Aysenur Cila

Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Measurement of vertebral rotation in standing versus supine position in adolescent idiopathic scoliosis

Thirty-three structural curves of 25 patients with adolescent idiopathic scoliosis were evaluated using computed tomography (CT) scans and plain radiography. The average Cobb angle on standing radiographs was 55.72° and was observed to be corrected spontaneously to 39.42° while the patients were in supine position (29.78% correction). Average apical rotation according to Perdriolle was 22.75° on standing radiographs and 16.78° on supine scanograms. The average rotation according to Aaro and Dahlborn on CT scans was 16.48°. Radiographic measurements were significantly different from axial CT slice or scanogram measurements (p = 0.000), but the two latter measurements, both obtained in the supine position, did not appear to be different (p = 0.495). Deformities on the transverse plane as well as on the coronal plane are influenced by patient positioning. If the patient lies supine, the scoliosis curve corrects spontaneously to some degree on both planes. Measurements obtained from the scanograms by the Perdriolle method in the supine position are very similar to those obtained by CT. Perdriolles is a simple, convenient, and reliable method to measure rotation on standing radiograms.

Is diffusion-weighted imaging useful in grading and differentiating histopathological subtypes of meningiomas?

PURPOSE Meningiomas are mostly benign, however atypical or malignant subtypes with more aggressive clinical course and higher recurrence rates can also be seen. The purpose of this study was to determine whether histopathological subtypes of meningiomas could be assessed preoperatively using apparent diffusion coefficient (ADC) values. MATERIALS AND METHODS Conventional magnetic resonance (MR) and diffusion-weighted (DW) imaging of 177 adult patients with pathologically proven meningiomas were retrospectively evaluated. Tumor size and the degree of associated edema were noted. The signal intensity of the lesions on DW imaging was evaluated and graded. Mean ADC values were obtained as the mean of measurements from three regions of interests within the mass. ADC ratios of meningioma/contralateral normal appearing subcortical parietal white matter were also calculated. RESULTS The histopathological analysis revealed 135 benign, 37 atypical and 5 malignant lesions. With classification according to the subtype, the mean ADC values and ratios of benign meningiomas were as 0.99±0.12×10(-3) mm(2)/s and 1.22±0.07, respectively. ADC values for atypical and malignant groups were both 0.84±0.1×10(-3) mm(2)/s. The ADC ratios were 1.05±0.1 and 0.96±0.2 for atypical and malignant subtypes, respectively. There was no statistically significant difference between the mean ADC ratios of the three subtypes (ANOVA test; P≥0.05). Gender, age of the patients and tumor size showed no statistically significant difference between the different histological groups. CONCLUSION DW MR imaging was not found to have any additional value in determining histological behaviour nor in differentiating histopathological subtypes of meningiomas.

The effect of clozapine on regional cerebral blood flow and brain metabolite ratios in schizophrenia: Relationship with treatment response

The purpose of this study was to investigate the effect of clozapine on regional cerebral blood flow (rCBF) and its relationship with response to treatment. In addition, we aimed to study the influence of clozapine on proton magnetic resonance spectroscopy ((1)H-MRS) findings in the dorsolateral prefrontal cortex (DLPFC) in a subgroup of patients. Psychopathology, neurocognitive functioning, and SPECT imaging of 22 patients were assessed at the baseline and 8 weeks after the initiation of clozapine treatment. In 10 of these patients intermediate-echo (TE: 135 ms) single-voxel (1)H-MRS was also performed at the baseline and after 8 weeks. Clozapine treatment increased the right frontal (superior and medial)/caudate perfusion ratio in the whole group, while it increased bilateral frontal (superior and medial)/caudate perfusion ratios in treatment responders. In addition, percentage changes in left and right frontal (superior and medial)/caudate perfusion ratios compared to the baseline were higher in treatment responders than in non-responders. The improvement in attention was related to the increase in percentage change in the right frontal (superior and medial)/caudate perfusion ratio, while the improvement in verbal fluency was related to the increase in percentage changes in both right and left frontal (superior and medial)/caudate perfusion ratios and to right frontal (superior and medial)/thalamus perfusion. Baseline frontal (superior and medial)/thalamus perfusion could explain 32% of the variability of percentage improvements in psychopathology. (1)H-MRS showed that the baseline PANSS general psychopathology score was inversely correlated with the baseline NAA/Cre ratio. An increased NAA/Cre ratio in DLPFC after 8 weeks of clozapine treatment was also revealed by (1)H-MRS. Our SPECT imaging results suggest the presence of an imbalance in fronto-striato-thalamic circuitry that changes with clozapine, especially in the responders, while (1)H-MRS results indicate a supportive effect of clozapine on neuronal integrity.

