Tanju Uçar

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury.

AIM Debate continues as to whether decompressive craniectomy (DC) is an effective treatment for severe traumatic brain injury (STBI). DC is mostly used as a second tier treatment option. The aim of this study was determined whether early bilateral DC is effective as a first tier treatment option in patients with STBI. MATERIAL AND METHODS The study compared two groups. Group 1 comprised 36 STBI patients for whom control of intracranial pressure (ICP) was not achieved with conservative treatment methods according to radiological and neurological findings. These patients underwent bilateral or unilateral DC as a second tier treatment. Group 2 comprised 40 STBI patients who underwent early bilateral DC as a first tier treatment. RESULTS Group 2 patients had a mean better outcome than Group 1 patients especially for patients with a GCS 6-8. Postoperative ICP was lower in Group 2 patients than Group 1 patients. CONCLUSION This study indicates that early bilateral DC can be effective for controlling ICP in STBI patients. It is likely the favorable outcome results for Group 2 patients reflects the relatively short time between trauma and surgery. Therefore, these data indicate early bilateral DC can be considered as a first tier treatment in STBI patients.

Primary primitive neuro-ectodermal tumor of cauda equina with intracranial seeding.

SummaryPrimitive neuro-ectodermal tumor (PNET) of the cauda equina is a rare entity. 18 cases have been reported in the literature so far, including 4 cases with intracranial seeding. Moreover parenchymal involvement of brain has never been reported as a form of intracranial seeding from PNET of the cauda equina. A 31 year-old female patient, with PNET of cauda equina showing intracranial seeding 6 months after surgery, is presented in this report. To our knowledge, this is the first adult case of spinal cord PNET with parenchymal involvement of brain. The histopathological, clinical and radiological findings as well as treatment of the patient were evaluated.

Conservative Management of Extradural Haematomas: Effects of Skull Fractures on Resorption Rate

SummaryIn conservative management of extradural haematomas (EDH), several mechanisms were described to explain the resorption of the haematoma. One of these was the transfer of the clot into the epicranial space through the skull fracture. In this study, the effects of skull fracture and associated intracranial lesions in the conservative management of EDH were investigated. Skull fracture and associated intracranial lesions were found in 71.11% and 51.1% of the patients, respectively.Resorption rate was calculated using an original formula and it was 0.548±0.227 in patients with skull fracture and 0.507±0.170 in patients with both skull fractures and additional intracranial lesions. These rates were found to be significantly higher than in the patients without fracture.In conclusion, in the patients with EDH planned to be managed conservatively, skull fracture and additional intracranial lesions must not be thought as risk factors, on the contrary, resorption of the clot might be earlier than in the others.

Conservative management of epidural haematomas. Prospective study of 15 cases.

SummaryConservative management of epidural haematoma (EDH) depends on a balance between expansion and resorption rate of the clot.15 patients with EDH whose CT scans demonstrated a small EDH and were asymptomatic or with minor symptoms or with a delayed diagnosis were treated conservatively. The thickness of haematoma ranged between 4.9–40.8 mm. In two patients, the haematoma extended from the posterior fossa to the supratentorial region. In 7 patients, additional intracranial pathology was detected. None of the patients had neurological deterioration on follow up. The second CT was performed on second day at the earliest, in fourth week at the latest.We conclude that the patients with EDH who are neurologically stable during the first 24 hours after trauma, with small EDH and with minor or no symptoms or signs, might be candidates for conservative management. An absolute precondition for conservative management is close supervision of the patient.

Outcomes of intrathecal baclofen (ITB) therapy in spacticity.

AIM Spasticity is associated with various neurological conditions. Intrathecal baclofen (ITB) is one of the popular treatments for severe spasticity. In this paper we present our experience in treating 30 patients with both spinal and supraspinal spasticity with chronic infusion of Baclofen to evaluate the long term efficacy of this treatment on spasticity, disability and pain, and to evaluate the side effects of intrathecal Baclofen. MATERIAL AND METHODS The medical records of 30 patients who underwent baclofen pump placement from 2000 to 2010 under Department of Neurosurgery at the University of Akdeniz at Antalya/Turkey, were reviewed. All study subjects had diffuse chronic, severe, and generalized spasticity (Ashworth score ≥ 3), and had shown inadequate response to various oral antispastic drugs including baclofen. All patients were evaluated by means of the Ashworth score, spasm frequency, Barthel index, Rankin scales and VAS. RESULTS Spasticity and spasm frequency and pain scores were clinically and statistically decreased in all patients. CONCLUSION ITB therapy increases the quality of lifestyle and functional independence by reducing not only cerebral but also spinal related spasticity in appropriately selected cases.

Bilateral cerebellopontine angle arachnoid cysts: case report.

OBJECTIVE AND IMPORTANCE A rare case of bilateral cerebellopontine angle (CPA) arachnoid cysts (ACs), accompanied by cerebellar tonsillar displacement toward the foramen magnum, is presented. CLINICAL PRESENTATION A 45-year-old woman presented with progressive dysphagia, vertigo, and truncal ataxia. Magnetic resonance imaging revealed bilateral CPA ACs and cerebellar tonsillar displacement. INTERVENTION The right CPA AC was excised via a suboccipital approach. Decompression of the foramen magnum and duraplasty were also performed. CONCLUSION The case reported here is the first case of bilateral CPA ACs. Decompression of the foramen magnum and excision of the cyst resulted in complete relief of symptoms.

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

BACKGROUND We investigated Glasgow Coma Scale (GCS) scores, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes, and long-term clinical outcomes in patients with severe traumatic brain injury (STBI) associated with bilateral non-reactive dilated pupils (BNDP) who underwent decompressive surgery (DS). METHODS The study group consisted of 28 patients (11 females, 17 males) with BNDP from among 147 patients who underwent DS due to STBI in our department. RESULTS The mean GCS score was 4.96±1.20 at admission and 4 preoperatively. Mean ICP in non-surviving patients after DS was higher (p<0.05). ICP decrease after DS was also higher in surviving patients than in non-surviving patients (p<0.05). The overall mortality rate was 61.02%. A GCS motor score >2 at admission was associated with lower mortality (p<0.05). Four of the surviving patients (14.28%) had a functional outcome (Glasgow Outcome Score: 4 and 5) at one year after hospital discharge. CONCLUSION Outcome in patients with BNDP after STBI may not always be fatal or poor. Rapid DS may increase the chance of functional survival, especially in patients with admission GCS score of 6 or 7.

Sutural diastasis caused by pseudotumor cerebri.

The diagnosis of pseudotumor cerebri is based on the triad of: (1) papilloedema, (2) elevated intracranial pressure with a normal cerebrospinal constituency and (3) normal central nervous system imaging studies. However, the diagnosis of pseudotumor cerebri is not always straightforward. We report a 19-year-old morbidly obese girl who developed pseudotumor cerebri associated with sutural diastasis of the cranium based on the direct radiographies. Following a ventriculo-peritoneal shunt operation, we demonstrated the closing and perisuturally sclerosis on all major cranial sutures. A careful examination of direct radiographies might be critical for diagnosis of pseudotumor cerebri. Prompt recognition, evaluation, and treatment are needed to prevent permanent visual loss.