Posttraumatic locked-in syndrome from combined brainstem and upper cervical injury in childhood: A case report.

Locked in syndrome (LIS) is a condition characterized by quadriplegia, lower cranial nerve palsies and mutism in which only vertical eye movements and upper eyelid movements are preserved while the patient's state of consciousness is intact. The most common cause of LIS is pontine infarction after vertebrobasilar system occlusion. We hereby present a case report of LIS secondary to cervicomedullary contusion after head trauma. Due to the possibility of neurological recovery, early and accurate diagnosis is important in posttraumatic nonvascular LIS cases and aggressive neurological and other systemic treatment and early neurological rehabilitaion options should also be eveluated. Neurological rehabilitaion of these ventilator dependent patients is difficult and should be improved.

Critical-illness polyneuropathy complicating cardiac operation.

Critical-illness polyneuropathy is a complication of septic syndrome. However, this complication has been largely unrecognized in cardiac surgery units. Difficulty in weaning from the ventilator is an important early manifestation. Electromyography should be routinely performed to establish the diagnosis. Here we report a case of polyneuropathy complicating surgical repair of acute aortic dissection.

Traumatic intracranial carotid tree aneurysms.

OBJECTIVE: This study was designed to elucidate the requirements for angiographic evaluation in blunt head injuries, the timing of angiography, and the selection of appropriate therapeutic approaches. METHODS: Twelve cases of traumatic aneurysms (TAs) in the intracranial carotid tree were analyzed in this study. Neurological examination results, computed tomographic scans, pre- and postembolization cerebral angiograms, and follow-up data were included. RESULTS: In 11 of 12 cases, TAs were of cranial base origin; in 1 case, the aneurysm was located in the distal anterior cerebral artery. In seven of the cases with cranial base lesions, aneurysms were located in the intracavernous segment of the internal carotid artery; all of the computed tomographic scans for these cases demonstrated sphenoid sinus wall fractures and hematoma in the sphenoid sinus. In two cases, although the initial angiograms revealed no lesions, a second study performed 2 weeks later demonstrated the presence of aneurysms. Nine of the aneurysms were treated with endovascular techniques, two were managed conservatively, and the remaining one patient died with massive epistaxis while awaiting surgical treatment. No morbidity or additional permanent neurological deficits occurred in the endovascularly treated patient group. CONCLUSION: Patients with head trauma who present with sphenoid sinus fractures and massive epistaxis should be evaluated for the development of TAs as soon as possible. If the patients exhibit fractures without epistaxis, angiography should be deferred for 2 to 3 weeks; if the first angiographic evaluation reveals normal findings, repeated epistaxis should prompt a second angiographic evaluation. Current treatment of TAs involves occlusion of the main artery through the use of endovascular techniques. Cases involving internal carotid artery TAs of cranial base origin and patients who do not tolerate test occlusion require extracranial-to-intracranial bypass surgery.

Intramedullary tuberculous abscess: a case report.

STUDY DESIGN: This case report shows an intramedullary thoracic spinal cord abscess secondary to Mycobacterium tuberculosis in a 7-year-old boy with chronic progressive paraparesis and hypesthesia below T10. OBJECTIVES: The treatment of this patient involved drainage of pus followed by appropriate chemotherapy. SUMMARY OF BACKGROUND DATA: Abscess and tuberculomas of the spinal cord are rare entities. They are indistinguishable from neoplasms. The possibility of tubercular abscess or granuloma should be kept in mind when an intraspinal mass is found, provided that the clinical history is unusual for tumor. METHODS: A left T7-T8 hemilaminectomy was performed. A quantity of pus was drained through a small myelotomy. A small specimen was taken, and antituberculosis treatment was given after surgery. RESULTS: Excellent clinical outcome was obtained with a combination of medical and surgical management. CONCLUSION: The treatment of intramedullary abscess consists of surgical evacuation of the pus. Appropriate treatment offers a favorable prognosis even in cases with severe deficits.

The effects of synthetic growth hormone on spinal cord injury.

