Effects of Low-Dose Unfractionated Heparin Pretreatment on Early Brain Injury after Subarachnoid Hemorrhage in Mice.

Heparin is a pleiotropic drug that antagonizes many pathophysiological mechanisms. In this study, we evaluated whether heparin prevents early brain injury (EBI) after subarachnoid hemorrhage (SAH) in mice. SAH was induced by endovascular perforation in mice randomly assigned to sham-operated (n = 8), SAH + vehicle (n = 12), SAH + 10 U heparin pretreatment (n = 11), and SAH + 30 U heparin pretreatment (n = 14) groups. At 24 h post-SAH, severity of SAH, neurological scores, and brain water content were evaluated. Low-dose heparin pretreatment improved neurobehavioral function, and decreased brain edema in the ipsilateral cerebral hemisphere to the perforation side. High-dose heparin had a tendency for increased SAH, which obscured the neuroprotective effects by heparin. Low-dose heparin pretreatment may decrease the development of post-SAH EBI.

Spontaneous elevation of a ping-pong fracture: case report and review of the literature.

Depressed skull fractures compromise 7-10% of the children admitted to hospital with a head injury. Depressed skull fractures that occur in children younger than 1 year are different from those found in older children. In neonates and infants, a depressed fracture forms an inward buckling of the bones forming a 'cup shape', termed a 'ping-pong fracture'. In neonates, spontaneous elevation of a ping-pong fracture after birth trauma is well documented. However, in infants, spontaneous elevation of a ping-pong fracture following head injury is extremely rare. Here, we present the case of an 11-month-old child, in whom a ping-pong fracture was spontaneously elevated within 2 h. In addition, the relevant literature is reviewed and discussed.

Subarachnoid Hemorrhage and Sevoflurane.

AIM: To examine whether post-treatment sevoflurane is protective against early brain injury (EBI) after subarachnoid hemorrhage (SAH) and how this neuroprotective effect occurs at different concentrations and durations of administration in mice. Furthermore, we tested whether the neuroprotective effect of post-treatment sevoflurane is associated with inhibition of apoptosis. MATERIAL AND METHODS: SAH was induced in mice by endovascular perforation. Animals were randomly assigned to five groups in each study. Study 1, sham-operated; SAH+vehicle-air; and SAH+1.5% sevoflurane for 30, 60, and 90 min. Study 2, SAH+3% sevoflurane for 30, 60, and 90 min. Study 3, SAH+4.5% sevoflurane for 30, 60, and 90 min. Neurobehavioral function and brain edema (brain water content) were evaluated 24 h after SAH. Neuroglial cell death was examined by terminal deoxynucleotidyl transferase-mediated uridine 5′-triphosphate-biotin nick end-labeling (TUNEL) staining. RESULTS: Administration of 1.5% sevoflurane for 60 min and 3% sevoflurane for 30 and 60 min significantly improved neurobehavioral function, brain edema, and attenuated neuronal cell death in the basal cortex at 24 h after SAH. CONCLUSION: Administration of 1.5% sevoflurane for 60 min and 3% for 30 and 60 min sevoflurane application attenuated the development of EBI after SAH, implying its use for anesthesia during acute aneurysm surgery or intervention.

The Vasorelaxant and Neuroprotective Effects of Mildronate in A Rabbit Subarachnoid Hemorrhage Model.

AIM: To investigate the effects of an anti-ischemic agent, mildronate, on subarachnoid hemorrhage-induced vasospasm. MATERIAL AND METHODS: Rabbits were randomly divided into four groups: control, subarachnoid hemorrhage (SAH), vehicle, and mildronate (n=8 animals per group). In the treatment group, 200 mg/kg of mildronate were intraperitoneally administered 5 minutes after the procedure and continued for 3 days as daily administrations of the same dose. At the end of the third day, the cerebrum, cerebellum, and brain stem were perfused, fixated, and removed for histopathological examination. Tissues were examined for arterial wall thickness, luminal area, and hippocampal neuronal degeneration. RESULTS: Mildronate group showed significantly increased luminal area and reduced wall thickness of the basilar artery compared with the subarachnoid hemorrhage group. In addition, the hippocampal cell degeneration score was significantly lower in the mildronate group than in the SAH and vehicle groups. CONCLUSION: These results show that mildronate exerts protective effects against SAH-induced vasospasm and secondary neural injury.

