Erdal Çetinalp

Prognosis and prognostic factors in nonaneurysmal perimesencephalic hemorrhage: A follow-up study in 29 patients

BACKGROUND Perimesencephalic nonaneurysmal hemorrhage is a benign form of subarachnoid hemorrhage with a low risk of rebleeding. The authors conducted a retrospective study to investigate the prognosis, possible prognostic factors, and long-term natural history in perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH). METHODS This report contains a retrospective analysis of 29 patients with PNSH who were followed from 1 month to 8 years with an average follow-up period of 5.4 years. We evaluated computed tomography (CT) scan features; clinical grade; loss of consciousness during hemorrhage; ventricular ratio; angiographic spasm; complications such as ischemic complications, early rebleeding, late rebleeding, epilepsy, hydrocephalus, and fixed ischemic deficit; and outcome. RESULTS There were 7 men and 22 women, and the ages ranged from 22 to 69 years (mean 49.5 years). In the group with PNSH 93% of the patients were in grade I-II, as compared to 70.8% of patients with non-PNSH according to the Hunt and Hess system. Loss of consciousness during hemorrhage was detected in 9 patients (31%). We observed acute hydrocephalus in 4 patients (13.7%). The first cerebral four-vessel angiograms disclosed vasospasm in 3 patients (10.3%). Patients with PNSH have the best outcome according to the activities of daily living (ADL) grading system when compared with other groups of patients with negative angiogram (aneurysmal pattern and invisible blood). CONCLUSION This study provides evidence that patients with PNSH have an uncomplicated course and a particularly favorable outcome.

The evaluation and comparison of cerebellar mutism in children and adults after posterior fossa surgery: report of two adult cases and review of the literature.

Summary.Summary. Background: Although there are some cases of cerebellar mutism in adults after posterior fossa surgery for cerebellar tumour it generally occurs in children. Reversible pathophsiology and the anatomical substrate of this syndrome still remain unclear. The predominance of cerebellar mutism in children is suggested to be related to the higher incidence of posterior fossa tumours in children. However, the question regarding the reason for the obvious difference in the incidence of this syndrome between the paediatric and adult population still remaing unanswered. The aim of this study was to evaluate and compare children and adult groups separately to understand the incidence and the clinical characteristics better and to elucidate the pathophysiological basis and predictive factors for this syndrome. Method: We reviewed, analysed, and compared the cases of cerebellar mutism individually in children and in adults reported in the English literature. We found 106 reported cases in children and 11 cases in adults which were suitable for analysis. We added two adult cases to these. Findings: The ages of the patients ranged from 2 to 16 (mean, 6.4 year) in children and from 17 to 74 (mean, 38.7 year) in adults. Although vermis was the main location in both groups, the incidence of vermis lesions was considered higher in the paediatric population (%91.5 versus %69.2). The rate of brain stem invasion was prominent in children (%31.1) when compared with adults (%7.6). The latency for the development of mutism and the duration of the mutism were similar in children and adults (mean, 1.4 d versus 2 d and mean, 5.07 wk versus 4.2 wk respectively). Mutism was transient in all the cases of both groups. Interpretation: Recent concepts of cerebellar physiology disclose the importance of the cerebellum in learning, language, and mental and social functions. Pontine nuclei, the thalamus, motor and sensory areas and supplementary motor areas have been proven necessary for the initiation of speech. It can be hypothesized that uncompleted maturation of the reciprocal links in childhood connecting the cerebellum to these structure makes the children more vulnerable to have postoperative cerebellar mutism in comparison to the adult population.

Isolated trigeminal neuralgia secondary to distal anterior inferior cerebellar artery aneurysm

A 43-year-old woman complaining of severe pain of the right side of the face was admitted to the Department of Neurosurgery. It had been present for three months and diagnosed as trigeminal neuralgia. The CT scan without contrast material had been considered normal at that time. Three months later, after a favourable response to carbamazepine, she suddenly developed right occipital headache and drowsiness. On admission, she was alert, and neurological examination revealed only mild neck stiffness. Computed tomographic scan demonstrated an acute hematoma in the right cerebellopontine angle and in the fourth ventricle. Vertebral angiography revealed an aneurysm of the right anterior inferior cerebellar artery (AICA). A posterior fossa approach disclosed a large, nearly totally thrombosed, saccular AICA aneurysm, which showed minimal compression to the pons at the trigeminal root entry zone. The aneurysm was clipped and excised. She showed an excellent recovery and was free of pain in the early postoperative period and at the last examination 16 months later. Aneurysms in the distal AICA are very rare lesions. Only 31 cases have been published so far. Distal AICA aneurysm in an extremely unusual cause of trigeminal neuralgia secondary to aneurysmal compression. The literature concerning AICA aneurysms and their clinical manifestations is reviewed and discussed.

