The effects of clenbuterol on cerebral vasospasm in an experimental rat model of subarachnoid hemorrhage.

OBJECTIVE: To investigate the possible therapeutic effects of clenbuterol on cerebral vasospasm after subarachnoid hemorrhage (SAH) in rats. METHODS: Eighteen male albino Wistar rats, each weighing 200-250 g, were randomized into three groups; Group 1 (Control group) (n = 6) having no SAH and no treatment; Group 2 (Sham group) (n = 6) having only SAH and Group 3 (Experimental group) (n = 6) having SAH treated with clenbuterol. Group 2 has been accepted as sham group to the experimental group. Experimental SAH was induced using a modified rat double hemorrhage model. Clenbuterol was administered twice daily in 12-hour intervals for three days at a dose of 0,1 mg/kg/day. The luminal diameter of the basilar artery was measured on each section with an optic micrometer by an experienced pathologist blinded to the groups. RESULTS: Mean basilar artery diameters were found to be different between the three groups (p < 0.001). Mean value of Group 2 was significantly lower than that of Group 1 (p < 0.001). While mean value of Group 3 was significantly greater than that of Group 2 (p = 0.001), Groups1 and 3 were found to be similar (p = 0242). CONCLUSION: Clenbuterol has favorable effects in the treatment of rat cerebral vasospasm (CVS). Further investigations are needed to evaluate both molecular effects and to find out effective treatment dose of clenbuterol on CVS.

Giant arachnoid granulation in a patient with benign intracranial hypertension (2009: 1b).

We report magnetic resonance (MR), computed tomography (CT) and angiographic imaging of an unusual giant arachnoid granulation 7(GAG) in the superior sagittal sinus in a man with headache and vertigo. Intrasinus pressure measurements revealed a significant pressure gradient across the lesion. MR imaging is useful to identify GAG and dural sinus thrombosis, whereas dural sinus pressure measurement in certain cases of GAGs can be used to evaluate the lesion as the cause of the patient's symptoms.

Spinal cord compression caused by vertebral hemangioma being symptomatic during pregnancy.

BACKGROUND: Hemangioma is one of the most common benign tumors of the spine, and it remains silent in the vast majority of subjects afflicted. Pregnancy is a known risk factor for symptomatic conversion of the previously silent vertebral hemangiomas. However, the occurrence is rare with only 26 cases reported in the English medical literature. CASE DESCRIPTION: A 22-year-old woman in her 36th week of gestation presented with acute onset of upper back pain and progressive paraplegia. Imaging studies revealed a T4 vertebral hemangioma, which involved the vertebral body, pedincules, transverse, and spinous process with a focal extradural extension of soft tissue component. She underwent emergent cesarean delivery and endovascular embolization, respectively. Her symptoms and neurologic deficits improved quickly. Her complaints restarted 2 years after embolization. Surgical treatment which consists of intraoperative vertebraplasty and segmental fixation was performed. The patient's postoperative recovery was excellent. CONCLUSION: According to literature review and our patient's outcome, pregnancy may induce neurologic symptoms and signs in silent spinal hemangiomas. The way of management is decided by whether the neurologic deficits depend on the deformity caused by hemangioma or some other factors including vascular insufficiency.

A case with rheumatod arthritis and atraumatic odontoid fracture: disappearence of bony landmarks.

We aim to draw attention to occult, atraumatic fractures of the odontoid process in patients with rheumatoid arthritis (RA) and to underline difficulties encountered during clinical and radiological diagnosis. A forty-seven years old man with RA for 4 years had occipital pain for 1 year without any history of trauma. Later, he developed weakness in the upper extremities, but he did not realize weakness in the lower extremities due to deformities. Contrast magnetic resonance imaging revealed a linear fracture of odontiod process and myelopathy. Cervical computed tomography scan revealed an old fracture border with separated and almost disappeared remnant of the tip of the odontoid without free particles in the cord. It was impossible to evaluate atlantoaxial and vertical subluxations with craniometric measurements due to destruction of the tip of odontoid. Following occipitocervical fusion and decompression and a rehabilitation program, his muscle strength improved; however, functional myelopathy stage did not change. Atraumatic fractures of the odontoid process may be more common than reported and may cause compression of the spinal cord or brain stem. Surgery is the treatment of choice but functional recovery is limited once neuronal damage has occurred. Erosion of the critical landmarks makes it difficult to diagnose and follow up atlantoaxial subluxation and/or vertical subluxation, therefore clinicians should consider radiographical follow-ups during the course of the disease.

