Cagatay Onal

Microanatomical architecture of dorello's canal and its clinical implications

OBJECTIVE We investigated the membranous architecture of the abducens nerve at the petroclival region and describe the characteristics of this area in cadaveric specimen and two children with hydrocephalus and sixth nerve palsy using magnetic resonance imaging (MRI). MATERIALS AND METHODS Five adult cadaver heads were used to investigate the petroclival part of the abducens nerve. The heads were injected with colored latex for microsurgical dissection, and the length of the dural sleeve of the abducens nerve and its width at the apex were measured. In one cadaver head, the area between the petroclival entrance porus of the abducens nerve and the cavernous sinus was histologically studied under light microscopy. In two patients with hydrocephalus and abducens nerve palsy, the petroclival area was screened by using the MRI fat suppression technique. RESULTS In the cadavers, the arachnoid membrane on the clivus extended within the dural sleeve as far as the petrous apex, as an extension of the subarachnoid space. The average length of the dural sleeve was 9.5 mm and the average width was 1.5 mm at the apex, where the nerve entered the cavernous sinus. MRI scans showed that the cerebrospinal fluid distance of the petroclival region was 5 mm in the first patient and 7 mm in the second. CONCLUSION The subarachnoid space inside the dural sleeve of the abducens nerve can be defined by using thin-slice MRI scans. Enlargement of the dural sleeve at the petroclival region may coexist with the abducens nerve palsy. It has been documented in this study that the arachnoid membrane forms a membraneous barrier between the subarachnoid and subdural spaces within Dorellos canal.

Post-traumatic early epilepsy in pediatric age group with emphasis on influential factors

ObjectivePosttraumatic epilepsy in the pediatric age group is mostly seen within the first week. An acute posttraumatic epileptic fit, which may induce secondary insults, should be hindered. The aim of the study is to define the risk factors for posttraumatic early epilepsy (PTEE) and the indications for prophylactic therapy.MethodsIn this survey, a total of 1,785 pediatric patients—under the age of 16—are studied. The majority of the patients (1,655) were treated in Haydarpaşa Numune Hospital within the years 1993–1999. The rest, which consists of 130 patients, were treated in Inönü University Turgut Özal Medical Center between the years 2001 and 2003. The patients were categorized according to age, gender, neurological manifestations, type of trauma, cranial pathology, number and type of epileptic fits, the interval between trauma and convulsion, electroencephalogram findings, and antiepileptic therapy. All these factors were challenged due to their effect on the evolution of PTEE.ResultsOnly 149 cases had PTEE (8.4%). There was no correlation between gender and the incidence of PTEE. The data showed that 11.7% of the patients at or under the age of 3 (p=0.00072), 30.8% of the patients with severe head injury (Glasgow Coma Scale=3–8; Children’s Coma Scale = 3–8; p=0.00000), 19.3% of the patients with depressed skull fractures (p=0.00038), 13.7% of the patients with intraparenchymal hemorrhage (p=0.0000072), and 21.6% of the patients with cerebral edema (p=0.000008) had PTEE. Only 20% of the patients with PTEE had a Glasgow Outcome Scale (GOS) of 3 or less (p=0.0000075).ConclusionThose patients at or under the age of 3, with severe head injury, cerebral edema, intraparenchymal hemorrhage, or depressed skull fracture, have a higher incidence of PTEE. Moreover, because the GOS of these patients are prone to be worse, antiepileptic therapy in acute stage may be effective in preventing the secondary brain damage.

Cavernous Hemangioma in a Child Presenting With Hemichorea: Response to Pimozide

The case of a 9-year-old boy with hemichorea due to cavernous hemangioma in the left caudate nucleus is presented. To our knowledge, only two children have been reported with hemichorea associated with cavernous hemangioma. Hemichorea in our patient responded to pimozide, a neuroleptic that blocks central nervous system dopaminergic receptors. (J Child Neurol 2001;16:685-688).

GLIOFIBROMA: AN INCOMPLETELY CHARACTERIZED TUMOR

Although gliofibroma is a rare and incompletely characterized tumor, recent publications have revealed new aspects of this entity. The case of a 16-year-old boy who was diagnosed as having a gliofibroma is presented here, and the problems regarding nosology are discussed in the light of the recent literature.

