Bektas Acikgoz

Intramedullary spinal cord metastases: diagnosis and treatment – an illustrated review

Summary.Background. Intramedullary spinal cord metastases (ISCM) are rare but, with increasing use of magnetic resonance imaging (MRI) are being encountered with increasing frequency. Optimum treatment remains controversial. On the basis of a review of previous reports and experience with a patient with an ISCM from a large cell lung cancer, we propose practical diagnostic and therapeutic approaches.Findings. We found 284 patients who had an Intramedullary spinal cord metastasis reported in English literature up to February 2004. 32 had been treated surgically. The mean survival in these patients was two times longer than in those treated by a conservative approach. Improvement and prolonged survival occurred in patient we treated by microsurgical dissection of the metastasis.Conclusion. Early diagnosis and early surgical resection can result in improvement in neurological deficits and in the quality of life of patients with a Intramedullary spinal cord metastasis.

A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery.

&NA; General and regional anesthesia (spinal and epidural) can be performed successfully for lumbar disc surgery. The aim of this study was to assess the superiority of general anesthesia or epidural anesthesia techniques in lumbar laminectomy and discectomy. Sixty patients undergoing lumbar partial hemilaminectomy and discectomy were randomly divided into two groups receiving standardized general anesthesia (GA) or epidural anesthesia (EA). Demographically, both groups were similar. Surgical onset time (36.72 ± 5.47 vs. 25.40 ± 7.83 minutes) was longer in the EA group, but total anesthesia time (154.32 ± 35.73 vs. 162.40 ± 26.79 minutes) did not differ between the two groups. Surgical time (118.80 ± 35.42 vs. 139.60 ± 26.80 minutes) was longer in the GA group. The heart rate and mean arterial pressure values of the EA group measured 15, 20, and 25 minutes after local anesthetic administration to the epidural catheter were found to be lower than in the GA group measured after induction of general anesthesia. The frequency of bradycardia (EA vs. GA, 3 vs. 2), tachycardia (3 vs. 7), and hypotension (6 vs. 4) during anesthesia did not differ between the groups, but the occurrence of hypertension (1 vs. 7) was higher in the GA group. Blood loss was less in the EA group than in the GA group (180.40 ± 70.38 vs. 288.60 ± 112.51 mL). Postanesthesia care unit (PACU) heart rate and mean arterial pressure were higher in the GA group. Peak pain scores in PACU and postoperative 24 hours were higher in the GA group when compared with the EA group. Nausea was more common in the GA group both in PACU and 24 hours after surgery. There was no difference between the hospitalization duration of the groups. In conclusion, this study suggests that EA is an important alternative to GA during lumbar disc surgery.

Effect of coenzyme Q10 on ischemia and neuronal damage in an experimental traumatic brain-injury model in rats.

BackgroundHead trauma is one of the most important clinical issues that not only can be fatal and disabling, requiring long-term treatment and care, but also can cause heavy financial burden. Formation or distribution of free oxygen radicals should be decreased to enable fixing of poor neurological outcomes and to prevent neuronal damage secondary to ischemia after trauma. Coenzyme Q10 (CoQ10), a component of the mitochondrial electron transport chain, is a strong antioxidant that plays a role in membrane stabilization. In this study, the role of CoQ10 in the treatment of head trauma is researched by analyzing the histopathological and biochemical effects of CoQ10 administered after experimental traumatic brain injury in rats. A traumatic brain-injury model was created in all rats. Trauma was inflicted on rats by the free fall of an object of 450 g weight from a height of 70 cm on the frontoparietal midline onto a metal disc fixed between the coronal and the lambdoid sutures after a midline incision was carried out.ResultsIn the biochemical tests, tissue malondialdehyde (MDA) levels were significantly higher in the traumatic brain-injury group compared to the sham group (p < 0.05). Administration of CoQ10 after trauma was shown to be protective because it significantly lowered the increased MDA levels (p < 0.05). Comparing the superoxide dismutase (SOD) levels of the four groups, trauma + CoQ10 group had SOD levels ranging between those of sham group and traumatic brain-injury group, and no statistically significant increase was detected. Histopathological results showed a statistically significant difference between the CoQ10 and the other trauma-subjected groups with reference to vascular congestion, neuronal loss, nuclear pyknosis, nuclear hyperchromasia, cytoplasmic eosinophilia, and axonal edema (p < 0.05).ConclusionNeuronal degenerative findings and the secondary brain damage and ischemia caused by oxidative stress are decreased by CoQ10 use in rats with traumatic brain injury.