The influence of cervical spinal cord stimulation on induced epileptic discharges in rats.

Spinal cord stimulation (SCS), also known as dorsal column stimulation, is a novel technique used widely in pain surgery. However, its effect on other pathologies such as epileptic disorders is unknown. The aim of this study is to evaluate the influence of electrical epidural stimulation of the upper cervical region on epileptic cortical discharges. The long term goal is to elucidate and evaluate a therapeutic central nervous system (CNS) electrical stimulation methodology to treat epilepsy. Twelve Wistar female rats were randomly divided into two groups. In group 1 (six rats under general anesthesia), C2-3 laminectomies were performed and epidural electrodes were placed to perform SCS. To induce epileptic discharges, 1 ml (200 IU) penicillin G was microinjected into the left somatomotor cortex via left stereotactic parietal craniotomies, 0.01 to 0.1 mA at 2 Hz was used to stimulate the spinal cord. In group 2 (the control group, six rats under general anesthesia), C2-3 laminectomies were performed without electrode placement and epileptic discharges were induced with penicillin G microinjections, as described above. Both groups were monitored with digital electroencencephalography (EEG) for 70 min in seven stages and recordings analyzed with power spectral analysis. Spinal cord stimulation decreased penicillin-induced median values of epileptic discharges. Epileptic wave frequencies decreased significantly with increasing intensities of SCS. The results of this study suggest that SCS used for drug resistant epilepsies may be a viable alternative treatment modal.

Postoperative mutism after removal of an anterior falcine meningioma.

Postoperative mutism is rare. We present a 65-year-old man who had transient mutism after resection of anterior falx meningioma. Mild left hemiparesis and palmomental reflex on the right were the only abnormal signs on neurological examination. CT scan and MRI demonstrated a mass at the anterior one-third portion of the falx just superior to the corpus callosum. The mass enhanced homogenously with administration of gadolinium DTPA. The patient underwent surgical resection of the lesion and adjacent falx cerebri. The operation was uneventful. On the second postoperative day he became mute. He could follow verbal commands, and write and read. Postoperative CT scan revealed a hypodense area in the right frontal lobe including a part of the anterior cingulate cortex and the anterior part of the corpus callosum. Histopathological examination revealed a mixed meningioma. Ten days postoperatively, he began to say simple words, and three weeks later he could talk normally. We consider that lesion of the supplementary motor area (SMA) may be responsible for postoperative mutism.

Implications of a neurosurgical intervention in a patient with a surgically repaired hypoplastic left heart syndrome.

Hypoplastic left heart syndrome (HLHS) accounts for 4-9% of congenital heart disease in children. The mortality rate among children with HLHS undergoing cardiac repair is well documented, but comparable data for noncardiac surgical procedures are not well known. Medically intractable epilepsy is one of those problems, which arises as a complication of cardiovascular surgery in HLHS and necessitates neurosurgical intervention. There is no published knowledge about neurosurgical procedures performed in children with HLHS in the English literature. Thus, we present a 10-year-old boy who developed medically intractable epilepsy after cardiac surgery for HLHS. The aim of this study is to outline the pre-, intra- and postoperative precautions needed for neurosurgical intervention in HLHS patients to decrease morbidity and mortality.

A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period.

