Neutrophil to Lymphocyte Ratio and Serum Biomarkers : A Potential Tool for Prediction of Clinically Relevant Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage (SAH) is a condition characterized by bleeding in the subarachnoid space, often resulting from the rupture of a cerebral aneurysm. Delayed cerebral ischemia caused by vasospasm is a significant cause of mortality and morbidity in SAH patients, and inflammatory markers such as systemic inflammatory response index (SIRI), systemic inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), and derived NLR (dNLR) have shown potential in predicting clinical vasospasm and outcomes in SAH patients. This article aims to investigate the relationship between inflammatory markers and cerebral vasospasm after aneurysmatic SAH (aSAH) and evaluate the predictive value of various indices, including SIRI, SII, NLR, and dNLR, in predicting clinical vasospasm. METHODS: A retrospective analysis was performed on a cohort of 96 patients who met the inclusion criteria out of a total of 139 patients admitted Trakya University Hospital with a confirmed diagnosis of aSAH between January 2013 and December 2021. Diagnostic procedures, neurological examinations, and laboratory tests were performed to assess the patients' condition. The Student's t-test compared age variables, while the chi-square test compared categorical variables between the non-vasospasm (NVS) and vasospasm (VS) groups. Receiver operating characteristic (ROC) curve analyses were used to evaluate the diagnostic accuracy of laboratory parameters, calculating the area under the ROC curve, cut-off values, sensitivity, and specificity. A significance level of p<0.05 was considered statistically significant. RESULTS: The study included 96 patients divided into two groups : NVS and VS. Various laboratory parameters, such as NLR, SII, and dNLR, were measured daily for 15 days, and statistically significant differences were found in NLR on 7 days, with specific cut-off values identified for each day. SII showed a significant difference on day 9, while dNLR had significant differences on days 2, 4, and 9. Graphs depicting the values of these markers for each day are provided. CONCLUSION: Neuroinflammatory biomarkers, when used alongside radiology and scoring scales, can aid in predicting prognosis, determining severity and treatment decisions for aSAH, and further studies with larger patient groups are needed to gain more insights.

The Effect of Cerebral Oxygen Saturation Changes on Early Postoperative Neuropsychological Function in Patients Undergoing Cranial Surgery.

AIM: To compare the incidence of postoperative neuropsychological dysfunction in patients managed with cerebral saturation monitoring versus traditional approaches. MATERIAL AND METHODS: A hundred patients undergoing elective intracranial surgery were divided into two groups to receive intraoperative management via cerebral saturation monitoring (Group O) or the conventional approach (Group C). The postoperative neuropsychological function was evaluated by the antisaccadic eye movement test (ASEM) and the Mini-Mental State Examination (MMSE). These tests were performed preoperatively and postoperatively on the first, second, and fifth days. The time for the modified Aldrete score to reach 9 (MAS 9), adverse effects, and pain using a Visual Analog Scale (VAS) scores were recorded. RESULTS: Patient characteristics and surgery data were not statistically different. The MAS 9 of group O was significantly lower than that of group C (p < 0.001). The MMSE at the postoperative 1, 2, and 5 days were significantly higher in Group O compared to Group C (p < 0.001). ASEM was similar between groups. Group O was subdivided according to the type of surgery applied with diagnosis, and there were no statistically significant between-group differences in terms of areas under the curve for the cerebral regional oxygen saturation. There was no between-group difference regarding the mean arterial pressure at any time perioperatively. The heart rate at 80, 90, 100, and 110 min intraoperatively was significantly higher in group C than in Group O. CONCLUSION: Intraoperative cerebral oxygenation monitoring can reduce patient mortality and morbidity by allowing early postoperative neurological evaluation to detect potential neurocognitive deficits.

The effects of the early and ultra-early intervention on the outcome in aneurysmatic subarachnoid hemorrhage.

