Murat Hanci

Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury

Objectives: To determine whether proton magnetic resonance spectroscopy (MRS), a newer radiographic technology, would be useful in the evaluation of the thalamus of patients in vegetative states resulting from traumatic brain injury. Methods: 14 victims of severe traumatic brain injury who were in the vegetative state and whose magnetic resonance images of the thalamus were normal underwent bilateral thalamic proton (MRS) studies. The N-acetyl aspartate to creatine (NAA:Cr) and choline to creatine (Cho:Cr) ratios were obtained for each patient. The proton thalamic MRS findings of patients who were in a persistent vegetative state (n = 8) and in patients who had regained awareness after being in the vegetative state (n = 6) were compared with proton thalamic MRS findings in five healthy volunteers. Results: While conventional magnetic resonance imaging suggested that each patient had a normal thalamus, proton MRS indicated that the thalamus of each patient in the series was damaged. The NAA:Cr ratio was significantly lower in the thalami of both the patients who remained in a persistent vegetative state for the duration of the study and in those who regained awareness after being in the vegetative state (p < 0.001). In addition, NAA:Cr ratios were lower in the group of patients who remained in a persistent vegetative state than in the group of patients who regained awareness after being in the vegetative state (p < 0.001). Conclusions: Results suggest that the NAA:Cr ratio within the thalamus is significant and that thalamic MRS may be helpful when attempting to determine the degree of severity of neuronal and axonal injury in patients in the vegetative state.

Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases.

Summary115 traumatic extradural haematoma cases who were treated surgically at Cerrahpasa Medical Faculty Neurosurgery Department between 1987 and 1992 are evaluated.When factors affecting the outcome were examined, a strong correlation was found between the result andGlasgow coma scale (GCS) (p<0.00001). The existence of a fracture, the interval between onset of haematoma symptoms and intervention and the existence of an intracerebral haematoma together with contusion accompanying intradural haematoma, affect the outcome in a negative direction. There was no statistical correlation between the outcome and the age of patient, localization of the haematoma and aetiology.

Syringomyelia – As a Late Complication of Tuberculous Meningitis

Summary The aim of this paper is to demonstrate the unusual MR features of thoracic syringomyelia following TB meningitis and to discuss the neurosurgical aspect of the treatment of this rare entity. Four years after a TB meningitis episode, a 30 year-old female patient developed a progressive spastic paraparesis. MR studies revealed multiloculated syrinxes throughout the thoracic cord. She had a syringosubarachnoid shunt with a silastic “T” tube inserted. On the first postoperative day, she showed a dramatic neurological improvement, but unfortunately her paraparesis progressed to the preoperative level within a month despite diminished size of the syrinxes on the control MRI examination. Two and a half years after the operation the patient complained of having a burning type of central pain, and further deterioration in neurological function. Thoracic spinal MRI examination demonstrated enlarged syringomyelic cavities. At the second operation syringo-peritoneal shunt insertion was performed via right T10–11 hemilaminectomy using a “T” tube. At present, 4 months after the second operation, the patients neurological examination demonstrated decreased spasticity, and improved strength in the legs compared to the preoperative level. MRI is the first choice of investigation in detecting TB related myelopathy as it provides a greater detail of pathological changes within and around the spinal cord such as syrinx formation and arachnoiditis. The MR findings are also helpful in deciding the management and predicting the outcome. Presence of multifocal loculations and arachnoid adhesions is the likely cause of treatment failures and poor prognosis.

Intramedullary tuberculous abscess: a case report.

Study Design This case report shows an intramedullary thoracic spinal cord abscess secondary to Mycobacterium tuberculosis in a 7‐year‐old boy with chronic progressive paraparesis and hypesthesia below T10. Objectives The treatment of this patient involved drainage of pus followed by appropriate chemotherapy. Summary of Background Data Abscess and tuberculomas of the spinal cord are rare entities. They are indistinguishable from neoplasms. The possibility of tubercular abscess or granuloma should be kept in mind when an intraspinal mass is found, provided that the clinical history is unusual for tumor. Methods A left T7‐T8 hemilaminectomy was performed. A quantity of pus was drained through a small myelotomy. A small specimen was taken, and antituberculosis treatment was given after surgery. Results Excellent clinical outcome was obtained with a combination of medical and surgical management. Conclusion The treatment of intramedullary abscess consists of surgical evacuation of the pus. Appropriate treatment offers a favorable prognosis even in cases with severe deficits.

Catabolic cytokine expressions in patients with degenerative disc disease.

