Bayram Cirak

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

BackgroundVentriculoperitoneal (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.MethodsThe 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.ResultsThe 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.ConclusionIn 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.

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.

A New Model for Tethered Cord Syndrome: A Biochemical, Electrophysiological, and Electron Microscopic Study

In order to investigate the pathophysiology of the tethered cord syndrome, a few experimental models have been developed and used previously. In this study, the authors present a new experimental model to investigate the biochemical, electrophysiological, and histopathological changes in the tethered spinal cord syndrome. A model was produced in guinea pigs using an application of cyanoacrylate to fixate the filum terminale and the surrounding tissue to the dorsal aspect of the sacrum following 5-gram stretching of the spinal cord. The experiments were performed on 40 animals divided into two groups. The responses to tethering were evaluated with hypoxanthine and lipid peroxidation, somatosensory and motor evoked potentials, and transmission electron microscope examination. The hypoxanthine and lipid peroxidation levels significantly increased, indicating an ischemic injury (p < 0.01). The average hypoxanthine level in the control group was 478.8 +/- 68.8 nmol/g wet tissue, while it was 651.2 +/- 71.5 nmol/g in the tethered cord group. The lipid peroxidation level in group I was 64.0 +/- 5.7 nmol/g wet tissue, whereas it was 84.0 +/- 4.7 nmol/g in group II. In the tethered cord group, the latencies of the somatosensory and motor evoked potentials significantly increased, and the amplitudes decreased. These changes indicated a defective conduction in the motor and sensorial nerve fibers. In the transmission electron microscopic examinations, besides the reversible changes like edema and destruction in the gray-white matter junction, irreversible changes like scarcity of neurofilaments and destruction in axons and damage in myelin sheaths were observed. We consider that this work can be used as an experimental model for tethered cord syndrome.

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 patients postoperative recovery was excellent. CONCLUSION According to literature review and our patients 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.

Proton magnetic resonance spectroscopic imaging in pediatric pilomyxoid astrocytoma.

ObjectsA pilomyxoid astrocytoma (PmA) is considered to be either a more aggressive variant of a pediatric pilocytic astrocytoma (PA) or a tumor of a separate entity.MethodsWe present two cases of pediatric optic-chiasmatic PmA. Proton magnetic resonance spectroscopic imaging (MRSI) of the PmA revealed decreased concentrations of total choline (Cho), creatine (Cr), and N-acetyl aspartate (NAA). In contrast, proton MR spectra of PAs showed elevated Cho and decreased Cr and NAA signals.ConclusionLow metabolite concentrations in PmAs detected by MRSI may therefore help to distinguish PmAs from PAs preoperatively.

Fronto-Orbitonasal Intradiploic Meningioma in a Child

Intradiploic meningioma, which may be classified as a subgroup of intraosseous meningioma, is a rarely encountered disorder. To date, less than 10 cases have been reported. Here, we report a case of fronto-orbitonasal intradiploic meningioma. A 12-year-old female with exophthalmos and diplopia was operated on for a cranial intradiploic mass lesion. Histopathological evaluation of the specimen confirmed the diagnosis of intradiploic psammomatous meningioma. Her exophthalmos did not change, but the diplopia disappeared. This case is unique in that it is an extensive case of intradiploic meningioma of the orbital roof and frontal base in a child. Intradiploic meningiomas generally are of psammomatous type. Especially tumors adjacent to the orbita cause exophthalmos; cases located on the other side of the calvarium may not cause any symptom or sign other than headache or sometimes a mass on the scalp. Treatment, as with meningiomas located in the intracranial cavity, is total resection of the lesion.

Melatonin as a free radical scavenger in experimental head trauma

Head trauma causes two kinds of injury in the neural tissue. One is the primary injury which occurs at the time of impact. The other one is a secondary injury and is a progressive process. Free radicals are produced during oxidative reactions formed after trauma. They have been thought to be responsible in the mechanism of the secondary injury. Some studies have been conducted to demonstrate the role of free oxygen radicals in neuronal injury. The alterations in the free radical level during the early posttraumatic period and the effect of a free radical scavenger on these alterations have not been studied as a whole. We aimed to demonstrate the free oxygen radical level changes in the early posttraumatic period and the effect of melatonin, which is a potent free radical scavenger, on the early posttraumatic free radical level. A two-staged experimental head trauma study was designed. In stage one, posttraumatic free radical level changes were determined. In the second stage, the effect of melatonin on the free radical level changes in the posttraumatic period was studied. Two main groups of rats each divided into four subgroups were studied. Rats in one of the main groups underwent severe head trauma, and malondealdehyde (MDA) levels were measured in the contused cerebral tissue at different time points. Rats in the other main group also underwent the same type of trauma, and melatonin was injected intraperitoneally at different time points after trauma. The MDA level alteration in the tissue was determined after the injection of melatonin. The MDA level increased rapidly in the early posttraumatic period. But in time, it decreased in the groups with only trauma. In the melatonin-treated group, the MDA level decreased after the injection of melatonin, when injected in the early posttraumatic period, compared to the control and trauma groups. However, melatonin increased MDA to a higher level than in the groups with only trauma and the control group when injected later than 2 h after trauma. The MDA level increases in the very early posttraumatic period of cerebral trauma and decreases in time. Melatonin, which is the most potent endogenous free radical scavenger, when injected intraperitoneally to the cerebral traumatized rats in the very early posttraumatic period, causes a significant decrease in the MDA level. But, melatonin, when injected more than 2 h after trauma, increases the MDA level in experimental cerebral trauma in rats.