BACKGROUND: The optimal timing of intervention for aneurysmatic subarachnoid hemorrhage is one of the historically controversial issues in neurosurgery. Although numerous studies investigated the subject, they had many limitations due to the nature of the disease. Early and ultra-early interventions have gained more and more supporters in recent decades. Nevertheless, the effects of the early and ultra-early intervention on the outcome of the disease are far from clarity. METHODS: A single-center retrospective cohort study was carried out at Trakya University Medical Faculty Training and Practice Hospital. The study includes data on all patients admitted with an aneurysmal subarachnoid hemorrhage between January 1, 2001, and December 31, 2005. Patients were divided into two groups according to their WFNS grade status: Good (I-III) or poor (IV-V) grades. Patients are also classified according to their Glasgow Outcome Scale score: Unfavorable (1-2) or favorable (3-5) outcomes. Data were analyzed statistically, and the effects of the early and ultra-early intervention on the outcome were assessed. RESULTS: A total of 580 patients were admitted in the study period. Among them, 494 were eligible for the study. The median age (interquartile range) was 55 (18) years. While 244 (49.4%) patients were women, 250 (50.6%) patients were men. Three hundred and fourteen (63.6%) patients were operated, and 25 patients (5.1%) were undergone endovascular treatment. The ultra-early intervention was achieved in 60 (12.1%) patients and 142 patients (28.7%, including the previous ultra-early intervention group) early intervention was achieved. A meaningful outcome difference was present between the poor-grade ultra-early treatment group and the rest (p=0.007). Analogously, a meaningful outcome difference was present between the poor-grade early treatment group and the rest (p<0.001). CONCLUSION: This study supports the growing trend toward early or ultra-early intervention in aneurysmatic subarachnoid hemorrhage. Our findings showed that both early and ultra-early interventions have positive effects on the outcome in poor-grade aneurysmatic subarachnoid hemorrhage patients. Future studies with more homogenized and larger samples should be realized to clarify the optimal timing of intervention for aneurysmatic subarachnoid hemorrhage.

Endotracheal Intubation for Penetrating Neck Trauma.

Tracheal intubation is performed as part of daily routine in the operating room, rarely with complications. However, management of airway for cases such as a penetrating neck trauma case might constitute exceptions, in which cases the stabilization of the neck to prevent any further neural damage is a significant source of concern for the anesthesiologist. Generally, intubation techniques for penetrating neck trauma were planned according to the initial position of patients. To our knowledge, this is the first case report of alterated the position of the patient during the anesthesia induction for direct laryngoscopy. We report a case of successful airway management of a patient with penetrating neck trauma, by endotracheal intubation with direct laryngoscopy (DL) technique.

Aromatase cytochrome P450 enzyme expression in prolactinomas and its relationship to tumor behavior.

The aim of the study was to evaluate the presence of aromatase cytochrome P450 enzyme (P450AROM) expression in normal pituitary tissues and tumor tissues of patients with prolactinoma and to examine the impact of the P450AROM expression on clinical outcome. Twenty-six consecutive human pituitary tissue samples were obtained from autopsies performed at the Institute of Forensic Medicine. Sixty-four patients who had an adenomectomy between 2000 and 2009 after prolactinoma diagnosis with histologically confirmed pituitary tumor tissues were retrospectively included in this study. The slices from the pituitary tissues were subjected to immunohistochemical staining for evaluation of P450AROM and estrogen receptor beta (ER beta) subunit. Immunohistochemistry results were compared according to age, gender, remission rate, resistance and invasion status of the patients. Higher than normal P450AROM expression was found in the pituitary tissues of the patients with prolactinoma (p < 0.001). P450AROM intensity had no relation to resistance or remission in patients with prolactinoma (p = 0.44, p = 0.45, respectively). The subgroup analysis showed that compared to males without invasive adenoma, males with invasive adenoma had higher P450AROM expression (p = 0.048). ER beta was found to have an impact on resistance (p = 0.049). This study shows that P450AROM expression is present in the pituitary tissues of patients with prolactinoma and that this presence could be important in development and tumor behavior of prolactinomas.

