Lumbosacral plexopathy secondary to discectomy and fixation.

Lumbosacral plexopathy (LSP) is a rare entity characterized by acute onset of pain followed by sensory and motor deficits, reflex changes and muscle atrophy. The diagnosis is based on clinical and EMG findings. LSP can result from pelvic tumors, infections, trauma, abdominopelvic or spinal surgery, radiation, intravenous drug abuse, diabetic neuropathy, vasculitis or maybe idiopathic. We present a case report of LSP following spinal surgery treated by pulse steroid and immunotherapy.

A comparative study for glioma classification using deep convolutional neural networks.

Gliomas are a type of central nervous system (CNS) tumor that accounts for the most of malignant brain tumors. The World Health Organization (WHO) divides gliomas into four grades based on the degree of malignancy. Gliomas of grades I-II are considered low-grade gliomas (LGGs), whereas gliomas of grades III-IV are termed high-grade gliomas (HGGs). Accurate classification of HGGs and LGGs prior to malignant transformation plays a crucial role in treatment planning. Magnetic resonance imaging (MRI) is the cornerstone for glioma diagnosis. However, examination of MRI data is a time-consuming process and error prone due to human intervention. In this study we introduced a custom convolutional neural network (CNN) based deep learning model trained from scratch and compared the performance with pretrained AlexNet, GoogLeNet and SqueezeNet through transfer learning for an effective glioma grade prediction. We trained and tested the models based on pathology-proven 104 clinical cases with glioma (50 LGGs, 54 HGGs). A combination of data augmentation techniques was used to expand the training data. Five-fold cross-validation was applied to evaluate the performance of each model. We compared the models in terms of averaged values of sensitivity, specificity, F1 score, accuracy, and area under the receiver operating characteristic curve (AUC). According to the experimental results, our custom-design deep CNN model achieved comparable or even better performance than the pretrained models. Sensitivity, specificity, F1 score, accuracy and AUC values of the custom model were 0.980, 0.963, 0.970, 0.971 and 0.989, respectively. GoogLeNet showed better performance than AlexNet and SqueezeNet in terms of accuracy and AUC with a sensitivity, specificity, F1 score, accuracy, and AUC values of 0.980, 0.889, 0.933, 0.933, and 0.987, respectively. AlexNet yielded a sensitivity, specificity, F1 score, accuracy, and AUC values of 0.940, 0.907, 0.922, 0.923 and 0.970, respectively. As for SqueezeNet, the sensitivity, specificity, F1 score, accuracy, and AUC values were 0.920, 0.870, 0.893, 0.894, and 0.975, respectively. The results have shown the effectiveness and robustness of the proposed custom model in classifying gliomas into LGG and HGG. The findings suggest that the deep CNNs and transfer learning approaches can be very useful to solve classification problems in the medical domain.

Severe hypertension and tachycardia during transforaminal endoscopic discectomy - Is indigocarmine to blame?

Endoscopic transforaminal discectomy is a minimally invasive technique used for the surgical treatment of herniated discs. Indigocarmine is a dye which is widely used to identify the ureteral orifice in urologic procedures. Hemodynamic effects such as hypotension and anaphylaxis in addition to hypertension, bradycardia and atrioventricular block have been reported in intravenous application of indigocarmine. The aim of this case report is to prepare anesthesiologists for such cases and make them consider invasive blood pressure monitorization. Both patients had radicular pain radiating to the leg and scheduled to undergo transforaminal endoscopic discectomy. Intraoperative vital signs were within normal limits, however severe hypertension and tachyarrhythmia developed following the injection. Hemodynamics in both patients returned to normal following lidocaine and nitroglycerine injection.

Light Microscopic Evaluation of Acute and Chronic Hypophyseal Endocrinopathy in a Kaolin-Induced Hydrocephalus Model.

