Sedat Cagli

Cerebellar mutism: report of seven cases and review of the literature.

It is well known that degenerative disease, hemorrhage, infection, and neoplastic disease of the cerebellum can lead to speech disorder. Mutism after posterior cranial fossa surgery was first reported by Rekate et al. and Yonemasu in 1985. We review and analyze the cases of cerebellar mutism that are reported in the literature that is available in English. We found 39 reported cases that included details regarding mutism. We review and analyze a total of 46 cases, including those of our seven patients. The ages of the patient ranged from 2 to 61 years (mean, 10.4 yr). Ninety-one percent of the patients were children. The vermis was the site of the mass lesions in > 90% of the cases. The pathological findings of the lesions were as follows: 33 medulloblastomas, 7 astrocytomas, 4 ependymomas, 1 metastatic tumor, and 1 arteriovenous malformation. All mass lesions were considered to be large or very large. The latency for the development of mutism ranged from 0 to 6 days (mean, 1.7 d). The mutism lasted from 4 days to 4 months (mean, 6.8 wk). Dysarthric speech ensued after the mutism was resolved in 35 of 46 patients. Mutism was transient in all of the cases. Cerebellar mutism is a transient complication of posterior fossa surgery for midline mass lesions.

Combined anterior and posterior approach for managing basilar invagination associated with type I Chiari malformation.

Ventral brainstem compression is common in patients with basilar invagination associated with type I Chiari malformation. The aim of this study was to investigate the reliability of a combined one-session anterior–posterior surgical approach for these patients. Nine patients underwent transoral odontoidectomy, posterior foramen magnum decompression, occipitocervical fixation, and bone grafting. All but two patients had ventral and dorsal operations in one surgical sitting. One of these two individuals had previously undergone posterior decompressive surgery at another hospital, but his condition had deteriorated rapidly afterward. The mean follow-up time was 19 months (range, 14–30 months). There was no mortality and no significant morbidity in this series. All but one of the patients showed significant improvement in their symptoms. Chiari malformations have a surprisingly high association with basilar invagination, and patients may have symptoms in both conditions. If there is a marked anterior compression, anterior transoral and posterior decompression, fusion, and instrumentation is an optimal strategy for treating patients with basilar invagination associated with type I Chiari malformation.

Neuroanatomy of cervical sympathetic trunk: a cadaveric study.

To reduce the risk of iatrogenic injury to sympathetic chain during anterior and anterolateral approaches to the cervical spine, its location has to be well defined and known by surgeons. We analyzed the course of sympathetic chain and its ganglia from C7 up to its entry into the cranial base and its relationship mainly with the longus colli (LC). Formalin fixed 20 human cadavers were dissected under operating microscope. Measurement of the dimensions of the ganglia, distance of the trunk to the LC, and the angles identifying the course of the chain were performed. Superior and inferior cervical/cervicothoracic ganglion were observed in all specimens, the middle cervical ganglion was observed in 48% of the specimens. The middle ganglion consisted of two ganglia in 10% of the dissected sides. Forty percent of the inferior cervical/cervicothoracic ganglion was at the C7 level, 25% was at C7‐Th1 disc level, and 35% was at Th1 level. Vertebral ganglion was detected in only 8% of the specimens. The course of the sympathetic trunk converges medially descending from upper cervical levels to the lower levels. Anterior surgical approach to the cervical spine is a commonly used procedure. Although Horner syndrome due to sympathetic injury is not a common sequence of cervical operations, our findings support the current few reports on the subject and should be useful to any surgeon who operates in the cervical region to avoid this uncommon complication. Clin. Anat. 22:324–330, 2009.

The Effects of Melatonin on the Antioxidant Systems in Experimental Spinal Injury

