Osman Simsek

Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study

SummaryBackground. Although surgical decompression of large hemispheric infarction is often a life-saving procedure, many patients remain functionally dependent. The aims of this study were to identify specific factors that can be used to predict functional outcome, thus establish predictive criteria to reduce poor surgical results.Method. In this non-randomized prospective study, we performed decompressive craniectomy in 32 patients (age range, 27 to 77 years) with large hemispheric infarctions. Based on their modified Rankin Score (RS), which was calculated 6 months postoperatively, patients were divided into two functional groups: good (RS 0–3, n = 7) and poor (RS 4–6, n = 25). The characteristics of the two groups were compared using statistical analysis.Findings. One-month mortality was 31%. However, most of the surviving patients were severely disabled (RS 4 or 5), and 6-month total mortality reached 50%. Increased age (≥60 years) (P = 0.010), preoperative midline shift greater than 10 mm (P = 0.008), low preoperative Glasgow Coma Score (GCS≤7) (P = 0.002), presence of preoperative anisocoria (P = 0.032), early (within the first three days of the stroke) clinical deterioration (P = 0.032), and an internal carotid artery infarct (P = 0.069) were the positive predictors of a poor outcome.Interpretation. We view decompressive craniectomy for space-occupying large hemispheric infarction as a life-sparing procedure that sometimes yields good functional outcomes. A dominant hemispheric infarction should not be an exclusion criterion when deciding to perform this operation. Early operation and careful patient selection based on the above-mentioned factors may improve the functional outcome of surgical management for large hemispheric infarction.

Nocardial brain abscess: Review of clinical management

Nocardiosis has become a significant opportunistic infection over the last two decades as the number of immunocompromised individuals has grown worldwide. We present two patients with nocardial brain abscess. The first patient was a 39-year-old woman with systemic lupus erythematosus. A left temporoparietal abscess was detected and aspirated through a burr-hole. Nocardia farcinica infection was diagnosed. The patient had an accompanying pulmonary infection and was thus treated with imipenem and amikacine for 3 weeks. She received oral minocycline for 1 year. The second patient was a 43-year-old man who was being treated with corticosteroids for glomerulonephritis. He was diagnosed with a ring-enhancing multiloculated abscess in the left cerebellar hemisphere, with an additional two small supratentorial lesions and triventricular hydrocephalus. Gross total excision of the cerebellar abscess was performed via a left suboccipital craniectomy. Culture revealed Nocardia asteroides, and the patient was successfully treated with intravenous ceftriaxone, then oral trimethoprime-sulfamethoxazole for 1 year. The clinical course, radiological findings, and management of nocardial brain abscess are discussed in light of the relevant literature, and current clinical management is reviewed through examination of the cases presented here.

Contralateral subdural effusion after aneurysm surgery and decompressive craniectomy: case report and review of the literature.

We report a complication of decompressive craniectomy in the treatment of aneurismal subarachnoid hemorrhage (SAH) and accompanying middle cerebral artery (MCA) infarction. A 56-year-old man presented with subarachnoid hemorrhage and right sylvian hematoma. He was diagnosed with high-grade SAH and medical therapy was employed. He showed rapid clinical deterioration on day 9 of his admission. Computed tomographic scans showed right MCA infarction and prominent midline shift. Because of the patients rapidly worsening condition, further evaluation to find origin of SAH could not be obtained, and decompressive right hemicraniectomy was performed. During sylvian dissection, right middle cerebral and posterior communicant artery aneurysms were detected and clipped. One week after operation, a contralateral frontoparietal subdural effusion and left to right midline shift was detected and drained through a burr-hole. Through successive percutaneous aspirations, effusion recurred and complete resolution was achieved after cranioplasty and subduroperitoneal shunt procedures. Decompressive craniectomy is generally accepted as a technically simple operation with a low incidence of complications. In the light of this current case, we hypothesize that a large craniectomy may facilitate the accumulation of recurrent effusion on contralateral side creating a resistance gradient between two hemispheres. This point may be especially true for subarachnoid hemorrhage cases requiring aneurysm surgery. We conclusively suggest that subdural effusions may be resistant to simple drainage techniques if a large contralateral craniectomy does exist, and early cranioplasty may be required for treatment in addition to drainage procedures.

Spontaneous spinal epidural hematoma after seizure: a case report.

A 14-year-old girl applied to our pediatric emergency department with loss of consciousness and a generalized tonic-clonic seizure. Her seizure was treated with midazolam (0.1 mg/kg, a total of 5 mg). The seizures ceased right after the midazolam injection. To exclude possible intracranial abnormality as a cause of the seizure, cranial computed tomography was performed, and she was hospitalized for further evaluation. Cranial computed tomography scan showed no signs of intracranial abnormality. Twenty minutes after the cessation of seizures, she regained consciousness. Two hours later, she noticed sensory loss in her lower limbs and progressive back pain. Neurologic evaluation revealed paresis of the upper limbs, diplegia of the lower limbs, and urinary retention. Her body temperature, pulse, respiration, and blood pressure were 36.2°C (97.2°F), 78 beats/min, 22 breaths/min, and 150/90 mm Hg, respectively. Cranial nerves were intact. Deep-tendon reflexes were hyperactive on both upper extremities and absent on both lower extremities, and there were no pathologic reflexes. She had no sensation below the level of T6. Other clinical findings were tenderness in the upper thoracic region and absence of sphincter tone. There were no other pathologic physical examination findings. The medical history was negative for anticoagulant therapy, vascular abnormality, trauma, and bleeding disorders. Initial investigations including a complete blood cell count, serum electrolytes, liver function tests, Introduction