External ventricular drainage for acute obstructive hydrocephalus developing following spontaneous intracerebral haemorrhages

There is no consensus in the literature on the effects of the development of hydrocephalus on survival and disability after intracerebral haemorrhage (ICH) and the benefits of external ventricular drainage (EVD). In this open, prospective study, we investigated the clinical courses, radiological findings and outcome scores of 47 consecutive patients who were admitted to our clinic with spontaneous ICH. Hydrocephalus developed in 6 (12.8%) of the 47 patients, and EVD was applied in these 6 cases. In one of the 6 patients, the lesion was additionally excised due to the large cerebellar haematoma. Intraventricular haemorrhage was more common in patients developing hydrocephalus (83.3% vs. 29.3% in patients without hydrocephalus; p<0.05) and the lesions of all the patients were in the proximity of the ventricular system. Hospital mortality and functional outcome were not significantly different between patients with and without hydrocephalus. Our results shown that acute obstructive hydrocephalus should be anticipated if haematoma is near the ventricle or if it is opening to the ventricle. EVD is a life-saving and effective procedure that should be performed in patients who develop hydrocephalus following spontaneous intracerebral haemorrhage.

The effects of dexmedetomidine dosage on cerebral vasospasm in a rat subarachnoid haemorrhage model.

We investigated the effect of two different doses of dexmedetomidine on vasospasm in a rat model of subarachnoid haemorrhage (SAH). SAH was induced by injecting 0.3 mL blood into the cisterna magna in all rat groups except the control (Group C). At 1 hour and 24 hours after SAH, 5 microg/kg dexmedetomidine was given to group D5, and 10 microg/kg dexmedetomidine was given to group D10. No medication was administered to the haemorrhage group (Group H). Malondialdehyde (MDA) and paraoxonase (PON) levels were measured at 48 hours after SAH. Mean wall thickness (MWT), mean luminal diameter (MLD), and proliferating cell nuclear antigen (PCNA) expression of the basilar artery were evaluated. MDA levels and MWT were lower in the dexmedetomidine groups. The lowest MDA levels and MWT were found in Group D10. The MLD was lowest in Group H. PCNA expression was observed only in Group D10. We concluded that dexmedetomidine reduces oxidative stress and vasospasm following SAH in a dose-dependent manner.

The effectiveness of dexmedetomidine in experimental spinal cord injury compared to methylprednisolone in rats.

The present study aimed to investigate the neuroprotective efficacy of dexmedetomidine in a rat experimental spinal cord injury model. The rats (n=40) were equally divided into four groups: G1, G2, G3, and G4. Rats in the G1 group underwent a laminectomy only. For the rats in the G2, G3, and G4 groups, spinal cord injury was induced by placing an aneurysm clip extradurally for 60 s at T10. The rats in G2 did not receive any post-injury treatment. Immediately after trauma was induced, rats in G3 were given methylprednisolone (30 mg/kg) and in G4, dexmedetomidine (10 microg/kg), both intraperitoneally. The rats were sacrificed under anesthesia 24 hours later and 1.5 cm lengths of injured spinal cord were obtained. Malonyldialdehyde values were significantly increased in G2 compared to G1, G3 and G4 (p<0.05). The neuronal cell count in G1 was significantly higher than in G2 and G3 (p=0.0001; p=0.007). G4 had higher cell counts compared to G2 and G3 (p=0.0001; p=0.05). These findings indicated that dexmedetomidine might have neuroprotective effects in spinal cord injury.