AIM: To demonstrate progression of acute and chronic endocrinopathies in a kaolin-induced hydrocephalus model using light microscopy. MATERIAL AND METHODS: Adult male Sprague-Dawley rats (n = 48) were divided into six groups. Hydrocephalus was induced by intracisternal injection of kaolin solution in the acute and chronic kaolin groups, whereas an identical volume of sterile saline was injected into the sham groups. RESULTS: Somatotropic cell concentrations were lower in the kaolin groups compared with their controls, but there was no difference in somatotropic cell concentration between the acute and chronic kaolin groups. Corticotropic cell concentrations were higher in the acute kaolin and sham groups compared with acute controls. Thyrotropic cell numbers were higher in the acute sham and kaolin groups compared with their controls, and although thyrotropic cell concentations were higher in the acute kaolin group than the acute sham group. No differences were observed between the acute and chronic controls and sham and kaolin groups regarding mammotropicand gonadototropic cell concentations. CONCLUSION: Somatotropic cells are most affected by hydrocephalus that causes pituitary dysfunction, and this effect was more prominent under acute and chronic phases.

A novel surgical technique for aggressive vertebral hemangiomas.

Vertebral hemangiomas are relatively common, but those causing spinal cord compression are rare. A 19-year-old male presented with thoracic back pain. The neurologic examination was normal and radiological examinations demonstrated an aggressive vertebral hemangioma centered within the T11 vertebral body. Damaged vertebral bone and soft tissue components of the mass were observed in the epidural space. Surgery was performed using a new technique involving radiofrequency ablation, injection of a hemostatic agent (FLOSEAL, Baxter, USA), and bone autograft placement in the affected vertebral body. There were no complications intra- or postoperatively, and the patient's back pain resolved completely during the postsurgical period. Bleeding is a serious issue in cases of aggressive vertebral hemangioma. This new technique provides improved bleeding control and strengthens the affected vertebra through autograft placement.

Vagal Nerve Stimulation Effects on Generalized-Partial Seizures and Medication in Adult Drug- Resistant Epilepsy Patients.

AIM: The aim of this study was to find out if vagal nerve stimulation (VNS) affect the generalized-partial seizure count and medical treatment in adult drug resistant epilepsy patients. MATERIAL AND METHODS: Twenty adult patients who were diagnosed with drug-resistant epilepsy were investigated retrospectively for vagal nerve stimulator implantation between 2001 and 2010 at the Neurosurgery Departments of Ufuk University and Gulhane Military Medical Academy. The effects of vagal nerve stimulation on generalized-partial seizures and medical treatment was scored and if a significant difference was found, a comparison was made by Wilcoxon Signed Ranks test and Pairwise. For all the group analyses, the statistical significant rank was accepted as a p value < 0.05. Bonferroni correction was made when it was needed during pairwise comparisons. RESULTS: VNS significantly decreased the scores of generalized-partial seizures. There was no decrease in the doses of antiepileptic drugs and the medical treatment was resumed as before the implantation. The results were correlated with the relevant literature. CONCLUSION: VNS is an alternative treatment option for drug resistant epilepsy for patients who are not ideal candidates for surgery or are not healed after epilepsy surgery.

Non-invasive detection and monitoring of experimental hydrocephalus with distortion product otoacoustic emissions.

OBJECTIVE: We aimed to find out the effects of short term and long term hydrocephalus and intracranial ventricular volume changes on cochlear functions by using distortion product otoacoustic emission (DPOAE) in experimental hydrocephalus rat models for the first time in literature. METHODS: This study was performed with 48 healthy, adult (8 weeks old), Sprague-Dawley rats which weighed between 200 and 240g. Six groups were formed in this study: short term control, short term sham, short term hydrocephalus, long term control, long term sham and long term hydrocephalus groups. Each group contained eight rats. Short term period was 4 weeks and long term period was 8 weeks after the study started. At the end of these periods, DPOAE measurements were performed and then rats were sacrificed to determine ventricular volumes. RESULTS: DPOAE values at all frequencies were significantly decreased in the short term hydrocephalus group when compared to the short term control and short term sham groups. DPOAE values at all frequencies were significantly decreased in the long term hydrocephalus group when compared to the long term control and long term sham groups. Besides, long term sham group which had higher ventricular volumes than long term control group also had lower DPOAE measurements. Significant associations were present between DPOAE measurements and ventricular volumes in hydrocephalus models. CONCLUSION: The functional disturbances in cochlear functions due to hydrocephalus have been demonstrated with DPOAE measurements in this study. DPOAE measurements may be thought as an easily applicable non-invasive method in detection and follow-up of patients with hydrocephalus. Our findings should be supported with clinical studies in humans.