Identification of Risk Factors for Postoperative Cerebrospinal Fluid Leakage and Comparison of Two Alternative Dural Augmentation Techniques in Posterior Fossa and Spinal Surgeries.

AIM: To investigate comparative efficacy of a novel absorbable adhesive membrane (TissuePatchDuralTM "TPD") and a fibrin glue (Tisseel "T") in reducing cerebrospinal fluid (CSF) leaks after posterior fossa and spinal procedures, and also to identify potential risk factors for CSF leakage. MATERIAL AND METHODS: This is a single-center, retrospective cohort study of 123 consecutive posterior fossa (n=77) and spinal (n=46) surgeries. Patients were grouped based on dural sealants used 2-group comparison: TPD (n=56) vs. no-TPD (n=67) and 3-group comparison: T only (n=43), TPD only (n=32) vs TPD+T (n=35). RESULTS: Mean age was 38.9 ± 22.2 years (62 males, 61 females). Baseline characteristics were similar between groups. Neither 2-group (TPD: 10.4% vs no-TPD: 8.9%; p=0.778) nor 3-group (T: 9.3% vs TPD: 6.3% vs TPD+T: 14.3%; p=0.539) comparisons revealed a significant difference in postoperative CSF leakage rates. Multivariate analysis showed that diagnosis (non-tumoral vs. tumor) (OR: 5.487; 95% CI: 1.118-26.937; p=0.036); previous surgery (OR: 9.268; 95% CI: 1.911-44.958; p=0.006), postoperative hydrocephalus (OR: 5.456; 95% CI: 1.250-23.821; p=0.024) were independent predictors of postoperative CSF leakage. CONCLUSION: TissuePatchDural < sup > TM < /sup > is a novel dural sealant patch which can be safely used to reinforce dural closure in posterior fossa and spinal surgeries, and its efficacy is comparable to widely used fibrin glue (Tisseel). Non-tumoral pathologies, previous surgery, and postoperative hydrocephalus appear to be independent risk factors for postoperative CSF leakage.

Medullomyoblastoma: teratoid nature of a quite rare neoplasm.

BACKGROUND: Medullomyoblastoma is a quite-rarely reported biphasic histologic variant of medulloblastoma since the first published description of a tumor consisting of medulloblastic and myogenic elements. Controversy over its origin still goes on. Here, an additional case of medullomyoblastoma variant is reported, and discussed are the clinicopathologic features and pathophysiologic mechanisms of and treatment options for this neoplasm. CASE REPORT: A 7-year-old girl was admitted to our clinic with headache, vomiting, and gait disturbances. An MRI scan on admission showed a solid tumor with a 2.5-cm axial diameter located in cerebellar vermis. The tumor was removed totally. Histologic examination revealed loose mesenchymal structures of the tumor and small muscle strands and isolated cells having large eosinophilic cytoplasm with striations. The muscular strands also demonstrated striations under light microscope. Glial fibrillary acidic protein, synaptophysin, and myogenin positivity are observed. CONCLUSION: There are some strong evidences that the medullomyoblastoma may be a teratoma. Survival time with the tumor is very short, outcome is poor, and the tumor can spread along cerebrospinal fluid pathways. Total resection, chemotherapy, and craniospinal irradiation are mainstays of the treatment of medullomyoblastomas.

Spinal subdural abscess: a rare cause of low back pain.

Spinal subdural abscess (SSA) is a rare but well-described entity. It may occur secondary to a systemic infectious focus or following a surgical procedure. There are only two SSA cases in the literature that are unrelated to such conditions and without any well-documented etiology. SSA is a neurosurgical emergency and diagnosis may be difficult. Progressive neurological deficits and severe pain with fever suggest the diagnosis. Surgical drainage and subsequent prompt antimicrobial therapy should be performed without delay. We report a patient with SSA unrelated to any predisposing condition and discuss underlying mechanisms of this disease.

Cervico-medullary compression ratio: A novel radiological parameter correlating with clinical severity in Chiari type 1 malformation.

