Evaluation of neurogranin levels in a rat model of diffuse axonal injury.

Diffuse axonal injury (DAI), one of the most common and devastating type of traumatic brain injury, is the result of the shear force on axons due to severe rotational acceleration and deceleration. Neurogranin (NRGN) is a postsynaptic protein secreted by excitatory neurons, and synaptic dysfunction can alter extracellular NRGN levels. In this study, we examined NRGN levels in serum and cerebrospinal fluid (CSF) after experimental DAI in terms of their diagnostic value. Experimental DAI was induced using the Marmarou technique in male Wistar albino rats. Serum and CSF NRGN levels of the sham group, one­hour, six­hour, 24­hour, and 72­hour post­DAI groups were measured by ELISA method. DAI was verified by staining with hematoxylin­eosin and ß­amyloid precursor protein in the rat brain samples. While no histopathological and immunohistochemical changes were observed in the early hours of the post­DAI groups, the staining of the ß­APP visibly increased over time, with positivity being most frequent and intense in the 72­hour group. It was found that serum NRGN levels were significantly lower in the 6­hour group than in the sham group. The serum NRGN levels in the 24­hour group were significantly higher than those in the sham group. This study showed a dichotomy of post­DAI serum NRGN levels in consecutive time periods. NRGN levels in CSF were higher in the one­hour group than in the sham group and returned to baseline by 72 hours, although not significantly. Our study provides an impression of serum and CSF NRGN levels in a rat DAI model in consecutive time periods. Further studies are needed to understand the diagnostic value of NRGN.

Prognostic significance of prolonged corrected QT interval in cerebral contusion.

Background & objectives: Cerebral contusion (CC) results in a release of catecholamines, autonomic dysfunction and neural stimulation that can lead to a number of cardiac adverse events, so it is critical to determine these. So the objective of this study was to investigate the prognostic significance of electrocardiographic changes, particularly the effects of a prolonged corrected QT (QTc) interval in CC. Methods: In this retrospective cohort study, 110 patients with CC were evaluated. Age, sex, concomitant diseases, Glasgow Coma Scale on admission, radiological assessment of the contusion (location, size, course and presence of cerebral oedema), need for surgical intervention, length of hospital stay and the extended Glasgow Outcome Scale (GOS-E) were statistically analysed within the QTc interval by routine electrocardiography (ECG) on admission. Results: The prolonged QTc interval was found to be associated with a higher incidence of cerebral oedema and a significantly higher risk of needing surgery. Patients with a prolonged QTc interval had a significantly larger contusion volume, greater midline shift and longer hospital stay, so their GOS-E score was significantly lower. A prolonged QTc interval on admission resulted in a hospital stay of more than eight days (sensitivity: 0.97 and specificity: 0.86), a higher risk of midline shift of more than 0.45 cm (P=0.006, sensitivity: 0.80 and specificity: 0.99) and a GOS-E score of <7 (sensitivity: 0.97 and specificity: 0.85). Interpretation & conclusions: ECG changes on admission showing a prolonged QTc interval have prognostic significance in CC. This simple and easily applicable information should be taken into consideration at the time of clinical decision making which may prevent an adverse events survivor.

Temporary 6TH cranial nerve paralysis after accidental durotomy in endoscopic disc surgery.

We present a unique case of 6th nerve palsy following accidental durotomy in endoscopic lumbar spine surgery, which has not been reported in the literature before. A 72- year-old female patient was admitted to our outpatient clinic complaining of right leg pain for 6 months. A 4/5 motor paresis was observed on her right toe with a positive Lasegue test at 45°. On her magnetic resonance imaging (MRI), a L5-S1 disc herniation was detected. The patient was planned for percutaneous endoscopic interlaminar disc surgery. The extruded disc was adherent to the dura. During removal, a dural tear was observed. She was relieved of her right leg pain immediately after surgery, but after 30 min postoperatively, she complained of double vision with left abducens nerve paralysis. On cranial MRI, no abnormality could be observed. Intravenous fluids were administered and the paralysis resolved on the postoperative 24th hour. The patient was discharged from the hospital and did not show any complaints on her follow-ups. A 6th nerve palsy can be caused due to alterations of intracranial pressure or mechanic injury. We believe that the durotomy following removing of the disc fragment caused a rapid drainage of CSF, leading to intracranial hypotension and injury of the abducens nerve. Intracranial pressure should be monitored perioperatively and brisk deteriorations has to result in immediate finishing of the surgery to avoid further secondary damage.