Congenital hypoplasia of the posterior arch of the atlas: case report and extensive review of the literature.

Congenital hypoplasia of the posterior arch of the atlas (C1), a developmental failure of chondrogenesis, is a rare anomaly and may range from partial clefts to total agenesis of the posterior arch. Ossification of the posterior arch usually occurs between the 3rd and 5th years of life. The incidence of posterior arch anomalies of the atlas is between 0.69% and 2.95%. For the evaluation of the patient, cervical lateral plain radiography, 2D or 3D reconstructed CT and MRI are very useful and important tools in initial diagnosis. Surgery is the treatment of choice in symptomatic compression. Excision of the posterior arch is performed. during surgery. After the surgery, patients may be followed up for instability and treated as necessary. A patient, admitted to the emergency department with head and neck trauma after a traffic accident is presented in this article. C1 hypoplasia was determined after detailed imagining studies and the radiology department consulted. When upper cervical anomalies are found in a young patient, the patient should be evaluated in detail with advanced radiological studies to avoid misinterpretation as fractures, luxation, osteolysis or instability. Consulting a radiologist could help making an accurate diagnosis and deciding on current therapeutic interventions.

Accessing the basilar artery apex: is the temporopolar transcavernous route an anatomically advantageous alternative?

The restricted operative field, difficulty of obtaining proximal vascular control, and close relationship to important anatomic structures limit approaches to basilar apex aneurysms. We used a cadaveric model to compare three surgical transcavernous routes to the basilar apex in the neutral configuration. Five cadaveric heads were dissected and analyzed. Working areas and length of exposure provided by the transcavernous (TC) approach via pterional, orbitozygomatic, and temporopolar (TP) routes were measured along with assessment of anatomic variation for the basilar apex region. In the pterional TC and orbitozygomatic TC approaches, the mean length of exposure of the basilar artery measured 6.9 and 7.2 mm, respectively (p = NS). The mean length of exposure in a TP TC approach increased to 9.3 mm (p < 0.05). Compared with the pterional and orbitozygomatic approaches, the TP TC approach provided a larger peribasilar area of exposure ipsilaterally and contralaterally (p < 0.05). The multiplanar working area related to the TP TC approach was 77.7 and 69.5% wider than for the pterional TC and orbitozygomatic TC, respectively. For a basilar apex in the neutral position, the TP TC approach may be advantageous, providing a wider working area for the basilar apex region, improving maneuverability for clip application, fine visualization of perforators, and better proximal control.

Total resection of inferiorly located sacral chordoma with posterior only approach: case report and review of the literature.

Chordoma is a primary sacral neoplasm of ectodermal origin and makes up %1- 4 of all primary bone tumors. It is usually present on the midline cerebrospinal axis and the most common locations are the spheno-clival region and the sacrum. The treatment of primary sacral tumors represents a challenge because of a large tumor mass at presentation and a hemorrhage risk in surgery. Sacral tumors may present a difficult problem to the surgeon who desires to obtain a clear margin of excision. Using the retrorectal fat tissue as a cleavage line in the posterior approach guides the neurosurgeon to resect the tumor totally and reduce the hemorrhage in sacral chordomas. In this case report, we tried to discuss the advantages of using of retrorectal fat tissue as a cleavage line in sacral chordomas under the literature.

Accessing the recesses of the fourth ventricle: comparison of tonsillar retraction and resection in the telovelar approach.