Anatomic basis of anterior and posterior instrumentation of the spine: morphometric study.

STUDY DESIGN: A morphometric study of the linear and angular parameters of the spinal vertebra was conducted by computerized tomographic scans and comparison with previous studies in literature. OBJECTIVES: Detailed knowledge of the spinal vertebral morphometry is important for proper instrumentation. The morphologic measurements vary among races. Morphometric studies have been conducted in white populations. This study aims to suggest dimensions for anterior and posterior spinal implants and to improve the instrumentation techniques. MATERIALS AND METHODS: The vertebral pedicles, bodies and intervertebral disc spaces of the subaxial cervical, thoracic and lumbar spine were studied in 48 healthy individuals by computerized tomographic scan methods. The following parameters were studied: pedicle length, pedicle width, transverse pedicle angle (TPA), sagittal pedicle angle, anterior corpus height, posterior corpus height, anterior disc height, middle disc height and posterior disc height. RESULTS: Our results were slightly different compared to previous studies. Individual differences were found in the same subgroups. The transverse pedicle diameter was largest at L5 (14.95 mm) and smallest at C3 (5.1 mm). The pedicle was longest at L5 (19.9 mm) and shortest at T10 (15.7).The TPA was largest at C3 (47.6 degrees ) and smallest at T6 (11.3 degrees ). The vertebral body was largest at L5 (34.9 mm) and smallest at C3 and C5 (15.6 mm). The vertebral body width was largest at L5 (46.6 mm) and smallest at C4 (22 mm). The intervertebral disc space height was largest at L2-3 (10 mm) and smallest at T1-2 (2.85 mm). There were no significant differences between the left and right sides. CONCLUSIONS: In our morphometric study of the spinal vertebrae, we found differences compared to a number of previous morphometric studies performed mainly on a white population. Also, we documented the individual morphometric differences of the same parameters in the same subgroups. These results emphasize the importance of preoperative computed tomography and conventional radiography of each patient in planning a surgical procedure and selecting the appropriate size of the instruments, thus avoiding possible postoperative complication related to implants.

Reconstruction of growing skull fracture with in situ galeal graft duraplasty and porous polyethylene sheet.

OBJECTIVE: In growing skull fractures with large calvarial defects, it is difficult to use autografts for reconstruction and it requires alternative materials for cranioplasty. In this report, the authors describe their experience and introduce reconstruction of the growing skull fractures' defects with a porous polyethylene sheet (Medpor) and with a novel technique of duraplasty with in situ galeal graft, which avoid the potentially risky dissection and exposure of brain tissue. The goal of this study was to clarify effective surgical methods and to provide the rationale for these techniques. METHODS: We performed this technique on 8 patients with large calvarial defects resulting from growing skull fractures. The skin flap was retracted, leaving the galeal plane adherent to the underlying defect. After removing the bony edges and exposing the underlying retracted dural margins, duraplasty was performed by suturing the galeal tissue left in situ on the defect of the dural margins. Bone reconstruction was performed by placing porous polyethylene sheet (Medpor). CONCLUSIONS: Duraplasty with in situ galeal tissue is a simple, safe, and effective technique to reconstruct dural defects in growing skull fracture, which avoids the risky dissection of the brain tissue. Also, by using Medpor, growing skull fractures can be effectively reconstructed with good cosmetic results.

Bypass to the intracranial giant or large internal carotid artery aneurysms: superficial temporal artery to middle cerebral artery bypass re-visited.

