound DS 103-282, 5-chloro-4,2 (2-imidazolin-2-yl-amino)-2,1,3-benzothiazol hydrochloride) is a centrally-acting muscle relaxant and a selective alpha 2 adrenoreceptor agonist which shows its effect by stimulating presynaptic alpha 2 adrenoreceptors in central ASPergic and GLUergic system by inhibiting aspartic acid and glutamic acid release. In this study, the effect of Tizanidine on vasospasm was evaluated. METHODS: We used a femoral artery vasospasm model in rats which has been described by Okada et al. 60 rats were examined in three groups. The first group was used as control group (Control) (n = 20), in the second group subarachnoid hemorrhage was performed (SAH) (n = 20), in the third group Tizanidine was administered in addition to SAH (SAH + Tizanidine administration) (n = 20). Animals in SAH + Tizanidine administration group received 0.3 mg/kg/day intraperitoneally for 7 days. Seven days after the experiment, after perfusion-fixation, 10 mm segments of both femoral arteries were removed and the femoral artery was prepared for light microscope examination, scanning and transmission electron microscopy and for morphometric analysis. RESULTS: There was a statistically significant difference between the electron, scanning and light microscopic observations and morphometric analysis of SAH + Tizanidine administration group and SAH group, and no statistically significant difference between SAH + Tizanidine administration group and control group. CONCLUSION: This study has disclosed that Tizanidine administration before the vasospasm reduces ultrastructural and morphometric vasospastic insult significantly. However, the clinical application of Tizanidine as a protective and therapeutic agent in cerebral vasospasm needs further studies including the employment of clinically more relevant SAH models.

Supratentorial haemangioblastoma: appearances on MR imaging.

Haemangioblastoma is a rare, benign tumour of vascular origin which usually occurs in the posterior fossa. Supratentorial haemangioblastomas are exceptionally rare. In this report we present three cases of supratentorial haemangioblastoma with MRI findings.

Myelopathy due to hereditary multiple exostoses: CT and MR studies.

Substantiated myelopathy in hereditary multiple exostoses is very rare. A few cases have been reported previously. We report a case of a 17-year-old boy with two exostoses in the cervical spine, in one of which caused a high cervical cord compression.

Angiotensin-converting enzyme inhibitor cilazapril prevents chronic morphologic vasospasm in rat.

It has been shown that a long-acting angiotensin-converting enzyme inhibitor cilazapril prevents morphologic changes in arteries secondary to hypertension and endothelial damage, which are analogous to the changes in cerebral arteries following subarachnoid hemorrhage. In this study, the effect of cilazapril on chronic vasospasm was investigated on the rat femoral artery vasospasm model, and morphometric analyses were performed. Animals were divided into three groups. In group 1, femoral arteries were removed after cardiac perfusion. In groups 2 and 3, right femoral arteries were exposed to 0.1 mL autologous whole blood and wrapped with silastic cuff. Animals in group 3 received cilazapril (10 mg/kg) for 7 consecutive days. After the perfusion-fixation, femoral arteries were examined by light and transmission electron microscopy and processed for morphometric analysis. Vessels from animals in group 2 showed a significant luminal narrowing and morphologic changes throughout the vessel wall, while vessels from animals treated with cilazapril appeared nearly normal. These results suggest that cilazapril may be effective in the prevention of chronic vasospasm.

Magnetic resonance imaging in cervical trauma associated with ankylosing spondylitis: report of two cases.

Findings on magnetic resonance imaging (MRI) in two cases of traumatic cervical fracture associated with ankylosing spondylitis are presented. In such patients cervical fracture usually occurs in the lower cervical spine from hyperextension injuries. Classic radiologic investigations including plain films, myelography, and computed tomography are insufficient because of osteopenia and distorted anatomy: MRI is superior to other techniques.

Interhemispheric subdural haematomas.

Eight cases of interhemispheric subdural haematomas (ISDHs) are described. Trauma was the most common cause. Two patients were hydrocephalic and one of them had also agenesis of the corpus callosum. The diagnoses were established by CT. In one of the cases with chronic ISDHs, CT findings suggested a subdural empyema. Conservative treatment was preferred for neurologically stable patients. In one of the patients, the haematoma migrated to the cerebral convexity after liquefaction.

A fluid level in an acute extradural haematoma.

We report a fluid level in an acute extradural haematoma developing after placement of a ventriculo-peritoneal shunt for hydrocephalus. This fluid level was thought to be due to a mixture of blood and cerebrospinal fluid.