The nonsurgical management of a penetrating orbitocranial injury reaching the brain stem: case report.

Penetrating and perforating periorbital puncture wounds by lead pencils are not rare, but ones that reach the brain stem are extremely unusual. We recently treated a patient with of this type of injury. A newly sharpened lead pencil was accidentally introduced through the subconjunctiva at the inner canthus of the right eye. It passed along the medial border of the globe transorbitally and went through the superior orbital fissure into the temporal fossa, then continued through the lateral side of the sella and posterior clinoid, reaching the brain stem. The entire pencil was removed inch by inch without incident under CT control. Meanwhile, the operative team remained ready in case of emergency bleeding. The patients postoperative course was uneventful, but the initial neurologic deficit of the patient remained fixed.

Percutaneous radiofrequency rhizotomy of lumbar spinal facets : the results of 46 cases

The results of percutaneous radiofrequency rhizotomy of lumbar spinal facets in 46 patients followed at least three months (mean 15 months) are reported and compared with those reported previously. Satisfactory pain relief three months after the procedure was achieved in 36.4 percent of patients without operations and in 41.7 percent of patients with operations other than fusion.No patient had previously undergone fusion.Treatment of low-back pain by using radio-frequency thermocoagulation of spinal facets is a simple, safe, and well-tolerated procedure. It can be used to relief of pain in spite of decreasing rates of success within the follow-up period.

Intracerebral ganglioglioma: clinical and radiological study of eleven surgically treated cases with follow-up

Abstract Background. Gangliogliomas are rare benign tumors of the CNS consisting of differentiated neural elements and low-grade glial cells. Methods. We reviewed our experience of 11 patients with histologically proven ganglioglioma who were surgically treated since 1986 at Çukurova University Medical Center. These patients presented at 18 to 45 years of age. Five were women and six were men. The most common initial symptom was seizures (in nine of 11 patients), which had sometimes persisted over long periods of time. At the time of diagnosis, four patients had focal neurological deficits and three had signs or symptoms of increased intracranial pressure. The cystic and well-circumscribed characteristics of these lesions were detected on computed tomography (CT). Despite their appearance on CT, all but one of the lesions were found to be mostly solid at operation. Magnetic resonance imaging (MRI) in six patients revealed abnormally high signal intensity on T2-imaging. The temporal lobe was the main tumor location (seven patients). All cases were diagnosed according to the Russel and Rubinstein histological criteria for ganglioglioma. Results. Ten patients had radical total resection and one had subtotal resection. No patient underwent postoperative radiation or chemotherapy. Except for one, all are still alive and free of progressive disease 1 to 11 years (mean 6.2) after operation. Six are seizure-free and three have improved seizure control under anticonvulsant therapy. Conclusions. We conclude that ganglioglioma is a distinct histological phenomenon with mildly predictable clinical symptoms (seizures), mildly characteristic radiological features, and long-term survival after surgical resection without the need of adjuvant treatment such as radiotherapy.

Arachnoid cyst with traumatic intracystic hemorrhage unassociated with subdural hematoma

Arachnoid cysts of the middle cranial fossa may manifest themselves in several different ways. Most often they remain asymptomatic and are only diagnosed incidentally on computed tomography or at autopsy. When they are symptomatic, headache, nausea, vomiting and seizures are most common in the patients with increased intracranial pressure. Increased intracranial pressure is caused by the ball-valve mechanism of the cysts membrane which is in communication with the general subarachnoid space or arachnoid cells which contain specialized membranes and enzymes which have secretory activity. A significant number of middle cranial fossa arachnoid cysts are associated with subdural hematoma which may, in turn, be associated with intracystic hemorrhage. We report an unusual case with posttraumatic, isolated intracystic hemorrhage of the arachnoid cyst in the sylvian area without subdural hematoma.

Prognosis and prognostic factors for unexplained subarachnoid hemorrhage: review of 84 cases.