OBJECTIVE: Hunterian ligation of the internal carotid artery is an acceptable treatment modality for inoperable intracranial carotid aneurysms. Despite the risk of thrombo-embolic complications, ligation together with superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is vital in some patients. Our aim is to present our experience in five patients in whom STA-MCA bypass and balloon occlusion were performed due to inoperable intracranial carotid artery aneurysms. METHODS: During the last five years, five patients with inoperable internal carotid artery (ICA) aneurysms were treated by STA-MCA bypass surgery followed by permanent endovascular ICA occlusion. Patients were selected for bypass surgery on the basis of failing balloon test occlusion. Patients were managed in the intensive care unit after surgical and endovascular procedures. RESULTS: Clinical improvement was noted in all patients and no major complication during the follow-up was seen. Aneurysmal thrombosis was confirmed in all patients. CONCLUSION: Hunterian ligation associated with bypass surgery is an effective treatment method in selected patients. The following points should be considered for a good outcome: (1) experienced surgeon for bypass surgery, (2) experienced neuroradiologist for endovascular occlusion of the parent vessel as close to the aneurysm neck as possible, and (3) judicious postoperative management by means of anticoagulation, fluid replacement, and pressure control.

Structure of the excitatory receptive fields of infragranular forelimb neurons in the rat primary somatosensory cortex responding to touch.

We quantitatively studied the excitatory receptive fields of 297 neurons recorded from the forelimb infragranular somatosensory cortex of the rat while touch stimuli were applied to discrete locations on the forelimbs. Receptive fields were highly heterogeneous, but they were regulated, on average, by an underlying spatio-temporal structure. We found the following. (i) Neurons responded with decreasing magnitude and increasing latency when the stimulus was moved from the primary location to secondary locations and to far ispilateral locations of their excitatory receptive fields, displaying smooth transitions from the primary location to secondary locations. (ii) Receptive field patterns revealed functional connectivity between the digits and ventral palm, which did not depend on whether the digits were stimulated dorsally or ventrally. (iii) The structure of the receptive fields (i.e. the neural responses to stimulation of secondary locations compared to the neural responses to stimulation of the primary location), reflected cortical (rather than body) distances. (iv) There was a functional separation between the forepaw and the rest of the forelimb. Namely: if the primary location was in the digits or palm, secondary locations were biased toward the digits and palm; if the primary location was in rest of the forelimb, secondary locations appeared equally distributed over forelimb, digits and palm. (v) More than 40% of neurons extended their receptive field to the ipsilateral forelimb, without any evident spatial organization. Overall, the stimuli evoked approximately 3 times more spikes from secondary responses than from primary responses. These results suggest that a rich repertoire of spatio-temporal responses is available for encoding tactile information. This highly distributed receptive field structure provides the electrophysiological architecture for studying organization and plasticity of cortical somatosensory processing.

Role of spike timing in the forelimb somatosensory cortex of the rat.

The aim of this study was to test the hypothesis that the significance of spike timing in somatosensory processing is not a specific feature of the whisker cortex but a more general characteristic of the primary somatosensory cortex. We recorded ensembles of neurons using microwire arrays implanted in the deep layers of the forelimb region of the rat primary somatosensory cortex in response to step stimuli delivered to the cutaneous surface of the contralateral body. We used a recently developed peristimulus time histogram (PSTH)-based classification method to investigate the temporal precision of the code by evaluating how changing the bin size (from 40 to 1 msec) would affect the ability of the ensemble responses to discriminate stimulus location on a single-trial basis. The information related to the discrimination was redundantly distributed within the ensembles, and the ability to discriminate stimulus location increased when decreasing the bin size, reaching a maximum at 4 msec. In our experiment, at 4 msec bin size the first spike per neuron after the stimulus conveyed almost as much information as the entire responses, so the temporal precision of the code was preserved in the first spikes. Subsequent spikes were less frequent but conveyed more information per spike. Finally, not only the trials correctly classified but also the trials incorrectly classified conveyed information about stimulus location with a similar temporal precision. We conclude that the role of spike timing in cortical somatosensory processing is not an exclusive feature of the highly specialized rat trigeminal system, but a more general property of the rat primary somatosensory cortex.