AIM Lumbar degenerative disc disease (DDD) is a common disease of advanced age characterized by progressive changes in the intervertebral disc and associated structures. There have been great efforts for years to explain its pathophysiological mechanism(s). This study aims to provide cytokine profile and in addition to the lymphocytes in a population of patients with lumbar DDD. MATERIAL AND METHODS Twenty-six patients whose clinical and radiological features were suggestive of lumbar DDD that underwent surgery and 14 autopsy cases as control were included. Patient disc samples were obtained during surgery whilst disc materials were collected during autopsy procedures from the controls. Major cytokines and lymphocytes were studied by using the flow cytometry method. RESULTS Significantly higher levels in disc samples in relation to IL-1β, IL-2, IL-4, IL-10, IL-12, TNF-α, CD8, CD56, CD19, and CD40 were found in the patients compared to the controls. Positive correlations were shown between CD3/CD4, CD25/CD3, CD25/CD4, CD19/CD4 but negative correlations were shown between CD19/CD3 and CD25/CD19 in both groups. CONCLUSION The findings suggest that both local inflammatory responses occur in lumbar DDD. Using specific cytokines either by local or systemic application may reverse the degenerative process.

Traumatic peripheral nerve injuries: demographic and electrophysiologic findings of 802 patients from a developing country.

Objective To study a series of patients with traumatic peripheral nerve injury during the past 10 years in Cerrahpasa Medical Faculty/Istanbul/Turkey. Methods The chart review of 802 patients was evaluated and we explored the type(s) and cause(s) of injury, and electromyographic findings. The study included 171 children and 631 adults and we excluded the patients who suffered from injuries due to the Marmara earthquakes that occurred in 1999. Results Injury was most common in the upper extremities in both children (78.36%) and adults (63.54%). The common causes of nerve injury in children were as follows: obstetric lesions (46.78%), iatrogenic lesions (16.95%), traffic accidents (15.7%), and sharp lacerations (12.8%), whereas the commonest cause of nerve injury in adults was due to sharp lacerations (27.57%), followed by iatrogenic lesions (25.67%), and traffic accidents (23.77%). The most commonly injured nerves were the brachial plexus and ulnar nerve in children and adults, respectively. Electromyography demonstrated that complete nerve injury predominated in both groups. Conclusions If preventive measures are taken into consideration satisfactorily, the incidence of disabling peripheral nerve injury may decrease, as such injuries are often treatable.

Bilateral traumatic abducens nerve paralysis with cervical spine flexion injury

Bilateral traumatic abducens nerve palsy is a rare condition. We report a case associated with cervical spine flexion injury. This may be the first such case report, as no similar case was found in our review of the literature. The mechanisms of injury in this case are relevant to theories that explain hyperextension injuries.

The effect of duration of compression on lipid peroxidation after experimental spinal cord injury

The present study was performed to evaluate the effect of duration of acute spinal cord compression on tissue lipid peroxidation in rats. A clip compression method (1) was used to produce acute spinal cord injury. Rats were divided into 3 groups, each consisting of 10. At 1 hour after trauma all rats were sacrificed, and MDA content of the injured spinal cord segment was measured. The tissue MDA contents were 3.922 μmolMDA/gww in group 1 (control), 10.192 μmol MDA/gww in group 2 (30 seconds compression), and 12.147 μmolMDA/gww in group 3 (60 seconds compression). These results demonstrate that the length of duration of compression significantly enhances lipid peroxidation. Our study supported the view that persisting compression may cause progression of secondary mechanisms which may irreversibly eliminate any potential for recovery.

Concomitant fracture of bilateral occipital condyle and inferior clivus: what is the mechanism of injury?

With the routine use of multi-slice high resolution computed tomography, increasing number of occipital condyle fractures have been reported in the last decade. The authors report a very rare case of bilateral occipital condyle fracture complicated by the fracture of the inferior clivus and discuss the possible mechanisms of injury.

Intrathecal Baclofen Toxicity and Deep Coma in Minutes

Abstract Background/Objective: In recent years, intrathecal baclofen (ITB) treatment in patients with refractory spasticity has been accepted as an effective therapy. However, this treatment modality may cause life- threatening complications. This report describes the clinical presentation, unfamiliar dilemmas, and treatment of a patient with ITB toxicity and raises awareness of problems that may arise. Methods: A 33-year-old man with refractory spasticity due to diffuse white matter injury was admitted for ITB treatment. The patient had respiratory difficulty followed by a generalized seizure and developed coma minutes after the drug administration. The patient was transferred into an intensive care unit immediately and managed accordingly. Results: After proper management, the patient was followed and continued to receive ITB treatment. Conclusions: ITB therapy is a very effective method of rehabilitation and medication in patients with refractory spasticity, but physicians must be aware of the serious complications that may develop just minutes after the drug is administered. Although safe, baclofen pumps are nevertheless mechanical devices that may malfunction. Therefore, physicians should be mindful of the possibility of life-threatening complications that may develop and lead to a patients death if proper treatment is not performed.