Management of Skull Base Fractures

The risk of developing an intracranial complication after head injury is greater in those who have sustained a skull fracture. Fractures of the basis cranii are usually the result of extension of a vault fracture. The most important complications of these fractures are cerebrospinal fluid (CSF) fistula, related infection and pneumocephalus with fistula, and cranial nerve and intracranial major vessel injury. Although CSF fistulas and posttraumatic meningitis have been discussed extensively in the literature, neurovascular complications of basilar skull fractures have not been so well described. Posttraumatic evaluation and management of basal skull fractures have not yet been standardized. Here, we have classified basal skull fractures according to site and evaluated the posttraumatic complications. Anterior and middle cranial base fractures generally cause upper cranial nerve injuries (I, II, III, IV, V, and VI) and vascular injuries to the carotid artery and middle cerebral artery. Posterior cranial base fractures are associated with injury to the lower cranial nerves (IX, X, XI, and XII) and major venous sinuses. Laterobasal fractures, including those of the petrous bone, are usually associated with deficits of facial and vestibulocochlear nerves (VII and VIII). Controversies in the management of skull base fractures and related complications have gained little attention in medical practice. Many authors have discussed prophylactic antibiotic therapy for CSF fistulas caused by basal skull fractures, but there has not been a standardized protocol for CSF leak management. Early evaluation of skull base fractures and related complications has been discussed in many articles, but the timing of surgical interventions for basal skull fractures and related complications has not been standardized.

IGF(CA)19 and IGFBP-3-202A/C gene polymorphism in patients with acromegaly

OBJECTIVE We aimed to investigate IGF-1 and IGFBP-3 gene polymorphisms in patients with acromegaly. DESIGN We included 34 patients with acromegaly and 37 healthy subjects to study. At baseline examinations, antropometric measurements were done. Genomic DNA from the patients and controls were prepared. Serum, glucose, insulin, total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, growth hormone (GH), Insulin-like growth factor I (IGF-I) and IGFBP-3 levels of subjects were analyzed. RESULTS The frequency of genotype IGF-1(CA)19 and IGFBP3-202 A/C gene was significantly different between control and patients. In acromegalic patients, a significant difference in the serum IGF-1 levels and LDL cholesterol levels among the three IGF(CA)19 genotype. LDL levels were positively correlated with IGF-1. Subjects having >194 bp genotype had higher IGF-1 and LDL cholesterol levels. We observed that the patients with 194 bp genotype have more invasive and bigger tumors and they require adjunctive therapies. Clinical characteristics among the three IGFBP3-202 A/C genotype, AA, AC and CC, did not display any significant difference. CONCLUSIONS In our study, 194 bp allele (20 CA repeats) of the IGF-I promoter have higher circulating IGF-I levels than others. We have found that the patients with 194 bp genotype are the resistant patients with active disease and they required high dose medication. We think this study may help to define the patients, who are resistant to drug therapy, and possible cardiovascular disease.

Brain stem abscesses in childhood

BackgroundSolitary brain stem abscess is a rare condition with high mortality and morbidity. These lesions were considered to be invariably fatal before 1974 when advanced diagnostic tools were not available. Recently, the diagnosis and prognosis of brain stem abscesses have been modified by the introduction of modern radiological tools, and several patients with a favorable outcome have been reported since then. Because the pons is the most common site of the abscesses, involvement of the sixth and seventh nerves is frequent. The midbrain is the second most likely location, and medullary abscesses are distinctly rare. Treatment of a brain stem abscess includes medical therapy alone, open microsurgical intervention, or stereotactic aspiration.Case reportWe report a case of a 7-year-old girl with a solitary brain stem abscess. Her neurological examination revealed involvement of the cranial nerves and pyramidal tracts. Microsurgical exposure and aspiration of the abscess resulted in rapid improvement in her neurological condition and radiological resolution of the lesion. We discuss this uncommon case to draw attention to the importance of early diagnosis and adequate treatment, and we review the relevant literature.