BACKGROUND: Ventriculoperitoneal (VP) shunts are used for intracranial pressure management and temporary cerebrospinal fluid (CSF) drainage. Infection of the central nervous system (CNS) is a major cause of morbidity and mortality in patients with CSF shunts. The aim of the present study was to evaluate the clinical features, pathogens, and outcomes of 22 patients with CSF shunt infections collected over 4 years. METHODS: The patients with shunt insertions were evaluated using; age, sex, etiology of hydrocephalus, shunt infection numbers, biochemical and microbiological parameters, prognosis, clinical infection features and clinical outcome. RESULTS: The most common causes of the etiology of hydrocephalus in shunt infected patients were congenital hydrocephalus-myelomeningocele (32%) and meningitis (23%). The commonest causative microorganism identified was Staphylococcus (S.) aureus, followed by Acinetobacter spp., and S. epidermidis. CONCLUSION: In a case of a shunt infection the timely usage of appropriate antibiotics, according to the antimicrobial susceptibility testing, and the removal of the shunt apparatus is essential for successful treatment.

Pure Motor Stroke Secondary to Cerebral Infarction of Recurrent Artery of Heubner after Mild Head Trauma: A Case Report.

BACKGROUND: The recurrent Heubner's artery is the distal part of the medial striate artery. Occlusion of the recurrent artery of Heubner, classically contralateral hemiparesis with fasciobrachiocrural predominance, is attributed to the occlusion of the recurrent artery of Heubner and is widely known as a stroke syndrome in adults. However, isolated occlusion of the deep perforating arteries following mild head trauma also occurs extremely rarely in childhood. CASE REPORT: Here we report the case of an 11-year-old boy with pure motor stroke. The brain MRI showed an acute ischemia in the recurrent artery of Heubner supply area following mild head trauma. His fasciobrachial hemiparesis and dysarthria were thought to be secondary to the stretching of deep perforating arteries leading to occlusion of the recurrent artery of Heubner. CONCLUSION: Post-traumatic pure motor ischemic stroke can be secondary to stretching of the deep perforating arteries especially in childhood.

Metastatic germ cell testicular tumor of the eye and brain: case report.

The aim of this report is to contribute to the clinical understanding of this rare combined pathology. Intraocular metastatic tumors are rarely encountered pathologies. Mostly encountered primary sites are breast, prostate, kidney, lung and skin. Testis as a primary site for orbital metastases is rather rare. Metastasis to orbit usually occurs to periorbital structures, but to vitreus is relatively rare. Here we describe a case of intraocular metastatic tumor to the vitreus originating from testicular embryonal cell carcinoma. Patient with intraocular tumor had also intracranial metastasis. He was operated on for intracranial lesion, after an uneventfull postoperative period he was discharged. 2 months later when he died, postmortem examination of the intraocular lesion reported as metastatic embryonal cell carcinoma. As a conclusion testicular embryonal cell carcinoma, eventhough rare, must be considered to metastasize to the eye.

Is external ventricular drainage useful in primary intraventricular hemorrhages?

Nontraumatic primary intraventricular hemorrhage (PIVH) is characterized by direct bleeding into the neuroventricular system. A very rare condition, PIVH accounts for 3% of all spontaneous intracerebral hemorrhages. Hypertension is a major cause of PIVH. Reports about PIVH in the literature are infrequent and it appears to be a relatively benign condition. Between 1998 and 2001, 15 patients with PIVH were evaluated in the Departments of Neurosurgery of Yüzüncü Yil and Pamukkale Universities; their prognosis and results of treatment with external ventricular drainage (EVD) were recorded. The diagnosis was established easily and rapidly with computed tomography. Prognoses of the patients were made by the Glasgow Coma Score (GCS). Hypertension was the most common etiology (n = 9, 60%); the prognosis for survivors (73.3%) was good (mortality, 26.6%). Elderly patients, who scored low on the GCS, and patients with coagulopathy had poor prognoses. All patients with PIVH underwent surgery with EVD within 24 hours of their hospital admission. Applying EVD had positive results and influenced the prognosis and early and late complications of PIVH accordingly.