OBJECTIVE: To compare the effectiveness of the telovelar approach with tonsillar manipulation for approaching the recesses of the fourth ventricle. METHODS: A telovelar approach was performed in 8 injected cadaveric heads. Areas of exposure were measured for the superolateral and lateral recesses. Horizontal angles were evaluated by targeting the cerebral aqueduct and medial margin of the lateral recess. Quantitative comparisons were made between the telovelar dissections and various tonsillar manipulations. RESULTS: Tonsillar retraction provided a comparable exposure of the superolateral recess with tonsillar resection (26.4 +/- 17.6 vs 25.2 +/- 12.5 mm2, respectively; P = .825). Tonsillar resection significantly increased exposure of the lateral recess compared with tonsillar retraction (31.1 +/- 13.3 vs 20.2 +/- 11.5 mm2, respectively; P = .002). Compared with tonsillar retraction, the horizontal angle to the lateral recess increased after either contralateral tonsillar retraction (22.7 +/- 4.8 vs 36.7 +/- 6.5 degrees) or tonsillar resection (22.7 +/- 4.8 vs 31.5 +/- 7.6 degrees; all adjusted P < .01). The horizontal angle to the cerebral aqueduct increased significantly with tonsillar resection compared with tonsillar retraction (17.6 +/- 2.3 vs 13.2 +/- 2.8 degrees; P < .001) CONCLUSION: Compared with tonsillar retraction, tonsillar resection provides a wider corridor to, and a larger area of exposure of, the cerebral aqueduct and lateral recess. Contralateral tonsillar retraction improves access to the lateral recess by widening the surgical view from the contralateral side.

A rare reason of foot drop caused by primary diffuse large b-cell lymphoma of the sciatic nerve: case report.

INTRODUCTION: Primary central nervous system lymphomas account for 2% of all malignant lymphomas. Although the involvement of peripheral nerves has been previously described as a dissemination of systemic lymphomas or a direct extension to the nerve trunk from contiguous lymphomas, primary involvement of the sciatic nerve is extremely rare. CASE: To the best of our knowledge, the primary localization of lymphoma within sciatic nerve has been reported only nine times. We report, a very rare example of a primary diffuse large B-cell lymphoma of the sciatic nerve. DISCUSSION: The patient presented with atypical sciatica. Such symptoms can be misdiagnosed as lumbar disc pathology and magnetic resonance imaging and electrophysiological studies avoid this misinterpretation.

Anatomical relationships of intracavernous internal carotid artery to intracavernous neural structures.

The objective is to correlate the intracavernous internal carotid artery (ICA) with the position of the intracavernous neural structures. The cavernous sinuses of nine injected cadaveric heads were dissected bilaterally. As measured on computed tomographic angiograms from 100 adults, anatomical relationships and measurements of intracavernous ICA and neural structures were studied and correlated to the intracavernous ICA curvature. Intracavernous ICAs were classified as normal and redundant. The meningohypophyseal trunk (MHT) of normal ICAs appeared to be closely related to the abducens nerve compared with redundant ICAs (5.5 ± 2.1 mm versus 10.0 ± 2.5 mm, respectively; p = 0.001). The position of the inferolateral trunk (ILT) varied along the horizontal segment of the intracavernous ICA. On imaging studies the ICA curvature correlated with the kyphotic degree of the skull and similarity of the ICA curvature between sides. The safety margin for preventing iatrogenic intracavernous nerve injury during surgical exploration or transarterial embolization of vascular lesions around the MHT is high with redundant ICAs. In contrast, a transvenous endovascular approach via the inferior petrosal sinus may be too distant to reach the MHT when ICAs are redundant. Approaching lesions of the inferolateral trunk may be the same regardless of ICA type.

Rapid, simple technique to extend depth of field in microneurosurgical images: technical note.