Modified Kickstand Rod Technique for the Correction of Adult Idiopathic Scoliosis.

Adult idiopathic scoliosis (ADIS) is the delayed form of adolescent idiopathic scoliosis (AIS) which is defined as a three-dimensional deformity with a lateral curvature of more than 10° in adults with prior history of AIS. Surgery is necessary for patients with symptoms of chronic pain, neuromotor deficits and cardiopulmonary problems with a Cobb angle exceeding 45°. In untreated patients, AIS may lead to ADIS which can cause serious problems like osteoarthritis, progressive deformity and spinal stenosis. In recent years, the kickstand rod technique has been introduced in addition to posterior transpedicular stabilization. A kickstand rod is an additional rod which is placed on a supporting iliac screw which is placed on the superior lateral edge of the ilium on the concave side of the deformity (or in other words on the ipsilateral side of the trunk shift) and is connected with a domino connector to the thoracolumbar junction. The rod is then distracted with the screw nuts locked on the contralateral side to achieve coronal correction. The classic kickstand works as a an additional aid to keep the spine in place during maneuvering. We established a modified kickstand rod technique where we put the rod on the concave side and apply compression between the rod on the screw heads and the kickstand to bring the concavity to the midline. The kickstand was used as a temporary tool like a lever to push the spine medially with compression. We believe that our technique can be a useful alternative for correction of coronal imbalance besides the classic one.

Perineal anesthesia following interlaminar endoscopic disc surgery.

Perineal anesthesia is defined as the loss of sensation to the area of buttocks, perianal space and thighs. It is often seen in cauda equina syndrome as a collection of acute symptoms mostly occurring secondary to a large disc herniations leading to neuropathy of multiple lumbar and sacral nerve roots. We present 30 years- old male patient who was admitted with sever left leg pain for over a month. On neurological examination a 3/5 plantarflexion paresis was observed on the left with hypoesthesia concordant to the S1 dermatome. A lumbar MRI showed a broad left L5-S1 disc herniation was detected. The patient underwent interlaminar endoscopic disc surgery and postoperatively, was relieved of his pain and a slightly improvement of his paresis was seen. On the first week follow-up he complained of anesthesia of his buttocks when sitting. On follow-up MRI, the disc was removed completely and no further pathologies could be seen. The patient continued physical therapy and on the 8th week postoperatively his paresis and perineal anesthesia resolved completely. Perineal anesthesia following endoscopic disc surgery was a complication we never have experienced at out clinic. Even when searching through medical databases we have not seen any reports in the literature in that way.

Treatment of Multiple Junctional Vertebra Fractures in a Single Case.

We present a unique case of multiple junctional vertebra fractures in a single patient requiring surgical intervention, the variety of which has not yet been reported in the literature. A 15-year old female was admitted to our emergency department after a suicide attempt from jumping from the window of a five-floor building. On admission her general status was critical, Glasgow Coma Scale (GCS) was 6, and on painful stimuli she was able to move all four extremities. On her spinal CT, a C1 right arcus fracture, a C7 corpus fracture, an L3 and L5 burst fracture and a right sacrum fracture were detected. The patient also suffered from pneumothorax, pleural effusion and pulmonary contusions. After she was stable and extubated, she did not show any motor or sensory deficits. As the patient still had some pleural effusion and pulmonary contusions, posterior approaches were avoided at first and a C6-T1 anterior stabilization with mini plate-screws was performed. After her pulmonary problems resolved, a series of spinal instrumentation surgeries were performed over the following weeks. A case like this in which multiple traumatic junctional fractures were treated with different surgical techniques has not been reported in the literature before. It is important to emphasize if and when surgical intervention is needed. A multidisciplinary assessment of trauma surgeons, neurosurgeons and anesthesiologists is vital for forming a further treatment plan.

Late recovery of stereotactic radiosurgery induced perilesional edema of an arteriovenous malformation after bevacizumab treatment.

