Tahsin Erman

PCNA and Ki-67 in central nervous system tumors: correlation with the histological type and grade.

Determination of proteins in the control of proliferation in normal cells helps a better understanding of cellular transformation and proliferation mechanisms. Measurement of proliferative activity is important in determining the tumor grade, recurrence span and malignancy. Proliferating cell nuclear antigen (PCNA) and Ki-67 are two of the nuclear markers used to demonstrate the proliferative phase of the cell cycle.In the present study, 63 central nervous system (CNS) tumors of various histologic types, diagnosed in Çukurova University Medical Faculty, Department of Pathology and graded according to WHO grading system were examined for PCNA and Ki-67 monoclonal antibodies using immunohistochemistry. Results were analyzed with statistical methods. Distribution of PCNA and Ki-67 LI (labeling index) values were determined for different tumor types. The highest PCNA and Ki-67 LI values were detected in medulloblastoma, malignant meningioma, primitive neuroectodermal tumor (PNET) and glioblastoma (GBM) groups, while pilocytic astrocytoma, meningioma, craniopharyngioma and oligodendroglioma showed the lowest values.In such tumors, the correlation between the increasing grade and PCNA and Ki-67 LI values were statistically significant. A correlation between the clinical outcome and Ki-67 and PCNA LI values was also detected.Conclusively, both markers can be used to evaluate the tumor grade and to asses the possibility of recurrence and malignancy in CNS tumors.

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.

Cerebrospinal Fluid Shunt Infections in Children

Infections of cerebrospinal fluid shunts continue to be a substantial source of mortality and morbidity in children with hydrocephalus. Although several therapeutic modalities are currently used for the treatment of shunt infections, there are no clear guidelines for treatment. The purpose of this study was to determine the common pathogens of cerebrospinal fluid shunt infections and evaluate the success of our management. Thirty-five children treated for ventriculoperitoneal shunt infections over the past 9 years were reviewed. The management protocol consisted of the removal of the infected shunt, the application of ventricular taps or reservoir placement, intraventricular antibiotic treatment, and the placement of a new shunt when cerebrospinal fluid sterility was achieved. Four patients were treated with antibiotics alone. Most episodes occurred within 4 months of shunt placement. The most common causative microorganism identified was Staphylococcus epidermidis, followed by S. aureus, and S. warneri. Three patients died from complications of shunt infections, 2 patients had a recurrent shunt infection, while the remaining 29 patients remained free from shunt-related complications. In agreement with the evidence published in the literature, our findings suggest that the above management protocol is effective for the treatment of cerebrospinal fluid shunt infections.

Chondromas of the falx cerebri and dural convexity: report of two cases and review of the literature

SummaryIntracranial chondromas usually arise from the base of the skull. They rarely originate from the convexity dura and falx. Here we describe two cases of intracranial chondroma located at the convexity dura and falx, discuss the genesis, radiologic, histologic features and review the literature.

The expression of survivin and Ki-67 in meningiomas: correlation with grade and clinical outcome

Identification of proteins involving in the control of proliferation in normal cells may lead to a better understanding of cellular transformation and proliferation mechanisms. Measurement of proliferative activity may help determine the tumor grade, recurrence and malignancy. Forty meningiomas of various histological grade, diagnosed in Baskent University and Çukurova University Medical Faculty, Departments of Pathology, were graded according to WHO grading system and survivin and Ki-67 monoclonal antibodies were administered by immunohistochemical method. Findings were analyzed with statistical methods; distribution of survivin expression and Ki-67 LI values were determined for different grade meningiomas. The correlation between increasing grades of meningiomas, particularly between grades I and III, survivin and Ki-67 LI values was statistically significant. In addition, we have found a positive correlation between clinical outcome, survivin and Ki-67 LI. For over expression of survivin in some of the grade I meningiomas and no or mild expression in some of the grades II and III meningiomas, however, it has been suggested that apoptosis inhibited by survivin is not the only factor responsible for progression of meningiomas.

Huge bilateral pulmonary and pleural metastasis from intracranial meningioma: a case report and review of the literature

SummaryA case of recurrent meningioma with atypical features and extracranial metastases is reported. A 34-year-old female was operated in 1996, 2000, and 2002, and frontal parasagital meningioma was extirpated. Histological diagnoses of all the resected tumors were meningotheliomatous meningioma, WHO Grade I. However, 2 years later, the tumor recurred in the frontal scalp and was removed again totally. Histological diagnosis was reported as an atypical meningioma; meningotheliomatous type; WHO Grade II. She received radiation therapy. But the tumor had metastasized to the lung and pleura. Transthoracic tru-cut biopsy was performed from large mass of the left lung. Cytopathology was consistent with malignant meningioma, metastasis from the patient’s known intracranial meningioma. Ki-67 staining index at the primary and metastatic sites of the present cases were 7 and 5%, respectively. We reviewed and discussed the histopathological features and mechanisms of metastasizing meningioma.

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.

Choroid plexus papilloma of bilateral lateral ventricle

Summary. Background: Choroid plexus papillomas are rare, accounting for less than 1% of all intracranial tumours in adults. However, they are relatively more common in childhood and constitute 1.5 to 4% of intracranial tumours. They are most often located in the lateral ventricle, followed by the fourth and third ventricles and, rarely, in the cerebellopontine angle. Bilateral lateral ventricle choroid plexus papilloma is very rare and only a few cases has been reported. Clinical presentation: A 3-year-old boy was admitted to our hospital with a history of irritability and vomiting. Neurological examination on admission was normal. A head computed tomographic scan and magnetic resonance imaging showed tumours in both lateral ventricles, hydrocephalus and a left temporal arachnoid cyst. The bilateral intraventricular mass enhanced densely and homogeneously. A presumptive diagnosis of choroid plexus papillomas was made. Intervention: The initial surgery was performed for removal of the lesion in the right lateral ventricle, and 20 days later removal of the left lateral ventricle tumour was carried out. Bilateral temporoparietal craniotomy and total removal of tumours was performed. Hydrocephalus was controlled by total tumour resection from both sides. The histology of these tumours was the same and revealed choroid plexus papilloma. Interpretation: Bilateral choroid plexus papilloma is extremely rare and distinct from diffuse villous hypertrophy and their surgical approaches are different from each other. Differential diagnosis should be made by MRI preoperatively. If bilateral choroid plexus papilloma is detected, total surgical resection should be performed. Total surgical removal of the neoplasm not only cures the tumour but also may lead to complete resolution of the hydrocephalus.

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.