Melatonin has been recently shown by various in-vivo and in-vitro studies to exert potent neutralising effects on hydroxyl radicals, stimulate glutathione peroxidase (GSH-Px) activity, and protect catalase (CAT) from the destructive activity of hydroxyl radicals in neural tissue. We aimed to investigate the possible effects of pharmacological dose of melatonin on some of the antioxidant defence systems in an in-vivo study of experimental spinal injury. Seven groups of adult male Sprague Dawley rats were used in the following scheme: Group I: Naïve (n = 6), Group II: Lesion (n = 8), Group III: Melatonin (n = 5), Group IV: Melatonin + Lesion (n = 8), Group V: Placebo + Lesion (n = 5), Group VI: Sham operation (n = 5), and Group VII: Placebo (n = 5). Experimental spinal injury was induced at level T7-T8 by 5 sec compression of the total cord with an aneurism clip on anaesthetised and laminectomized animals. The total 10mg/kg dose of melatonin (Sigma) dissolved in alcohol-water was administered i.p. four times in 2.5 mg/kg doses, at 20min pre-, at the time of and at 1h and 2h post-compression. At 24±2h post-injury, the rats were euthanized and the lesioned segments of cord were dissected and homogenised with special care taken to distribute equal amount of injured tissue in each sample for analysis of reduced glutathione (GSH), oxidised glutathione (GSSG), superoxide dismutase (SOD), and CAT activity. Compression injury decreased GSH/GSSG ratio significantly (p <. 0001). Melatonin, by itself, significantly decreased GSSG content (p <. 05) and increased CAT activity (p <. 05) in the naive rats. Melatonin treatment decreased GSSG activity, thus elevating GSH/GSSG ratio, and also increased SOD and CAT activity without reaching statistical significance in the lesioned animals. In conclusion, pharmacological dose of systemically applied melatonin seemed to support some features of the antioxidant defence systems in our hands.

Online electrochemical monitoring of nitric oxide during photodynamic therapy

Photodynamic therapy (PDT), as a novel treatment modality, is based on the use of a photosensitizing agent with an excitation light source for the treatment of various malignancies. Its effect is mediated through reactive oxygen species and nitric oxide (NO), which are shown to be present in apoptosis. Individual differences among patients and even in different areas of the same tumor in one patient may cause a major problem with PDT: dose calculation during application of the light. An electrochemical sensor is proposed for online monitoring of NO generation as a solution of this problem. 5-Aminolevulinic acid (ALA) was administered as the photosensitizer in rat cerebellum. An amperometric sensor, selective to NO, was designed and tested both in vitro and in vivo during PDT. ALA-mediated PDT resulted in rapid generation of NO, starting as early as the application of light on the tissue. Simultaneous amperometric recordings have been carried out for 5 min during PDT. The progressive increase in NO concentration peaked at 1.10 min and then the response current began to decrease until it reached a plateau at around 70% of its peak value. This study, for the first time, electrochemically demonstrates the generation of NO during PDT. Rapid and stable responses obtained by the experimental setup confirmed that this method could be used as an online monitoring system for PDT-mediated apoptosis.

Vertebroplasty and kyphoplasty under local anesthesia: review of 91 patients.

AIM Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive methods for the treatment of vertebral compression fractures (VCF). In this study, we aimed to present our experience with VP and KP performed under local anesthesia and percutaneously. MATERIAL AND METHODS Between 2002 and 2008, 91 patients (total 112 vertebrae) with VCF due to osteoporosis, tumor and trauma underwent VP or KP. After radiological and routine evaluations, all patients were operated under local anesthesia. Mean operation time was 20 minutes per vertebrae. We never stopped the operation because of intolerance of any patient and all of them were discharged on the day of operation or the next day except one. RESULTS All patients had severe back pain. Mean preoperative Visual Analogue Scale (VAS) score for pain was 8.3 and the mean postoperative value was 2.7. Mean anterior wall and mid-vertebral body heights increased by 32% and 43%, respectively. The mean kyphotic angle decreased from 15.4 to 11.2. Cement leakage was observed in 4 patients and one of them underwent an open operation (decompression and stabilization) because of cement leakage to the epidural space. There was no other complication. CONCLUSION Vertebroplasty and kyphoplasty are safe, effective and minimally invasive procedures. Elderly patients can thefore avoid the potential complications of general surgery and be mobilized and discharged early.

Local interstitial chemotherapy with sustained release bucladesine in de novo glioblastoma multiforme: a preliminary study.

This clinical study was designed to evaluate the safety and efficacy of the sustained release form of dibutryl adenosine-3′,5′-cyclic monophosphate (dB-cAMP, bucladesine) placed in the tumor resection cavity at the time of recurrence of the de novo glioblastoma multiforme (GBM) patients.In a randomized prospective manner, 40 patients who were diagnosed as GBM in their first operations were included in this study. Four different therapy protocols were used: First group of 10 patients had tumor resection only. Second group assessed had only systemic chemotherapy as six i.v. infusions of fotémustine after tumor resection. Third group had implantation of bucladesine-loaded biodegradable polymeric sustained release (bcl-SR) pellets while the last group received six i.v. infusions of systemic fotémustine as in the second group in addition to local implantation of bcl-SR pellets. A biodegradable polymer, poly-dl-lactide-co-glycolide with molecular weight of 80 000, was used as carrier matrix for the drug with an approximately 4–5 months of release time. Maximal doses of 20 mg of bucladesine with a mean dose of 15.5 mg were implanted. No bone marrow suppression occurred and there were no wound infections as far as the local bucladesine-loaded polymer therapy is concerned.In this randomized prospective trial of local interstitial chemotherapy with long acting bcl-SR did show a statistically significant delay of recurrence on the treatment of GBM patients. Best treatment results obtained from the local bcl-SR + systemic fotémustine treated group in which survival rate estimated by the Kaplan–Meier method was 70% in de novo GBM at 12 months.