Gigantic intracranial mass of hydatid cyst

traumatic, or spontaneous rupture ofan existing primary cyst in the brain[15, 19, 22, 25]. In very rare cases,spontaneous or surgical rupture of acyst located in the left ventricle ofthe heart or in one of the great ves-sels may also cause multiple second-ary hydatid cysts in target organs, in-cluding the neural structures [2, 3,29]. Primary cysts, unlike the sec-ondary type, are generally, but notalways, fertile [1, 7, 18, 27].As no extraneural hydatidosis wasdetected, the reported case can easilybe categorized as a “primary multi-ple cerebral hydatid cyst,” which isdefinitely a very rare entity. A verylimited number of patients have beenreported in this category so far, andmost of them have been in the pedi-atric age group [4, 5, 8, 12, 14, 24,27]. A recent report from IstanbulUniversity Istanbul School of Medi-cine Department of Neurosurgerydeals with the long-term range(8–45 years) follow-up of pediatricintracranial hydatidosis: only 1 pa-tient out of 30 in whom this condi-tion was documented was reported tohave multiple primary intracranialhydatid cysts, for an incidence of3.3% [20]. This 7-year-old boy had afatal outcome after four operations in2 years for removal of more than 18hydatid cysts, including intraventric-ular cysts, either by hydatid birth orby the PAIR (puncture, aspiration, ir-rigation, resection) technique. Hewas the only patient in the serieswho required a ventriculoperitonealshunt as the fifth surgical procedure[20]. Cataltepe et al., in Ankara, intheir review of the Hacettepe series,reported 2 cases of primary multipleintracranial hydatid cysts in a total of120 patients, 76% of whom were un-der 15 years of age. The incidence ofprimary multiple intracranial hydatidcysts in their combined series ofadult and pediatric patients was1.7% [9].Perhaps a more likely pathogene-sis in the case reported by Ozkan etal. is the rupture of a viable primarycyst of the brain following a trivialtrauma, leading to secondary hyda-tid cysts [6, 13, 28]. Even thoughthere is no record of such a sequenceof events in the history, the appear-ance of the cysts “as they are closelygrouped and flattened one againstthe other in a single, large nidus,” asin the case reported by Nurchi et al.,provides strong support for this the-ory [18]. Besides the remarkablesimilarity in radiological character-istics, the numerous hydatid cystsextracted in these two pediatric pa-tients also imply the relevance ofthis scenario. Nurchi et al.’s hypoth-esis was that the multiplicity hadmost probably resulted from a fortu-itous tear of the primary cyst, whichhad a superficial location – verysimilar to that of the cyst in Ozkanet al.’s case, which is didacticallydocumented in axial and sagittal MRimages [18, 23].

Cerebellar abscess and syringomyelia due to isoniazid-resistant Mycobacterium tuberculosis.

A 19-year-old immunocompetent man was admitted to hospital with diplopia, nausea, vomiting and change in mental status. The patient had a history of tuberculous meningitis that was diagnosed at another hospital 6 months before the present admission, and at that time anti-tuberculosis treatment was initiated using a first-line drug combination. A computed tomography (CT) scan of the brain revealed non-communicating hydrocephalus. A ventriculo-peritoneal shunt was inserted surgically. Two months later, the patient was hospitalized again for fever, dysphagia and left hemiparesis. At that time, his cranial CT findings were within normal limits; however, magnetic resonance imaging (MRI) revealed an irregular multilocular peripheral contrast-enhancing lesion in the posterior fossa. The abscess was surgically drained. The presence of acid-fast bacilli in the abscess material was demonstrated by Ziehl-Neelsen staining. Mycobacterium tuberculosis grew on Lowenstein-Jensen culture medium, and the strain was found to be resistant to isoniazid. One month after the operation, the patient became quadriparetic. Cervical MRI revealed a cervico-thoracic syringomyelitic cavity, after which a syringoperitoneal shunt was placed. Treatment with four drugs was continued for 10 months, and then treatment with three drugs for a total period of 18 months. The patient recovered, with residual quadriparesis. Even though very rare, isoniazid-resistant M. tuberculosis may be the causative agent of progressive tuberculosis.

Prevalence and Outcome of Congenital Heart Disease in Patients With Neural Tube Defect

A prospective clinical study was designed to establish the risk factors, the prevalence, and the progress of congenital heart defects in children with neural tube defects. Study included 90 children with a mean age of 13.5 ± 30.4 months. There were 53 (59%) patients with spina bifida occulta and 37 (41%) patients with spina bifida aperta. The overall prevalence of congenital heart disease was 27.8% (40.5% in spina bifida aperta and 18.9% in spina bifida occulta; P = .024). There was no statistically significant difference for maternal age, usage of periconceptional folate, and maternal diabetes between the patient and control groups. The authors conclude that congenital heart defects are more common than reported in neural tube defects, and screening echocardiograms are warranted. This should be kept in mind especially in patients requiring minor or major surgical procedures. Furthermore, routine obstetric examination and therefore the use of periconceptional folic acid during pregnancy is still lacking in our country.