The aim of this study was to determine the effect of synthetic growth hormone on healing process of reversible injured spinal cord. The rat was selected for the experiment in preference to larger animals for economy and availability. Under general anesthesia one level laminectomy was carried out at T-1 with the dura mater intact. The injury was created by Rivlin and Tator's clip method. Recovery of motor function was assessed for up to 4 weeks using inclined plane test of hind limb motor function. Although the effect of the drug is evident after 3 weeks, the study must be held for longer periods for a sufficient regeneration time to maintain a significant statistical evaluation.

Blood degradation products play a role in cerebral ischemia caused by acute subdural hematoma.

The pathogenesis of ischemic brain lesions with traumatic hematoma is multifactorial. It has been suggested that the presence of subdural hematoma in patients with severe head injury is associated with elevated intracranial pressure and higher mortality. In this study we created acute subdural mass in the rats by injecting 250 microliters of autologous blood and silicone oil into the subdural space. The goal of this study was to determine the effect of subdural hematoma versus silicone oil on the adjacent brain parenchyma. Twenty-four hours after the injection, of the hematoma in the subdural space in rats produced an extensive zone of underlying ischemic damage but silicone oil did not. This study has shown that pressure alone caused by silicone oil is insufficient to cause significant neuronal damage or loss.

Is it possible to recover from uncal herniation? Analysis of 71 head injured cases.

BACKGROUND: Uncal herniation (UH) caused by head trauma may become a fatal process if not treated rapidly. METHODS: We analysed the factors affecting the outcome in 71 surgically treated patients who had intracranial haematoma diagnosed by computerized tomography (CT), between January 1987 and June 1994 with the symptoms of UH. Age, incident-treatment interval, Glasgow Coma Scale (GCS), type of the lesion and the presence of polytrauma were correlated with Glasgow Outcome Scales (GOS) using SPSS PC+ statistical software. RESULTS: 49.3% of our patients were referred because of a fall from a height and 46.5% because of a motor vehicle accident. 12.7% of the patients were polytraumatized. The mean GCS of the series was 5.662. The mean GCS of the patients expired and who were in good recovery state were 4.8 and 6.9 respectively. Age, presence of polytrauma, type of the lesion and time interval between the incident and the treatment was found to be statistically insignificant when correlated with GOS. The correlation value between the GCS values and GOS was found to be highly significant (p < 0.00001). CONCLUSIONS: The findings showed that the degree of the herniation is the most important factor that affects the prognosis of the patients with UH. The reversibility of UH becomes more difficult if there are complications added during the grades of its progression but it may not be necessarily fatal and be reversible if appropriate interventions are rapidly performed.

Spinal cord injury caused by gunshot wound during pregnancy.

We report a case of a pregnant woman with acute spinal cord injury (C5) caused by gunshot wound and discuss the respective maternal and fetal considerations. Neither decompressive surgery nor corticosteroid protocols were used. At 37 weeks, the patient delivered a normal female infant after induction of labor and epidural anesthesia, with no medical or obstetrical complications. With conservative management and rehabilitation, this patient had significant recovery of function.

Intradural migration of a bullet following spinal gunshot injury.

STUDY DESIGN: Case report. OBJECTIVES: To report a penetrating gunshot injury at L1 with migration within the spinal canal to S2. SETTING: Istanbul, Turkey. METHODS: A 44-year-old man was admitted with an entrance gunshot wound on the left upper quadrant. An emergency exploratory laparotomy with left nephrectomy and transverse colon repair were performed. He had complete spinal cord injury below the level of L1. Lumbar magnetic resonance imaging (MRI) revealed hemorrhagic areas in conus medullaris and L1 corpus. The bullet was lodged at the S2 level. S1-S2 laminectomies were performed for the removal of the bullet. The antibiotic therapy was given for 17 days. RESULTS: No meningitis or wound infection was observed after the operation. At discharge his neurological status was improved. CONCLUSIONS: The present case presented the movement of an intraspinal bullet after a spinal gunshot injury. No signs of infection were detected postoperatively. Lumbar MRI was used safely without any change in neurological status or patient discomfort.

Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases.

115 traumatic extradural haematoma cases who were treated surgically at Cerrahpasa Medical Faculty Neurosurgery Department between 1987 and 1992 are evaluated. When factors affecting the outcome were examined, a strong correlation was found between the result and Glasgow coma scale (GCS) (p < 0.00001). The existence of a fracture, the interval between onset of haematoma symptoms and intervention and the existence of an intracerebral haematoma together with contusion accompanying intradural haematoma, affect the outcome in a negative direction. There was no statistical correlation between the outcome and the age of patient, localization of the haematoma and aetiology.

Craniopharyngioma extended into the posterior fossa.

A 7-year-old girl with a craniopharyngioma with a rare extension into the posterior fossa is presented. MRI revealed a solid calcified mass in the sellar and suprasellar region with a cyst expanded to the posterior fossa up to the foramen magnum and causing hydrocephalus and brainstem displacement. The tumor was removed totally with right pterional approach.

A great misfortune: second traumatic spinal cord injury.

OBJECTIVE: A second and a separate traumatic spinal cord injury, which results in neurological deterioration, is very rare. In this report we describe a patient who became tetraplegic after sustaining a second spinal trauma. CASE REPORT: A 27-year-old female had a C(7)-T(1) dislocation after a motor vehicle accident. She was neurologically intact and she had undergone a posterior fusion between C(6)-T(2). She made a complete recovery. Eight months after her initial trauma, she sustained a second motor vehicle accident causing a C(5) burst fracture. CONCLUSION: Second traumatic spinal cord injury is a rare entity. Motor vehicle accidents are the most common cause of this type of injury. Whatever the treatment strategy is, the best treatment modality for traumatic spinal cord injury is prevention.

Intraspinal schwannoma of the accessory nerve.

The second example of a schwannoma originating from the cervical portion of the accessory nerve is reported. The tumour was diagnosed by MRI and confirmed by surgery. The tumour was small and was located entirely within the cervical subarachnoid space without causing any detectable neurological deficit.

Late onset Pott's paraplegia.

BACKGROUND: Pott's disease may cause late neurological involvement due to development of sharp kyphosis. Anterior decompression and fusion is the treatment of choice for this disorder. OBJECTIVE: To determine the mid-term clinical results of patients with late onset Pott's paraplegia, who underwent anterior decompression and grafting after neurological deterioration. SETTING: A university hospital in Istanbul, Turkey. METHODS: Eight patients who developed late onset paraplegia with a mean period of 24.6 years (range, 9-46 years) after the active disease were treated with anterior decompression and grafting. The mean age at surgery was 36.1 years (range, 18-63 years) and the mean duration of neurological deterioration before surgery was 7.4 weeks (range, 2-13 weeks). The mean kyphosis angle of the patients was 105.63 degrees (range, 80 degrees- 135 degrees). No attempt to correct the curve was made in any operation. All but two patients' neurological status were evaluated according to the International Standards for Neurological and Functional Classification of Spinal Cord Injury determined by ASIA-IMSOP on admission. RESULTS: Neurological status of all patients showed progression either in Frankel scale or in motor scores in the early postoperative period. One patient needed to be reoperated on because of a deterioration of neurological status 26 months after surgery. The mean length of time since the operations is 75.9 months (range, 48 173 months) and all the patients are carrying out their lives independently with a mean motor score of 97.5 and full pin-prick and light touch scores. CONCLUSIONS: Anterior decompression and grafting is an effective procedure for the treatment of late onset paraplegia in Pott's disease.

A study of the factors affecting the outcome of vertebromedullary injuries.