The posterior inferior cerebellar artery and its branches in relation to the cerebellomedullary fissure.

The conventional approach to the fourth ventricle is by splitting the vermis on the suboccipital surface of the cerebellum. By a unilateral transcerebellomedullary fissure approach, it is possible to provide sufficient operative space from cerebral aqueduct to obex without splitting the vermis. This approach needs meticulous dissection of the cerebellomedullary fissure and preservation of the posterior inferior cerebellar artery (PICA) and its branches. The tonsillomedullary and telovelotonsillar segments of the PICA are the most important vessels encountered in the transcerebellomedullary fissure approach. The PICA was examined under a surgical microscope in a total of 40 specimens by perfusing with a mixture of 10% Indian ink and gelatin. The passing of the tonsillomedullary segment of the PICA through the cerebellomedullary fissure was observed superior to the tonsil in 5%, at the level of the upper pole of the tonsil in 17.5%, at the middle of the tonsil in 37.5% and at the level of the lower pole of the tonsil in 37.5% specimens. When the PICA arose from the lateral medullary (LM) segment of the vertebral artery (VA), a caudal loop was present in 90%, when the PICA originated from the premedullary segment of the VA, the loop was present in 87.5% specimens. When the PICA arose from the basilar artery (BA), the loop was absent, and the tonsillomedullary segment of the PICA showed a straight course (100%). A thorough understanding of the relationship of the branches of the PICA to the cerebellar tonsils are prerequisites for surgery in and around the fourth ventricle. Clin. Anat. 21:119–126, 2008.

Primary glioblastoma of the Medulla Spinalis: A Report of Three Cases and Review of the literature

Primary spinal glioblastoma multiforme (spinal GBM) is not a very common entity. This paper presents an outline of this rare neoplasm, its clinical presentation, course, management and outcome and reports a 3-case series of spinal GBM. In this 3-case series with spinal GBM, one of the patients was operated for hydrocephalous 10 months later following the tumor surgery and another patient had cerebral metastasis after the surgery. In the postoperative period, two of the cases received radiotherapy and one received combined radiotherapy and chemotherapy with steroid therapy together following the tumor surgery. The review of the pertinent literature has revealed that due to the scarcity of the reported cases of primary spinal GBMs, this issue requires a closer look. GBM behaves more aggressive in medulla spinalis than it behaves when it originates from cerebrum. It may disseminate to the cerebrum during its course and it may cause hydrocephalus due to this dissemination (metastasis).

Creation of 3-Dimensional Life Size: Patient-Specific C1 Fracture Models for Screw Fixation

BACKGROUND Transarticular screw fixation has fatal complications such as vertebral artery (VA), carotid artery, and spinal cord injuries. The landmarks for deciding the entry point for C1 lateral mass screws were clarified by using life-size 3-dimensional (3D) patient-specific spine models. METHODS This study included a total of 10 patients with C1 fractures. Dual-energy computed tomography (CT) scan data from C1 pre- and postscrewing were modified into 3D patient-specific life-size cervical spine models. The detailed information, such as bony and vascular elements, of 13 separate parameters of C1 was used as an intraoperative reference. RESULTS 3D patient-specific models were created preoperatively with the fracture and postoperatively with the screwed vertebrae. After CT scans of the models were measured, the life-size patient-specific models were proven to be individualized. 3D models assisted in determining the fracture locations, pedicle sizes, and positions of the VA. The range of the measurements for ideal point of entry reveals the need for patient-specific intervention was required. CONCLUSIONS 3D models were used in surgical planning maximizing the possibility of ideal screw position and providing individualized information concerning cervical spinal anatomy. The individualized 3D printing screw insertion template was user-friendly, of moderate cost, and it enabled a radiation-free cervical screw insertion.