Course of nonsurgical management of burst fractures with intact posterior ligamentous complex: an MRI study.

Study Design. Prospective study. Objectives. To evaluate the results of nonsurgical management of burst fractures with intact posterior ligamentous complex and to investigate the effect of trauma and/or residual kyphotic deformity on adjacent and next adjacent (neighboring) discs. Summary of Background Data. Conservative treatment based on integrity of posterior ligamentous complex is controversial, probably because of poor evaluation by clinical and indirect radiographic findings. Degenerative changes in the adjacent discs due to trauma and/or residual kyphotic deformity is a common expectation. Material and Methods. Fifteen consecutive patients who were intact neurologically with burst fractures (T11-L2) were treated nonsurgically with the indication based solely on the integrity of posterior ligamentous complex determined by MRI. Correction of deformity and stabilization with a total body cast under sedation were the mainstays of treatment. Patients were mobilized the next day, and casts were removed at the end of the third month follow-up period with no further external stabilization. Local kyphosis angle, sagittal index, and percent of compression of anterior body height were measured on pretreatment, post-treatment, third month, and latest follow-up radiographs. All of the preoperative and latest follow-up MRI studies of the patients were obtained to examine the discs adjacent and next adjacent to the fractured levels. The self-reported perceptions of the patients of function, pain and appearance were analyzed using the Likert Questionnaire. Results. There were eight female and seven male patients with an average age of 28 (range, 15–49) years. Average follow-up period was 31 (range, 24–51) months. Average local kyphosis angle was found to be 16.5° (0–34°) after trauma. It was corrected to 5° (range, 19–25°) and deteriorated to 14.6° (range, 2–25°) at the third month and to 17° (range, 2–29°) at the final follow-up review. There was a similar tendency for both sagittal index and percent anterior body height. The pretreatment MRI analysis revealed changes in the shape of the discs (narrowing or herniation into the body) with no change in the signal intensity of nucleus pulposus in eight of the cranial and four of the caudal adjacent discs. On follow-up MRI, there was only one intact disc with a normal shape cranially. All others had height loss, but only one had complete loss of signal intensity. Caudally, two additional discs had changes in shape without any gross changes in signal intensity of nucleus pulposus, whereas two had changes in signal intensity without change in shape. Only two of the next adjacent discs had changes in shape or signal intensity at the time of injury or at latest follow-up review. Average score of function, pain, and appearance were 3.9 (range, 3–5), 3.7 (range, 2–5), and 3.7 (range, 2–5), respectively, at the latest follow-up review. All patients were back at work in 3.6 (range, 1–9) months on average and all were satisfied with their treatment. Conclusions. The present study revealed that an intact posterior ligamentous complex might not prevent loss of correction gained by nonsurgical management of burst fractures. Significant loss occurs in the first 3 months despite external stabilization. However, the magnitude of residual deformity usually remains close to the initial deformity. Although changes in the shape of adjacent discs occur due to trauma and/or natural course, significant loss in signal intensity of nucleus pulposus is unlikely. Patient outcome seems to be highly satisfactory despite residual deformity.

Multilevel myelopathy in Maroteaux-Lamy syndrome and review of the literature

An 18-year-old male with Maroteaux-Lamy syndrome was presented with spastic quadriparesis. Magnetic resonance imaging of whole spinal canal revealed stenosis at multiple levels of cervical, thoracic and lumbar regions. By the guidance of combined evaluations of neurological examination, neuroradiological and electrophysiological findings, the most responsible spinal segment was detected each time he developed myelopathy and he underwent craniocervical, cervical and thoracolumbar decompressions consecutively. Ligamentum flavum hypertrophy was found to be the principal pathology responsible for the cord compression and myelopathy for all levels. The etiology of myelopathy and priority of the level for which decompression should be done in diffuse spinal stenosis were discussed with the literature review of Maroteaux-Lamy syndrome.