MATERIALS AND METHODS: We present a 41-year old male patient who was admitted to our clinic with epileptic seizures, headaches and hemiparesis 14 months after SRS treatment for a left fronto-parietal Spetzler-Martin Grade III arteriovenous malformation (AVM). On his first-year follow-up perilesional edema was observed for which the patient received steroid treatment, but the patient did not show any benefit from it. In the cases of steroid resistant perilesional edemas, bevacizumab can be used for reducing symptoms and even radiological perilesional edema as well. RESULTS: In our case, we have seen the effect of bevacizumab for symptomatic perilesional edema in a AVM patient after SRS treatment after radiological / neurological recovery. Our patient's headaches decreased rapidly after 2 days after treatment and was able to mobilize himself after 2 months but total resolution of symptoms and radiological findings observed after 1,5 years. CONCLUSIONS: The duration and optimum dose of bevacizumab therapy needed to further investigation. Our study showed that bevacizumab was a long-term and effective treatment option for the cases with peritumoral edema resistant to glucocorticoid treatment, where the patient had conditions such as severe headache and neurological deficits.

Rapid disappearance of pneumorrhachis after chest tube placement.

INTRODUCTION: We present a rare case of traumatic pneumorrhachis with the combination of hemothorax which resolved rapidly after insertion of a chest tube. CASE PRESENTATION: A 55 year old male was admitted to our emergency department after falling from a ladder. His general condition was well, GCS was 15 with no motor deficits. On his spinal CT a fracture on multiple ribs leading to right sided hemothorax was observed with air in the T6-T8 spinal canal. A chest tube was placed and as he did not have any neurological deficits surgical intervention to the pneumorrhachis was not considered. On the next day's a follow-up CT the air in the spinal canal was reduced and on the 5th day resolved completely. CONCLUSION: Traumatic pneumorrhachis is a rare phenomenon and is not fully understood how the air from the posterior mediastinal wall can spread to the epidural or subarachnoid space. One hypothesis for subarachnoid air is that the high pressure air from a pneumothorax or pneumomediastinum pushes in a one-valve mechanism through the fascial layers of the posterior mediastinum through the neural foramina into the spinal canal. In our case, after the insertion of the chest tube the air in the subarachnoid space resolved and the patient's tingling sensation on his legs disappeared. We believe that the negative pressure of the chest tube did a somehow reverse effect of the air flow back from the spinal canal into the chest tube which has not been reported in the literature before.

Late-onset Metastasis of Intracranial Papillary Thyroid Carcinoma.

BACKGROUND: Papillary thyroid carcinoma is the most common subtype of thyroid cancers, accounting for >90% of all thyroid carcinomas. Despite a favorable long-term survival rate of 94.4%, people with distant metastases show worse outcome. Cerebral metastases are slightly uncommon and stand for only 1%-3% of all metastases. CASE DESCRIPTION: We present a 56-year-old male patient complaining of serious headaches for >20 days. He underwent thyroidectomy surgery 13 years ago due to papillary thyroid carcinoma and was reported "tumor free" on his follow-ups without any complaints. On his cranial magnetic resonance imaging scan a right temporal mass lesion was detected. During surgery, the tumor was removed and reported as papillary thyroid carcinoma metastasis. CONCLUSION: A case in which a patient with papillary thyroid carcinoma developed brain metastasis after such a long time was not reported in the literature before.

Transorbital penetrating head trauma leading to serious cerebral edema - A case report.

Penetrating transorbital head injuries are rarely seen. We present a 6-year old male patient who was referred to our department after a wooden stick penetrated his right eye. On admission his general condition was well and he showed no neurologic deficits. On his cranial computed tomography (CT) there was a fracture on his right orbital wall and minimal subarachnoid hemorrhage in his right frontal lobe. On later follow-ups the patient's condition worsened and his control CT showed diffuse cerebral edema. The patient underwent emergent decompressive surgery. Due to this immediate intervention the patient was released from the hospital with no major deficits later. Up to our knowledge, there are no cases in the literature reported in which decompressive craniectomy was necessary after a transorbital penetrating head trauma.

Giant Calvarial Ewing's Sarcoma: A Case Report.

Ewing's sarcoma (EWS) is the second most common primary bone tumor seen in children and adolescents, first being osteosarcoma. Skull lesions are seen in 6 to 9% of cases. The tumor tends to reside most frequently on frontal and parietal bones. In the literature, majority of papers on calvarial EWS present cases with intracranial involvement; extracranial extension is reported in only eight cases. The case that we are presenting in this report is a 23-year-old male patient with multiple infiltrations in femur, costal bones, and calvarium which had been diagnosed radiologically and histopathologically as EWS. The calvarial metastasis had reached a very huge size with dimensions of approximately 7.5 × 7.5 × 9.5 cm and was successfully excised totally. Twelve months of follow-up revealed no recurrence in the surgical site showing that total removal of giant cranial EWS may improve morbidity of these patients.