OBJECTIVE We conducted a retrospective study to investigate the prognosis, possible prognostic factors, and long-term natural history of subarachnoid hemorrhage of unexplained cause. METHODS This report contains a retrospective analysis of data for 84 patients with subarachnoid hemorrhage of unknown cause who were monitored for 1 month to 9.5 years, with an average follow-up period of 5.6 years. We evaluated the associations between computed tomographic (CT) scan features, clinical grade, loss of consciousness during hemorrhage, ventricular ratio, angiographic spasm, complications (such as death resulting from ischemia, early rebleeding, late rebleeding, epilepsy, hydrocephalus, and fixed ischemic deficits), and outcomes, using a nonparametric, two-sample, Kolmogorov-Smirnov test. The &khgr;2 test was used to test the independence of two categorical variables. RESULTS CT class exhibited a significant association with clinical grade (&ggr; = 0.865, P = 0.006), loss of consciousness during hemorrhage (&ggr; = 0.69, P = 0.001), and ventricular ratio (&ggr; = 0.8175, P = 0.01) but a nonsignificant association with angiographic vasospasm (&ggr; = 0.21, P = 0.2). Death resulting from ischemic complications and fixed ischemic deficits were strongly associated with clinical grade (P = 0.003 and P = 0.008, respectively) but weakly associated with CT class (P = 0.06 and P = 0.084, respectively). Angiographic vasospasm was strongly associated only with fixed ischemic deficits among complications (P = 0.001). Clinical outcome was strongly positively associated with CT class (&ggr; = 0.685, P = 0.001), clinical grade (&ggr; = 0.81, P = 0.001), and ventricular ratio (&ggr; = 0.57, P = 0.002) but weakly positively associated with loss of consciousness during hemorrhage (&ggr; = 0.459, P = 0.0487) and angiographic vasospasm (&ggr; = 0.48, P = 0.04). CONCLUSION Our study confirms earlier studies reporting a good prognosis for survival, but it does not confirm the earlier statements regarding low morbidity rates. Although clinical grade and the presence and amount of subarachnoid blood on CT scans are the major prognostic factors related to the incidence of ischemic complications, clinical grade and CT class are also the main parameters, with ventricular ratio, indicating clinical outcomes for patients with subarachnoid hemorrhage of unknown cause.

Intracranial Arachnoid Cysts: Clinical Features and Management of 35 Cases and Review of the Literature

The purpose of this study is to evaluate the distribution, clinical features, and treatment modalities of arachnoid cysts (ACs) in our clinic. The study was carried out between January 1, 1996 and November 31, 2002 at the Neurosurgery Department of Çukurova University Hospital, Adana, Turkey. Thirty-five patients (13 female and 22 male) with ACs demonstrated by cranial magnetic resonance imaging or computed tomography during this period were enrolled and discussed in this study. The middle cranial fossa was the most common location of ACs; ACs were located in the middle cranial fossa in 22 (62.9%) cases, followed by the cerebellopontine angle in 4 (11.4%) cases, the cerebral convexity in 3 (8.6%) cases, the suprasellar region in 2 (5.7%) cases, the quadrigeminal cisterns in 2 (5.7%) cases, and the retrocerebellar region in 2 (5.7%) cases. All cysts were unilateral: 25 (71.4%) were located on the left side, and 10 (28.6%) were located on the right side. The mean age at onset of clinical manifestations was 3 years, 6 months (range: 1 month to 12 years). The mean age at diagnosis was 8 years (range: 1–32 years). The most frequent clinical features on presentation were epileptic seizures (42.9%) and headache (28.6%). A few patients (9 [25.7%]) underwent surgery. Surgical intervention with microsurgical excision and fenestration was performed in 7 patients, and cystoperitoneal shunting was performed in 2 patients. The major indications for surgery of ACs are intractable seizures, intracranial hypertension, and compression of neuronal tissues. Headache only is not a surgical indication. Microsurgical excision and fenestration are safe and effective for the surgical treatment of ACs.

Unilateral hydrocephalus resulting from occlusion of foramen of Monro: a new procedure in the treatment: stereotactic fenestration of the septum pellucidum.

Obstruction at the foramen of Monro resulting in unilateral hydrocephalus is an uncommon entity that may be caused by a wide range of lesions including tumors, vascular malformations, and inflammatory conditions. A case of unilateral hydrocephalus secondary to congenital atresia of the foramen of Monro treated with stereotactic fenestration of the septum pellucidum is presented.