OBJECTIVES: Chiari malformation type 1 (CM-1) is associated with cough headache, intracranial hypertension, cerebellar and spinal cord symptoms/signs. Herniated cerebellar tonsil length (HCTL) is widely used radiological parameter to determine the severity of CM-1, but with limited utility due to its weak correlation with some clinico-radiological findings. In this study, we aimed to evaluate a novel, practical parameter (cervico-medullary compression ratio; "CMCR") for its relationship with clinico-radiological findings in CM-1. PATIENTS AND METHODS: Thirty-five adult patients (17 F, 18 M) with CM-1 were included in this retrospective study. Head CT and craniospinal MR images were assessed. CMCR was calculated as the ratio of herniated cerebellar tonsil surface area to foramen magnum surface area, and HCTL was measured. These two parameters were correlated with clinical and radiological findings. RESULTS: The mean CMCR was 0.60 ± 0.15 and mean HCTL was 8.91 ± 3.4 mm with no significant difference between gender and age groups for both parameters. For cough headache (0.64 ± 0.14 vs 0.52 ± 0.15, p = 0.043) and syringomyelia (0.67 ± 0.11 vs 0.56 ± 0.16, p = 0.039), only CMCR; for intracranial hypertension (CMCR: 0.64 ± 0.14 vs 0.55 ± 0.16, p = 0.049; HCTL: 9.66 ± 3.59 mm vs 7.79 ± 3.03 mm; p = 0.045) and cerebellar symptoms (CMCR: 0.65 ± 0.14 vs 0.54 ± 0.16, p = 0.048; HCTL: 10.4 ± 3.5 mm vs 7.4 ± 2.8 mm, p = 0.041), both CMCR and HTCL were significantly different between patients with and without respective findings. However, neither CMCR nor HTCL was different between patients with and without spinal cord symptoms and hydrocephalus. CONCLUSION: CMCR is a superior numerical parameter than HCTL for the assessment of clinical severity in CM-1 cases and needs further validation with larger studies.

Revisiting Ligament-Sparing Lumbar Microdiscectomy: When to Preserve Ligamentum Flavum and How to Evaluate Radiological Results for Epidural Fibrosis.

OBJECTIVE: Preserving the ligamentum flavum (LF) during lumbar spine surgery can help to limit the extent of postoperative epidural fibrosis (EF), which is a potential cause of persistent leg pain. We present a retrospective analysis of microdiscectomy with preservation of the LF to evaluate the effects of the two LF mobilizing techniques (reflecting inferiorly or medially vs. removing completely) on EF and clinical outcomes. METHODS: Microdiscectomy was performed through a unilateral laminotomy in 93 patients (52 male, 41 female; mean age, 46 years; range, 25-65 years) with L3-L4 (n = 3), L4-L5 (n = 40), and L5-S1 (n = 50) lumbar disc herniation. Patients whose LF was removed were assigned to group 1 (n=42), and patients whose LF was preserved by mobilizing it medially (n = 31) or inferiorly (n = 20) were assigned to groups 2 and 3, respectively. Follow-up visual analog scale (VAS) scores and magnetic resonance images were evaluated. RESULTS: EF scores, particularly for the anterior quadrants, were significantly higher in group 1 than in groups 2 (P = 0.012) and 3 (P = 0.001). Likewise, postoperative VAS scores in group 1 were also significantly higher than in groups 2 (P = 0.009) and 3 (P = 0.044). CONCLUSIONS: Our results demonstrate that 1) preserving the LF during lumbar microdiscectomy reduces the formation of postoperative EF and improves clinical outcomes; 2) EF in the anterior, rather than the posterior epidural space, is correlated with clinical results; and 3) the ligament mobilizing technique used should be individually tailored on the basis of the features of disc herniation.

Experience Reduces Surgical and Hardware-Related Complications of Deep Brain Stimulation Surgery: A Single-Center Study of 181 Patients Operated in Six Years.

OBJECTIVE: Deep brain stimulation (DBS) surgery has increasingly been performed for the treatment of movement disorders and is associated with a wide array of complications. We aimed to present our experience and discuss strategies to minimize adverse events in light of this contemporary series and others in the literature. METHODS: A retrospective chart review was conducted to collect data on age, sex, indication, operation date, surgical technique, and perioperative and late complications. RESULTS: A total of 181 patients (113 males, 68 females) underwent DBS implantation surgery (359 leads) in the past six years. Indications and targets were as follows: Parkinson's disease (STN) (n=159), dystonia (GPi) (n=13), and essential tremor (Vim) (n=9). Mean age was 55.2 ± 11.7 (range 9-74) years. Mean follow-up duration was 3.4 ± 1.6 years. No mortality or permanent morbidity was observed. Major perioperative complications were confusion (6.6%), intracerebral hemorrhage (2.2%), stroke (1.1%), and seizures (1.1%). Long-term adverse events included wound (7.2%), mostly infection, and hardware-related (5.5%) complications. Among several factors, only surgical experience was found to be related with overall complication rates (early period: 31% versus late period: 10%; p=0.001). CONCLUSION: The rates of both early and late complications of DBS surgery are acceptably low and decrease significantly with cumulative experience.

