Erhan Arslan

Posterior epidural migration of lumbar disc fragments: report of three cases.

Study Design. Report of three cases. Objectives. To describe a rare location of intervertebral disc migration. Summary of Background Data. Migration of sequestered disc fragments to the posterior extradural space is rare, and posterior migration of the free fragments causing cauda equina syndrome is exceptionally rare. Methods. Three patients with posteriorly migrated epidural disc fragments were evaluated with radiograph, computed tomography, and magnetic resonance imaging and underwent surgery. Results. All of the patients responded well to operative therapy with complete relief of symptoms. Conclusions. Early surgery should be the first choice of therapy in patients with large posteriorly migrated sequestered disc fragments, to prevent severe neurologic deficits such as cauda equina and conus medullaris syndromes.

Massive Congenital Intracranial Immature Teratoma of the Lateral Ventricle with Retro-Orbital Extension: A Case Report and Review of the Literature

Germ cell tumors comprise 0.4–3.1% of all intracranial tumors, and teratoma constitutes 9–30% of them. Congenital intracranial tumors are very rare and only account for 0.5–1.5% of all childhood brain tumors. The most common type of these tumors present at birth is teratomas, which represent 0.5% of all intracranial tumors. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. In this study, we report a neonatal intracranial immature teratoma at the lateral ventricle because of its rare location. A 5-day-old female neonate presented with a history of irritability and left eye protrusion since birth. A head computed tomographic (CT) scan and magnetic resonance imaging (MRI) disclosed a large tumor filling the left lateral ventricle and extending into the ipsilateral retro-orbital space. With left frontotemporoparietal craniotomy, a large grayish-white lobulated vascular mass was encountered, and total removal of tumor was performed. Histological examination revealed the diagnosis of immature teratoma. The prognosis of congenital intracranial immature teratoma is usually poor because the lesions are extensive when they are identified. Prenatal ultrasonography is necessary for the prenatal diagnosis. Fetal MRI should be made for the evaluation of intracranial tumor. If the tumor is detected before the 24th week of gestation, termination of the pregnancy should be considered.

Effects of Clotrimazole on Experimental Spinal Cord Ischemia/Reperfusion Injury in Rats

Objective. The effect of clotrimazole was examined using a spinal cord ischemia/reperfusion model. Methods. Twenty albino Wistar rats weighing 234 ± 12.3 g were used in this study. Rats were anesthetized intraperitoneally with 50 mg/kg ketamine HCl. All animals underwent laparotomy under aseptic conditions. Abdominal aortas of the animals in all but the sham group were exposed. After opening the retroperitoneum, the infrarenal abdominal aorta was clipped for 45 minutes to produce ischemia/reperfusion injury. Polyethylene glycol (PEG, 1 mL) was administrated to the vehicle group. PEG (1 mL) and clotrimazole (30 mg/kg) were administered intraperitoneally in the clotrimazole group. Total laminectomy of T8–T12 was performed on all rats under a microscope. Spinal cords were excised for a length of 2-cm rostrally and 1-cm caudally to the injury site and deep frozen at −76°C for biochemical studies. The levels of malondialdehyde, glutathione-peroxidase, superoxide dismutase, and catalase were measured as an indicator of ischemia level. The most cranial part of the specimens was evaluated morphologically. Results. Treatment with clotrimazole significantly decreased malondialdehyde, glutathione-peroxidase, superoxide dismutase, and catalase levels in comparison with other groups (P = 0.008). Morphologic evaluation revealed that clotrimazole protected the axons and their myelin sheaths from ischemic damage. Conclusion. This study showed the neuroprotective effects of clotrimazole on spinal cord ischemia/reperfusion injury.

CERVICAL CONGENITAL MIDLINE MENINGOCELES IN ADULTS

OBJECTIVEThe clinical presentation, biomechanical evaluation, and surgical techniques for repairing cervical meningoceles in adulthood are presented. Cervical meningoceles are typically diagnosed in childhood and are rarely reported among spinal dysraphic lesions in adulthood. In most cases, the cervical spinal cord is found tethered to the dura and other soft tissues by fibrous or fibroneural elements. Cervical lesions, unlike those that arise more caudally, rarely leak cerebrospinal fluid. METHODSWe report 5 male patients with meningoceles, aged 20 to 22 years (mean age, 20.4 years), in whom the primary evolution of the lesion occurred between 1999 and 2006. RESULTSAll 5 patients presented to the hospital with cervical pain and mass. One patient had had a cerebrospinal fluid leak from the center of the lesion intermittently since birth. Another patient presented with neurological deficits and hypesthesia of the left hand. All patients underwent surgery. The lesion was excised, a partial laminectomy was performed, the internal tethering fibrous bands were released, and the neck of the structure was ligated. There was no neurological deterioration after surgery. No postoperative complications were observed during the 12-month follow-up period for each patient. CONCLUSIONThe goals of surgical exploration of these lesions are prevention of neurological deterioration, prevention of infection, and acceptable cosmetic outcome. Cervical meningoceles are tethering lesions of the spinal cord that may cause biomechanical injury with repetitive flexion-extension movements of the head and spine. It is therefore advisable to remove these lesions neurosurgically as soon as the diagnosis is made. Surgical intervention for cervical meningoceles should consist of exploration of the intradural fibrous bands with laminectomy, untethering of the spinal cord, and resection of the stalk and cyst of the meningocele.