OBJECTIVE: To increase the extent of the depth of field and focal sharpness in highly magnified image series from cadaveric microneurosurgical anatomic study or live surgery photographs obtained with the operating microscope, providing a higher quality and more satisfactory photographic and imaging experience. METHODS: We used a computer workstation, CombineZM software (Alan Hadley, United Kingdom, www.hadleyweb.pwp.blueyonder.co.uk/), an injected cadaver head specimen, and an operating microscope equipped with a digital single-lens reflex camera. Fifteen images were obtained of the dissection area through an anterior petrosal approach. The focus point was fixed to different points in each image. The images were loaded into CombineZM software for processing. RESULTS: The stacking process of photographs with CombineZM freeware provides significant increase in extent of depth of field and wider area of image clarity, producing a sharp, high-quality image. CONCLUSION: An image processed from a stack of photographs from cadaveric microneurosurgical studies or from the operating microscope in live surgery can be rendered to show extended 3-dimensional depth of field and clarity. This method offers improvements for editing, displaying, and publishing neurosurgical anatomic images.

Greater superficial petrosal nerve dissection: back to front or front to back?

OBJECTIVE: To introduce a novel surgical technique for the dissection of the greater superficial petrosal nerve (GSPN) in the middle fossa approach. METHODS: Interdural temporal elevation was performed with a front-to-back technique to preserve the GSPN in 12 sides of 6 injected cadaveric heads dissected through a middle fossa approach. RESULTS: The GSPN emerged from the facial hiatus in a shallow bony groove proximally, ran into a deeper sphenopetrosal groove, and eventually reached the mandibular nerve. With front-to-back dissection, this nerve was easily identified at the posterior border of the mandibular nerve. Dissection from front to back minimized the retraction force applied to the proximal part of the GSPN, which was preserved in all specimens. CONCLUSION: The temporal dura can be elevated safely with a front-to-back technique to preserve the GSPN and to help maintain the physiological integrity of the facial nerve.

Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature.

Although the first reported surgery for lumbar disc herniation was published many years ago, there still remains little agreement for the most effective treatment protocol for symptomatic cases. Many patients with extruded lumbar disc herniation require surgical intervention due to radiculopathy of lower extremities but some neurological symptoms of intervertebral disc herniation may frequently improve with conservative treatment. In this paper, two cases of spontaneous regression of extruded lumbar herniated discs are presented. The disc regressions of two patients were correlated with clinical improvement and documented with follow up MRI studies. Additionally the clinical course of lumbar disc herniation was discussed with mechanisms, features of MRI, immunohistological pathology and treatment options of past clinical studies.

Subcutaneous granuloma annulare of the scalp in childhood: a case report and review of the literature.

Granuloma annulare is a benign inflammatory skin lesion of unknown etiology that is usually seen in adults and children and subtypes of it includes localized granuloma annulare, generalized granuloma annulare, subcutaneous granuloma annulare and arcuate dermal erythema. Etiology and pathogenesis of granuloma annulare are obscure, although there is much evidence for an immunologic mechanism. Precipitating factors are insect bites, sunburn, photochemotherapy, drugs, physical trauma, acute phlebitis and sepsis after surgery. Some investigators were suggested a relationship of granuloma annulare to a latent or clinically manifest diabetes or rheumatoid arthritis. In contrast, an association of subcutaneous granuloma annulare with these diseases in childhood has not been reported in the literature. Subcutaneous granuloma annulare of the scalp is rare lesion in childhood and nodules on the scalp are usually non-, or slightly mobile, whereas lesions on the extremities are freely mobile. For definitive diagnosis, a biopsy should be performed but wide surgical intervention or medical treatment is not indicated. In case of recurrence, no additional diagnostic studies are necessary.

Diagnostic and surgical pitfalls of an unusual primary central nervous system lymphoma.

BACKGROUND: Here we describe a case of PCNSL which was located peripherally as a single lesion and showed no evidence of pathological findings of lymphoma at the first biopsy. CASE DESCRIPTION: A 56-year-old man was admitted to the hospital with a talking disorder and attention deficit. The neurological examination was normal. There was a left temporoparietal, 24 x 20 mm. enhanced lesion on MRI. The patient underwent a craniotomy and the lesion was excised totally. The pathological examination revealed glial tissue which showed reactive astrocyte proliferations. A month later, an MRI was performed and a recurrent tumor was seen near the first lesion's location. The second operation was performed via the same craniotomy, the tumor was excised totally and the second pathological examination revealed diffuse large-cell, B-lymphoma. There were no pathological findings on abdominal, thoracic and bone marrow investigations. CONCLUSION: PCNSL may show various biological behaviors. Using steroids before the biopsy may lead to diagnostic and therapeutic failure.