Cervical compression myelopathy: is fusion the main prognostic indicator?

OBJECT: A variety of factors may affect the neurological improvement in patients with cervical compression myelopathy (CCM) after surgery. The aim of this study was to report and discuss the prognostic factors in a group of patients with insufficient decompression of the spinal canal. METHODS: A prospective follow up and analysis of 20 consecutive patients with CCM treated between 2000 and 2002 was performed. All patients were surgically treated via an anterior approach, either by anterior cervical discectomy and fusion with instrumentation or by cervical corpectomy and fusion with instrumentation. The surgical results were examined using the modified Japanese Orthopaedic Asssociation disability scale, with reference to the findings of magnetic resonance imaging, computed tomography, and radiography. Seventeen patients (85%) experienced a 50% or more recovery rate as calculated using the Hirabayashi formula during the follow-up period (mean 32.5 months), despite a persistently narrow spinal canal and permanent or increased intramedullary high-intensity signal after surgery. CONCLUSIONS: Results of the study showed that patients with CCM benefited from anterior cervical discectomy and fusion with instrumentation or cervical corpectomy and fusion with instrumentation procedures despite insufficient decompression of the spinal canal. Fusion of the affected level(s) might be the reason for the acquired high recovery rates. The authors also conclude that the neurological improvement is not correlated with the reversal of or decrease in the intramedullary high-intensity signal change after surgery.

Corticosteroid pre-treated primary CNS lymphoma: a detailed analysis of stereotactic biopsy findings and consideration of interobserver variability.

Prior corticosteroid therapy presents a major challenge in the diagnosis of CNS lymphomas, particularly in stereotactic biopsies. In this study we analysed the cytological, histopathological and immunohistochemical features in stereotactic biopsies of 25 primary CNS lymphoma cases pre-treated with corticosteroids. We documented the extent and the frequency of each finding. We also investigated the significance of subjectivity in evaluation of these biopsies in 3 seperate sessions including the final diagnostic decision. In 48% of our cases the diagnosis was straightforward. These cases were characterized by prominent blasts either in diffuse paranchymal infiltrates or in perivascular regions. The remaining 52% demonstrated some degree of variability among pathologists. Lymphoid atypia other than the typical blastic morphology appeared as a subjective finding and this was more pronounced in cytology preparations. In our study, corticosteroid pre-treatment in primary CNS lymphoma was associated with a large spectrum of histopathological, immunohistochemical and cytological findings. Combined use of an extended immunohistochemical panel would increase the possibility of conclusive diagnosis. Nevertheless some of these findings and therefore the diagnosis are open to subjectivity.

The impact of antibiotic-impregnated catheters on ventriculoperitoneal shunt infection.

BACKGROUND/AIM: Ventriculoperitoneal shunt infections remain an important problem and result mainlyfrom perioperative colonization of shunt components by skin flora. Antibiotic-impregnated shunts have been designed to prevent such colonization. T'his study evaluates the incidence of shunt infection after the insertion of antibiotic-impregnated shunts in a population of children with hydrocephalus. MATERIALS AND METHODS: All pediatric patients who had undergone cerebrospinal fluid shunt insertion retrospectively were reviewed over a 6-year period between May 2004 and December 2010. The primary outcome measure was the rate of shunt infections. Patients were followed up with for an average of 26.2 months after shunt surgery, and shunt infections were evaluated. RESULTS: A total of 123 pediatric patients underwent 211 shunt placement procedures. Of these operations, 193 (91%) were performed with nonimpregnated catheters and 18 shunts (9%) were placed with antibiotic-impregnated shunt catheters. Of the patients with nonimpregnated catheters, 12 (6%) experienced shunt infection, whereas none of the patients with antibiotic-impregnated catheters experienced shunt infection within the 26.2-month follow-up period (P < 0.01). CONCLUSION: The antibiotic-impregnated catheters significantly reduced the incidence of shunt infection in children with hydrocephalus during the postoperative period. Antibiotic-impregnated catheters are effective devices to prevent perioperative colonization of shunt components.