Between 1982 and 1991, 194 patients were treated for cervical vertebromedullary injuries in the Department of Neurosurgery, Cerrahpasa Medical Faculty of the University of Istanbul. The data were evaluated with the multiple regression method using the SPSS/PC statistical package to predict the factors influencing the outcome. In the initial neurological examination, motor deficit was detected in 63.4% of the patients, sensorial deficit was seen in 53.6% of the patients and respiratory failure in 12.9%. Of these patients 46.4% were treated surgically and 53.6% medically. Evaluating the findings and outcomes with the Frankel scale, no change in neurological status was detected in 44.8% of the patients. Improvement was detected in 36.1% and deterioration in 19.1%, the mortality rate being 18.6%. It is concluded that the main factor predicting the outcome of patients with vertebromedullary injury is the initial neurological status (P < 0.0001).

Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury.

OBJECTIVES: To determine whether proton magnetic resonance spectroscopy (MRS), a newer radiographic technology, would be useful in the evaluation of the thalamus of patients in vegetative states resulting from traumatic brain injury. METHODS: 14 victims of severe traumatic brain injury who were in the vegetative state and whose magnetic resonance images of the thalamus were normal underwent bilateral thalamic proton (MRS) studies. The N-acetyl aspartate to creatine (NAA:Cr) and choline to creatine (Cho:Cr) ratios were obtained for each patient. The proton thalamic MRS findings of patients who were in a persistent vegetative state (n = 8) and in patients who had regained awareness after being in the vegetative state (n = 6) were compared with proton thalamic MRS findings in five healthy volunteers. RESULTS: While conventional magnetic resonance imaging suggested that each patient had a normal thalamus, proton MRS indicated that the thalamus of each patient in the series was damaged. The NAA:Cr ratio was significantly lower in the thalami of both the patients who remained in a persistent vegetative state for the duration of the study and in those who regained awareness after being in the vegetative state (p < 0.001). In addition, NAA:Cr ratios were lower in the group of patients who remained in a persistent vegetative state than in the group of patients who regained awareness after being in the vegetative state (p < 0.001). CONCLUSIONS: Results suggest that the NAA:Cr ratio within the thalamus is significant and that thalamic MRS may be helpful when attempting to determine the degree of severity of neuronal and axonal injury in patients in the vegetative state.

Capillary haemangiomas of the spinal cord: report of two cases.

The clinicopathological features of two cases of capillary haemangioma of the spinal cord are described. The presenting symptoms were similar to those of common intradural, intramedullary tumours or tumour-like mass lesions. Radiological features of these two lesions resembled other vascular lesions of the spinal cord. The patients underwent surgery, and recoveries were good. Histologically, the lesions resembled capillary haemangioma of superficial tissues that are composed of lobules of small capillaries with feeding vessels. A fibrous capsule enveloped the lesions. Capillary haemangiomas of the central nervous system are rare. Awareness of their existence may help the surgeon to avoid misdiagnosis and overtreatment of these benign tumour-like lesions.

Atypical intradural spinal tuberculosis: report of three cases.

OBJECTIVE: To report three cases of intradural spinal tuberculosis (TB) by calling attention to atypical forms of spinal TB. SETTING: A University Hospital, Istanbul, Turkey. METHODS: Histopathological, radiological, surgical and physical examination findings of three patients with spinal TB were retrospectively reviewed. RESULTS: Based on histopathological, surgical and radiological findings, diagnosis of intramedullary abscess had been made in the first case and early and late phases of arachnoiditis in the other two patients, respectively. The clinical outcome was evaluated as satisfactory for the patient with intramedullary abscess who had been treated with medical and surgical interventions. The remaining two patients with arachnoiditis, who had been treated by shunting or simple decompression, had a relatively less favorable clinical outcome. CONCLUSION: Spinal TB, in its atypical forms, is a rare clinical entity and low index of suspicion on the part of the surgeon may result in misdiagnosis such as neoplasm. In cases presenting with an intraspinal mass lesion, possibility of a tuberculous abscess and/or a granuloma should be considered in the differential diagnosis.

Cerebral candidiasis presenting as a mass lesion.

The authors report of a case of pseudotumour caused by Candida species without evidence of any underlying disease. No portal of entry of the infection was found. Total removal followed by treatment with flucanazole resulted in a favorable outcome. We discuss the differential diagnosis of a huge calcified intracranial mass lesion without any soft tissue component.