Attenuation of postlaminectomy epidural fibrosis with monoclonal antibodies against intercellular adhesion molecule-1 and CD-18.

BACKGROUND CONTEXT: Data from studies in other diseases state implicate cellular adhesion molecules as mediators of fibrosis and scarring. We sought to explore and assess the effect of using monoclonal antibodies against intercellular adhesion molecule-1 (ICAM-1) and its ligand CD-18 to decrease epidural fibrosis in an animal spinal surgery model. PURPOSE: We hypothesize that use of antiadhesion molecules (anti-ICAM-1 and anti-CD-18) decreases epidural fibrosis in rats after spinal surgery compared with nontreated group and monoclonal anti human immunoglobulin (Ig)G group. STUDY DESIGN: Experimental animal spine surgery (laminectomy) protocol with application of antiadhesion molecules (anti-ICAM-1 and anti-CD-18 group as a specific monoclonal antibody) to surgical site in test group compared with monoclonal antihuman IgG group (as a nonspecific monoclonal antibody) and nontreated group. METHODS: Thirty Sprague Dawley male or female rats weighing 175 to 250 g were used randomly for three groups (nontreated, anti-ICAM-1 and anti-CD-18, monoclonal antihuman IgG). Laminectomy was performed at level L4 in all animal groups. After injection of materials (except nontreated group), the surgical sites were closed in layers. Three weeks later, all rats were killed. Twenty-seven rats were available for histological analysis. The histological sections were evaluated for fibroblast numbers of fibrous tissue within the laminectomy side, adhesion degree between dura mater and fibrous tissue, and new bone formation in the laminectomy region. RESULTS: Comparing the fibroblast numbers in fibrous tissue within groups, the number of fibroblasts were significantly less in anti-ICAM-1 and anti-CD-18 group than nontreated group (p=.037). The number of fibroblasts of monoclonal anti human IgG group was not significantly different from anti-ICAM-1 and anti-CD-18 (p=.608) and the nontreated group (p=.508). In the anti-ICAM-1 and anti-CD-18 applied group, adhesion degree was found significantly less than monoclonal antihuman IgG (p=.036) and nontreated group (p=.036) statistically. There were no significant difference between the monoclonal antihuman IgG group and the nontreated group about adhesion degree (p=.645). CONCLUSIONS: Therapy that targets ICAM-1 could be valuable in the management of epidural fibrosis. Blocking the function of ICAM-1 may provide cellular protection against epidural fibrosis and also it may serve as an important component in this period, acting to promote leukocyte migration across epidural area after laminectomy.

In vivo human brain biochemistry after aerobic exercise: preliminary report on functional magnetic resonance spectroscopy.

BACKGROUND: Our aim was to disclose whether the positive psychological changes observed after a single bout of aerobic exercise have a biochemical correlate that can be visualized by proton magnetic resonance spectroscopy (MRS) of the human brain. METHODS: Right-handed male volunteers underwent psychological testing and MRS of the frontal lobe of the left hemisphere, both before and after 20 minutes of jogging at about 70% of their maximal aerobic capacity. RESULTS: Although there was a significant decrease on the postexercise anxiety test scores (z = -2.201, P < .05), there was no significant difference between the preexercise and postexercise scores of positive and negative affect. Considering both "amplitude" and "area under the curve" values calculated for the peaks of metabolites N-acetylaspartate (NAA), creatine, and choline, none were found to be significantly changed (P > .05) after the exercise. CONCLUSION: This is, to our knowledge, the first study to report on a functional application of MRS to mood states. Because it offers the ability to directly measure metabolic changes in the brain during neuronal activation, "functional MRS" may be a potential new tool that may be used as an adjunct to functional magnetic resonance imaging.