Comparison of regression tree data mining methods for prediction of mortality in head injury

With this research, we sought to examine the performance of six different regression tree data mining methods to predict mortality in head injury. Using a data set consisting of 1603 head injury cases, we assessed the performance of: the Classification and Regression Trees (CART) method; the Chi-squared Automatic Interaction Detector (CHAID) method; the Exhaustive CHAID (E-CHAID) method; the Quick, Unbiased, Efficient Statistical Tree (QUEST) method; the Random Forest Regression and Classification (RFRC) method; and the Boosted Tree Classifiers and Regression (BTCR) method, in each case based on sensitivity, specificity, positive/negative predictive, and accuracy rates. Next, we compared their areas under the (Receiver Operating Characteristic) ROC curves. Finally, we examined whether they could be grouped in meaningful clusters with hierarchical cluster analysis. Areas under the ROC curves of regression tree data mining methods ranged from 0.801 to 0.954 (p<0.001 for all). In predicting mortality in head injury under the ROC curve, the BTCR method achieved both the highest area (0.954) and accuracy rate (93.0%), while the CART method achieved both the lowest area (0.801) and accuracy rate (91.1%). All of the regression tree data mining methods were clustered in the same grouping, but the BTCR method was at the origin of the cluster while the CART and QUEST methods produced results that were least like the others. The BTCR, demonstrating a 93.0% accuracy rate and showing statistically significantly differences from the others, may be a helpful tool in medical decision-making for predicting mortality in head injury.

Giant cervicothoracic extradural arachnoid cyst: case report

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid - filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4–T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

Isolated Bone Metastasis in Testicular Germ Cell Tumors: A Case Report and Review of the Literature

Background: In testicular germ cell tumors (GCT), bone metastases are usually seen late in the disease progress and are almost always associated with involvement of other sites. However, isolated bone metastasis is an extremely rare finding in these patients. Case Report: A 43- year-old man was admitted to the neurosurgery department of our hospital suffering from dysarthria, ataxia, headaches and a progressive swelling above the parietooccipital region of the skull. Radiological, biochemical and pathologic tests showed that the lesion of the skull was an isolated skull metastasis as an initial manifestation of nonseminomatous GCT of the testis. Discussion: When a young patient presents with bone pain or painless swelling, even if it is an unusual site and isolated, testicular GCT should be considered as a differential diagnosis, as these lesions could be the first evidence of metastatic GCT.

Giant calcified subdural empyemas

We report two cases of chronic calcified and ossified subdural empyema diagnosed during surgery and operated on successfully using an extraordinary large osteoplastic craniotomy. After surveying the literature, we must emphasize the unusual occurrence of the chronic subdural empyemas presenting with calcification-ossification and large size as observed in both of our cases.

Avulsion fracture of the anterior iliac crest after bone graft harvest: case report and review of techniques, risk factors and treatment.

The anterior iliac crest is the harvest site preferred by many surgeons because of the quantity and quality of bone obtainable and the simplicity of harvesting techniques. Avulsion fracture of the iliac crest following bone grafting is an extremely rare occurrence. We present a case report of avulsion fracture of the anterior iliac crest following bone graft harvesting for anterior cervical fusion in a 63-year-old man. Non-operative treatment was the method of our treatment in the patient. By means of the presented case, iliac crest bone grafting techniques, risk factors of avulsion fracture, and treatment options were reviewed.

Infection in the patients with isolated head injury: risk factors and the impact on treatment cost

BACKGROUND We aimed to determine risk factors and the impact on treatment cost of infection in patients with isolated head injury. METHODS Data acquired from 299 patients (239 males, 60 females; mean age 35,1±23,2 years) with isolated head trauma who were hospitalized for more than 72 hours at Trakya University Training and Research Hospital between 2001-2007 were evaluated retrospectively. Data including age, gender, initial neurological examination, radiological findings, duration of hospitalization, need for surgery, cost of infection treatment, total cost of care, and outcome scores were determined. Two groups divided according to the development of infection were compared for risk factors and the impact of infection on the cost of treatment. RESULTS In the group of patients with infection, the mean Glasgow Coma Scale score at delivery was lower; anisocoria, light reflex loss, lateralized deficit, skull base fracture, subdural hematoma, and cerebral edema findings were more frequent. A four-times longer hospital stay, 10-times higher total cost and a significantly increased mortality rate were determined in this group. For the patients with light head injury, in the group of patients with infection, the mean age was found to be higher. CONCLUSION For patients with isolated head injury, there are some risk factors for the development of infection that increase the hospitalization duration, total cost of care and mortality rates.