MR imaging characteristics of pilomyxoid astrocytomas.

BACKGROUND AND PURPOSE: Pilomyxoid astrocytoma (PMA) is a recently described tumor that typically occurs in the chiasmatic-hypothalamic region in young children and has unique histopathologic and clinical characteristics. These tumors have been previously diagnosed as pilocytic astrocytoma (PA). PMA appears to have a higher rate of recurrence and CSF dissemination than typical PA. METHODS: We analyzed MR findings in four patients with PMA and compared them with those of typical chiasmatic-hypothalamic PA. RESULTS: MR findings of PMA were chiasmatic or hypothalamic enhancing solid tumor with hydrocephalus, highly homogeneous T2 signal intensity that extended into the deep white and gray matter, and CSF dissemination. CONCLUSION: Larger series are needed before the MR imaging findings of chiasmatic or hypothalamic enhancing solid tumor with hydrocephalus, highly homogeneous T2 signal intensity extending into the deep white and gray matter, and CSF dissemination can be used in the differential diagnosis of such tumors.

Lipid peroxidation in cerebral tumors.

BACKGROUND: Serum and tissue concentrations of tumor markers or some metabolites are considered to be helpful in diagnosis and follow-up of the central nervous system (CNS) disease. However, markers currently available are not sufficiently sensitive and specific to be used as actual diagnostic tools. Differentiation between the malignant and benign lesions of the CNS is very important, both for determining the optimum therapeutic approach and to predict morbidity and mortality of the disease. Accurate diagnosis of a malignant disease is mostly performed through a surgical resection and histopathologic evaluation. Free oxygen radicals (FOR) are thought to take part in oncogenesis and cellular differentiation. We explored whether FORs can be used as diagnostic tumor markers. METHODS: We investigated the concentration of malondialdehyde (MDA) in the serum and tumor tissue of patients with glial tumor. We have studied 30 patients with malign glial tumor (grades III and IV astrocytoma), 30 patients with low grade glial tumor, 28 healthy individuals, and 10 patients with nontumorous lesions (lobectomy for epilepsy). RESULTS: Patients with CNS tumors showed higher serum MDA concentration compared to control groups (epilepsy patients and healthy subjects). These patients had a higher tumor tissue MDA concentration compared to lobectomy tissue from epilepsy patients. Serum and tissue MDA concentrations were also higher in the malignant glial tumor group compared to the low grade glial tumor group. CONCLUSIONS: Although not specific, tissue and serum concentrations of FORs can be used as a marker to detect the presence and grade of CNS tumors. Further studies are needed to determine the optimum cutoff value for use of serum and tissue MDA concentrations in brain tumors.

Intracerebellar granulocytic sarcoma complicating acute myelogenous leukemia: a case report and review of the literature.

Granulocytic sarcoma is a solid mass composed of premature precursors of granulocytic series cells in an extramedullary region. Intraparenchymal central nervous system localization without skull or meningeal invasion is extremely rare. Although different theories have been proposed to explain the mechanism of this unusual disorder, its exact mechanism is still unclear. Some degree of improvement can be achieved after surgery and radiotherapy but its prognosis is poor and most patients die within months. Nine cases of purely intraparenchymal granulocytic sarcomas have been reported in the literature. Here, we report the tenth case and review the current literature.

Left hemisphere and male sex dominance of cerebral hemiatrophy (Dyke-Davidoff-Masson Syndrome).

Although radiological findings of cerebral hemiatrophy (Dyke-Davidoff-Masson Syndrome) are well known, there is no systematic study about the gender and the affected side in this syndrome. Brain images in 26 patients (mean aged 11) with cerebral hemiatrophy were retrospectively reviewed. Nineteen patients (73.5%) were male and seven patients (26.5%) were female. Left hemisphere involvement was seen in 18 patients (69.2%) and right hemisphere involvement was seen in eight patients (30.8%). We conclude that male gender and left side involvement are frequent in cerebral hemiatrophy disease.