L'hermitte-Duclos disease in an elderly patient: A case report and review of the literature.

L'hermitte-Duclos disease (LDD) is an extremely rare cerebellar lesion of uncertain etiology. Occasionally, the patients with LDD may even have sudden neurological deterioration due to acute heniation as seen in the present case report. It is also imperative to distinguish this disease from other malignant lesion of the cerebellum and cerebellar malformations with its varied natural course of history and hence better ability to prognosticate such patients. Herein, we reported a successfully treated case of LDD following a long history of vaguely defined neurological complaints in an elderly patient and reviewed the literature.

Is intraoperative ultrasound required in cervical spinal tumors? A prospective study.

AIM: To determine the role of intraoperative ultrasonography (IOUSG) in the surgical management of patients with intradural spinal tumors. MATERIAL AND METHODS: Twenty-six patients with intradural spinal cord tumors were surgically treated under intraoperative ultrasonographic guidance between January 2007 and May 2011. Guidance with IOUSG was used in 26 patients, of which 14 fourteen had extramedullary and 12 had intramedullary tumors. Intraoperative ultrasound assistance was used to localize each tumor exactly before opening the dura. The extent of tumor resection was verified using axial and sagittal sonographic views. The extent of tumor resection achieved with IOUSG guidance was assessed on postoperative early control MRI sections. RESULTS: Total tumor resection was achieved in 22 (84%) of 26 cases. All of the residual tumors were typically intramedullary and infiltrative. The sensitivity of IOUSG for the determination of the extent of resection was found to be 92%. Ultrasonography was found to be effective in identification of tumor boundaries and protection of spinal cord vessels. The average time spent for IOUSG assessment was 7 minutes. CONCLUSION: Intraoperative ultrasonography is practical, reliable and highly sensitive for spinal cord surgery. It not only enhances surgical orientation, but also reduces morbidity and helps to resect the tumor completely.

The protective effect of low-dose methotrexate on ischemia-reperfusion injury of the rabbit spinal cord.

Methotrexate was developed as a cytostatic agent, but at low doses, it has shown potent anti-inflammatory activity. Previous studies have demonstrated that the anti-inflammatory effects of methotrexate are primarily mediated by the release of adenosine. In this study, we hypothesized that low-dose methotrexate has protective effects in spinal cord ischemia-reperfusion injury. Rabbits were randomized into the following four groups of eight animals each: group 1 (control), group 2 (ischemia), group 3 (methylprednisolone) and group 4 (methotrexate). In the control group only a laparotomy was performed. In all the other groups, the spinal cord ischemia model was created by the occlusion of the aorta just caudal to the renal artery. Neurological evaluation was performed with the Tarlov scoring system. Levels of myeloperoxidase, malondialdehyde and catalase were analyzed, as were the activities of xanthine oxidase and caspase-3. Histopathological and ultrastructural evaluations were also performed. After ischemia-reperfusion injury, increases were found in the serum and tissue myeloperoxidase levels, tissue malondialdehyde levels, xanthine oxidase activity and caspase-3 activity. In contrast, both serum and tissue catalase levels were decreased. After the administration of a low-dose of methotrexate, decreases were observed in the serum and tissue myeloperoxidase levels, tissue malondialdehyde levels, xanthine oxidase activity and caspase-3 activity. In contrast, both the serum and tissue catalase levels were increased. Furthermore, low-dose methotrexate treatment showed improved results concerning the histopathological scores, the ultrastructural score and the Tarlov scores. Our results revealed that low-dose methotrexate exhibits meaningful neuroprotective activity following ischemia-reperfusion injury of the spinal cord.

Operative illustrations of the Osborne's ligament.

The cubital tunnel syndrome is widely considered as the second most frequent compression neuropathy in the upper extremities although the existence of a compressive cause has not been determined conclusively. As far as we know, operational photography of compression of the ulnar nerve at the elbow is almost never found in the literature. In this paper, operational and pathological photographs of the Osborne's ligament as a cause of ulnar entrapment neuropathy at the elbow are presented. There is still an ambiguity as to whether compressive or tractional etiology or both of these factors may occur progressively to be a factor in the development of neuropathy. This report may be considered as concrete evidence for the compressive etiology for ulnar neuropathies.