A rare complication of spinal surgery: cerebellar hemorrhage.

Remote cerebellar hemorrhage (RCH) after spinal surgery is encountered extremely rarely. A 64 year-old female patient developed symptoms of deteriorating consciousness and diplopia arising on the first postoperative day after recurrent spinal surgery. Cranial CT scan showed cerebral edema and evidence of a cerebellar hemorrhage. Urgent suboccipital decompressive craniectomy and expanded duraplasty were performed. Repeat CT at 24 h revealed hydrocephalus and an external ventricular drain (EVD) was inserted for 20 days. The patients consciousness deteriorated after withdrawal of the EVD and a ventriculoperitoneal shunt was placed. The patient recovered completely except for gait ataxia and left foot drop. Although the exact cause is unknown iatrogenic dural opening resulting in excessive cerebrospinal fluid (CSF) drainage and secondary development of venous infarction have been suggested to lead to RCH.

Primary spinal extranodal Hodgkin's disease at two levels

About 90% of Hodgkins disease cases originate from lymph nodes whereas 10% from extranodal regions. Patients rarely present with spinal cord compression due to epidural Hodgkins disease. Primary spinal extradural Hodgkins disease which does not have any other organ involvement in the body is even rarer. A 39-year-old male patient who complained of lumbar pain had normal findings upon neurological examination. Radiological examination revealed a mass on the epidural space at level L3 and the involvement of the vertebral corpus accompanied by the involvement of C6 vertebral body. Primary focus could not be identified despite further investigation. The patient underwent L3 laminectomy and posterior decompression and biopsy was obtained from the lesion extending to epidural space. The pathological result was reported as lymphocyte dominant type Hodgkins disease. Flow cytometry was performed to the lesion, also. The patient was evaluated as Stage 4A according to Ann Arbor classification. Postoperative radiotherapy was applied to lumbar and cervical region. In the literature we have not come across any case of primary spinal extranodal Hodgkins disease with involvement at two levels. In conclusion, although it might be extremely rare, primary spinal extranodal Hodgkins disease with involvement at two levels might be observed.

Neurocutaneous melanosis associated with Dandy-Walker malformation

SummaryNeurocutaneous melanosis is an uncommon congenital disorder consisting of benign or malignant melanocytic tumors of the leptomeninges with large or numerous cutaneous congenital melanocytic nevi. The Dandy-Walker malformation occurs as an enlarged posterior fossa with high insertion of the tentorium, hypoplasia or aplasia of the cerebellar vermis, and cystic dilatation of the fourth ventricle. To our knowledge, the association of these two conditions has been reported only 14 times. In this article, we present a newborn patient with neurocutaneous melanosis associated with Dandy-Walker malformation, which was diagnosed by magnetic resonance imaging.

Migration of a bullet in the spinal canal

Migration of a bullet within the spinal canal after gunshot injury is rare. We report here the case of a penetrating gunshot injury of the lumbar spine at L3 with migration of the bullet within the spinal canal S2. The patient had marked paraparesis (proximal 1/5, distal 0/5 muscle strength) and anaesthesia at L3 and below, and had a hypocompliant, hyper-reflexive bladder with decreased capacity, and absent anal tonus. We removed osseous fragments in the canal with an L3 laminectomy and extracted the bullet by S2 laminectomy. After surgery, we observed an improvement in paraparesis, an increase in bladder capacity and urinary compliance, and improvement in anal tonus. The appropriate course of action in this type of injury remains unclear, because the number of cases described in the literature is not sufficient to provide a basis on which to make a definitive therapeutic decision. We herein review the literature describing cases in which a bullet in the spinal canal has migrated; we describe the treatment used and the outcomes in these cases.