Cockayne syndrome: Review of 25 cases

Clinical and laboratory findings of 25 patients with classical Cockayne syndrome (CS) are reviewed. A history of consanguinity was present in 21 patients, and 15 patients had at least 1 affected sibling. Apart from the cardinal features of dwarfism, microcephaly, and mental retardation, the most consistent clinical features included photosensitivity (84%), gait disturbances (84%), progeroid appearance (84%), and ocular abnormalities (88%). The most consistent laboratory findings comprised abnormal nerve conduction (slowed conduction in 13 of the 16 cases with an ENMG), and an abnormal brainstem auditory evoked response (BAER) and/or audiometry (abnormal in 13 of the 17 cases in whom either one of them were available). Cerebral atrophy and calcification of the basal ganglia were the next more common laboratory findings. Clinical criteria are useful in most instances in the diagnosis of CS. In patients in whom the clinical features are controversial for a diagnosis of Cockayne syndrome, studies directed to disorders of myelination involving both peripheral and central nervous systems in conjunction with audiometry may aid in the diagnosis.

Multifocal fibrosclerosis: a new case report and review of the literature.

Abstract. A case of multifocal fibrosclerosis is presented with MR images. Bilateral sclerosing orbital pseudotumor invading cavernous sinuses were the presenting disorder. Magnetic resonance imaging showed involvement of paranasal sinuses bilaterally and multiple supratentorial dural masses. Retroperitoneal fibrosis was associated with the condition. Multifocal involvement should be considered in patients with sclerosing orbital pseudotumor and an imaging approach should be performed on the appropriate clinical condition to document possible coexistence of other disorders including retroperitoneal fibrosis, mediastinal fibrosis, sclerosing cholangitis, and Riedels thyroiditis

Diffusion-weighted MR imaging and MR spectroscopy in glutaric aciduria type 1

Although conventional magnetic resonance imaging (MRI) findings of glutaric aciduria type 1 (GA-1) have been well established, diffusion weighted MR imaging (DWI) and proton MR spectroscopy (MRS) findings are limited. We report widespread restricted diffusion in the white matter and increased diffusion in bilateral putamen in a case of GA-1. The MRS showed decreased N-acetyl-aspartate (NAA)/creatine (Cr) ratio compared with a sex and age-matched control with no significant change in choline (Cho)/Cr ratio. The presence of the lactate peak reflecting disturbed mitochondrial functions in this disease has never been reported.

Diffusion MR Imaging Features of Skull Base Osteomyelitis Compared with Skull Base Malignancy

BACKGROUND AND PURPOSE: SBO is a life-threatening infection that may have radiologic features similar to those of the neoplastic processes. The purpose of this study was to evaluate the DWI findings in SBO to facilitate the differential diagnosis. MATERIALS AND METHODS: The MR imaging findings of 9 patients with SBO were retrospectively evaluated and compared with MR imaging studies from 9 patients with NPC, 9 with lymphoma, and 9 with metastatic disease of the skull base. ADC measurements were performed from the ADCST and the ADCNST in all 4 groups. RESULTS: The mean ADCST values were 1.26 ± 0.19 × 10−3 mm2/s for SBO, 0.74 ± 0.18 × 10−3 mm2/s for NPC, 0.59 ± 0.11 × 10−3 mm2/s for lymphoma, and 0.99 ± 0.34 × 10−3 mm2/s for metastatic disease, respectively. The mean ADC value of SBO was significantly higher than those of NPC and lymphoma (P < .0001). There was no significant difference for the comparison of SBO and metastatic lesions. When an ADC value equal to or higher than 1.08 × 10−3 mm2/s was used to rule out lymphoma and NPC, the accuracy was 96%. CONCLUSIONS: Although SBO is a relatively rare condition, its differential diagnosis from neoplastic processes of the skull base is essential to start appropriate treatment promptly. ADC values may help to distinguish patients with SBO from those with malignant lesions.