Trigeminal neuralgia caused by intracranial epidermoid tumor: report of a case and review of the different therapeutic modalities.

Trigeminal neuralgia (TGN) is characterized by recurrent paroxysms of unilateral facial pain that typically is severe, lancinating, and activated with cutaneous stimulation. Paroxysms typically last for 1 to 2 seconds. Etiology includes compression of the trigeminal nerve by vascular structures, tumors and multiple sclerosis plaques in the medulla spinalis. TGN is rather rare as a presenting symptom with intracranial tumors. Epidermoid tumors comprise 1% of all intracranial tumors. The majority of epidermoid tumors are located at the pontocerebellar angle, the third ventricle, and the suprasellar region. Symptomatology is not different from other tumors located at the same sites. Trigeminal neuralgia may be caused by tumor compressing the nerve itself, an inflammatory response to the epidermoid tumor or vascular compression of the nerve. We describe the case of a 30-year old female presenting with right-sided facial pain. Her past history revealed multiple teeth extractions done to relieve facial pain. Radiological evaluation, including magnetic resonance imaging (MRI), showed a pontocerebellar angle (PCA) epidermoid tumor. TGN resolved completely after total tumor resection. A temporary facial paralysis consequent to surgical removal of the tumor improved 6 months postoperatively, and she remained painfree, without medications.

Management of medically intractable genitofemoral and ilioingunal neuralgia.

AIM: To evaluate the effectiveness of invasive procedures in medically intractable genitofemoral and ilioingunal neuralgia. MATERIAL AND METHODS: This is a prospective study of 20 patients with genitofemoral and ilioinguinal neuralgias who were treated at our medical center between 2007 and 2011. Genitofemoral and ilioinguinal nerve blocks were performed in all cases after medical treatment had failed to alleviate the patients' pain. Neurectomy was performed for the patients whose pain did not improve. Patient histories, physical examinations and visual analogue scale scores before and after treatments were analyzed. RESULTS: Fourteen (70%) of the patients were treated with nerve blocks and six (30%) of the patients whose pain did not improve with nerve block application underwent neurectomy which resulted in pain relief. CONCLUSION: For patients with medically intractable genitofemoral and ilioinguinal neuralgias, nerve blocks and neurectomies can be applied safely for pain control.

Application of ATC/DDD methodology to evaluate perioperative antimicrobial prophylaxis.

OBJECTIVE: To evaluate quality of perioperative antibiotic prophylaxis (PAP) and to calculate the cost per procedure in a Turkish university hospital. SETTING: A 352-bed teaching hospital in Denizli, Turkey. METHOD: An prospective audit was performed between July and October 2010. All clean, clean-contaminated and contaminated elective surgical procedures in ten surgical wards were recorded. Antimicrobial use was calculated per procedure using the ATC-DDD system. The appropriateness of antibiotic use for each procedure was evaluated according to international guidelines on PAP. In addition, the cost per procedure was calculated. RESULTS: Overall, in 577 of the 625 (92.3%) of the studied procedures, PAP was used. PAP was indicated in 12.5% of the group where it was not used, and not indicated in 7.1% of the group where it was used. Unnecessarily prolonged antimicrobial prophylaxis was observed in 56.9% of the procedures, mean duration was 2.6 ± 2.7 days. The most frequently used antimicrobials were cefazolin (117.9 DDD/100-operation) and sulbactam/ampicillin (102.2 DDD/100-operation). The timing of the starting dose was appropriate in 545 procedures (94.5%). In the group that received PAP, only 80 (13.7%) of the procedures were found to be fully appropriate and correct. The density of antimicrobial use per operation was 2.8 DDD. The mean cost of the use of prophylactic antimicrobials 18.6 per procedure. CONCLUSION: The density of antimicrobial use in PAP was found to be very high in our hospital. Antibiotic overuse extended into the postoperative period.