The effects of splenectomy on lipid peroxidation and neuronal loss in experimental spinal cord ischemia/reperfusion injury.

AIM The aim of this study is to investigate the effects of prior splenectomy on oxidative stress and neuronal loss following spinal cord ischemia and reperfusion injury. MATERIAL AND METHODS Twenty-one Sprague Dawley rats were randomly divided into three groups as sham laparatomy (n=7), spinal cord ischemia/reperfusion (SCIR) injury (n=7) and splenectomy+spinal cord ischemia/reperfusion (SSCIR) injury (n=7). In the latter group, splenectomy was performed 3 days before the SCIR injury. The activity of lipid peroxidation in the spinal cord was assessed by malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) activities. The difference between the 3 groups was compared using Kruskal-Wallis test. The histological differences were assessed by counting the viable neurons. RESULTS SCIR injury resulted in a decrease of tissue lipid peroxidation activities. There was statistically significance between the three groups (p < 0.05), but there was not any significance between the SCIR and SSCIR injury groups (p > 0.05). The number of viable neurons was higher in SSCIR group when comparing with SCIR group (p < 0.05). CONCLUSION SCIR injury affects lipid peroxidation in rats. Prior splenectomy does not attenuate lipid peroxidation, but prevents neuronal loss after SCIR injury.

Solitary plasmacytoma with intracranial intraorbital and, paranasal sinus extension

Intracranial solitary plasmacytomas (ICSPs) are extremely rare tumours in neurosurgical practice, and are often misdiagnosed preoperatively. Here we present a solitary intracranial plasmacytoma with orbital, nasal and paranasal sinus extension. A subtotal excision of the tumour was performed and the complete response was seen after postoperative radio-chemotherapy. The neuroradiological and neurosurgical features of the case are discussed with the pertinent literature.

Histological structure of filum terminale in human fetuses.

OBJECT The structure of the filum terminale (FT) is important in the development of tethered cord syndrome (TCS) in children. Although many studies have been performed on the histological structure of the FT in adults, there has been no detailed investigation for those of fetuses. The aim of this study was to examine the histological structure of the FT in normal human fetuses and to compare the results with those of previous studies. METHODS The histological examination of the FT was performed in 15 normal human fetuses; 11 of them were female and 4 were male. The gestational age of the fetuses ranged between 14 weeks and 35 weeks, and they weighed between 180 g and 1750 g. The FT of each fetus was cut and examined for adipose tissue, fibrous tissue, peripheral nerve, ganglion, ependymal cells, gliosis, elastic fibers, and collagen types (Types I and III). RESULTS Adipose tissue was observed in 2 specimens (13%), whereas fibrous tissue was found in 8 specimens. Peripheral nerve was detected in 11 (73%), ganglion in 6, ependymal cells in 5, and glial tissue in 7 FT samples. Type III collagen was present in 12 specimens (80%) with different concentrations, whereas Type I collagen and elastic fibers were not detected. CONCLUSIONS The normal structure of the FT in fetuses is different from its structure in adults. The FT has no elasticity during intrauterine life because of the lack of elastic fibers. More detailed studies are needed to understand the histological basis of TCS in children.

Meningitis and pneuomocephalus. A rare complication of external dacryocystorhinostomy

Meningitis due to fracture of the fovea ethmoidalis during external dacryocystorhinostomy is a rare complication. We report a case of pneumocephalus and meningitis in a 51-year-old female who underwent an external dacryocystorhinostomy (DCR). Although extracranial complications during or after external DCR have been well-described, only one case of meningitis has been reported in the literature. Physical examination, computerised tomography, lumbar puncture, and bacteriologic cultures were used to make the diagnosis. The patient responded well to antibiotic therapy. Her symptoms resolved immediately and she was discharged on the 21st post-operative day. This complication emphasises the importance of careful surgical technique and a thorough knowledge of regional anatomy, during DCR and similar procedures.

CSF Hydrothorax as a Late Complication of Ventriculoatrial Shunt Catheter Displacement.

A 21-year-old man was admitted to our emergency department with chest pain and progressively increasing dyspnoea commencing 1 week previously. His self-history revealed that he had received a ventriculo-atrial shunt at the age of 2 weeks due to congenital hydrocephalus (Figure 1a). At physical examination, no breathing sounds were heard on the right side. Neurological examination was normal. Total blood counts and C-reactive protein (CRP) were within normal limits. Chest X-ray showed right-sided hydrothorax and a catheter tip at the right thoracic apex (Figure 1b). The patient was transferred to the neurosurgery department. A consultation was held with the thoracic department. Thoracentesis was performed 3 times in 1 week, but the hydrothorax still persisted (Figure 1c). Subsequent removal of the ventriculo-atrial shunt catheter with disconnection on the scalp was performed. The distal tip of the catheter was left in the vessel. Symptoms improved rapidly. Chest X-ray revealed resolution of pleural effusion and re-expansion of the right lung (Figure 1d, e). Recovery was uneventful and no further thoracentesis or new shunt catheter were required. The patient was discharged 7 days later in good condition. The patient has remained in good clinical condition at the 2-year follow-up, and hydrocephalus has been arrested. FIG. 1. a-e. The patient’s cranial computed tomography (CT) shows the ventricular shunt catheter at the right lateral ventricle (a); Chest X-ray shows right sided hydrothorax (b); Chest X-ray after thoracentesis shows persisting hydrothorax (c); Chest X-ray ... We suggest that the shunt catheter may migrate from the intravascular space to the thoracic cavity through the area of entry into the internal jugular vein near the brachiocephalic trunk as a result of age-related upward pull. This was suggested by the catheter position in the right thoracic apex. The absence of bleeding into the thoracic cavity while the catheter tip was being exvasated may be attributed to the process having occurred over an extended period. The vessel wall was therefore repaired during this long period. Complications of ventriculoperitoneal or ventriculo-atrial shunts commonly occur due to obstruction, disconnection or infection (1–3). There are some reports of hydrothorax as a complication of ventriculoperitoneal (V-P) shunting (4). Taub et al. (5) classified V-P shunt thoracic complications into three types: 1) intrathoracic trauma during shunt replacement, 2) peritoneal catheter migration into the thoracic cavity, and 3) pleural effusion with cerebrospinal fluid (CSF) ascites. The peritoneal catheter may migrate into the thoracic cavity in either a supradiaphragmatic or transdiaphragmatic manner. In supradiaphragmatic migration, the peritoneal catheter is accidentally inserted into and out of the pleural cavity during the tunnelling procedure, especially at the supraclavicular fossa, which is the most dangerous area (6, 7). In transdiaphragmatic migration, the peritoneal catheter is gradually pulled into the thoracic cavity due to the negative pressure effect of inspiration. Increased intra-abdominal pressure due to peritoneal malabsorption also facilitates this process (5). The peritoneal catheter may migrate from a pre-existing hiatus into the diaphragm or may perforate it. Congenital hiatuses or weak points in the diaphragm are areas where the peritoneal catheter tip may pass into the thoracic cavity. Local inflammation around the peritoneal catheter tip may also facilitate the passage of the shunt tip through the diaphragm (4, 6). Hydrothorax may sometimes occur in association with CSF ascites. Peritoneal malabsorption leads to excessive CSF collection in the peritoneal cavity. CSF may pass through the thoracic cavity via congenital hiatuses (foramen Bochdalek or foramen of Morgagni) with increased intra-abdominal pressure (6). Ventriculo-pleural shunts have only been used infrequently for hydrocephalus. CSF hydrothorax is also one of the serious thoracic complications of ventriculo-pleural shunts (8). In particular, the long-term results are less satisfactory for ventriculo-pleural shunts, because shunt obstruction or pleural effusions are most frequently developed in 3 years (8). The late hydrothorax complicating the ventriculo-pleural shunts can be explained by two hypotheses: (a) Decreased CSF absorption in the pleural space as a result of impaired pleural absorptive capacity secondary to pleural damage due to prior infection and/or chronic exposure to CSF and (b) over-drainage of CSF into the pleural space (8, 9). The present case behaved as a ventriculo-pleural shunt due to prolonged drainage of CSF into the pleural space from the right thoracic apex. The possible mechanisms of hydrothorax formation in our patient with ventriculo-atrial shunts are the same as those in ventriculo-pleural shunt. To the best of our knowledge, this is the first reported case of CSF hydrothorax as a late complication of ventriculo-atrial shunt catheter displacement. We therefore wish to report this unique complication of ventriculo-atrial shunt.

Long-Term Results of Orbital Roof Repair with Titanium Mesh in a Case of Traumatic Intraorbital Encephalocele: A Case Report and Review of Literature

Orbital roof fractures associated with cranial and maxillofacial trauma are rarely encountered. Traumatic intraorbital encephaloceles due to orbital roof fractures developing in the early posttraumatic period are even rarer. A variety of materials, such as alloplastic implants or autogenous materials, have been used for the reconstruction of orbital roof, but data regarding the long-term results of these materials are very limited. We report a case of intraorbital encephalocele developing in the early posttraumatic period (2 days) in a child patient and the long-term results of titanium mesh used for the reconstruction of the orbital roof. The case is presented with a pertinent review of literature.