Tarkan Calisaneller

Akinetic mutism after fourth ventricle choroid plexus papilloma: treatment with a dopamine agonist

BACKGROUND Akinetic mutism is a behavioral state wherein a patient seems to be awake but does not move or speak. Several patients are reported to have developed mutism after posterior fossa surgery. We present a patient who developed akinetic mutism after total excision of a choroid plexus papilloma of the fourth ventricle, and who was treated with bromocriptine. CASE DESCRIPTION An 18-year-old woman was admitted with akinetic mutism, which had developed 6 days after posterior fossa surgery. She had had no neurologic deficit in the first 5 days after surgery and could communicate with her family. Despite antioedematous therapy and daily lumbar punctures to drain cerebrospinal fluid, there was no clinical improvement after she entered the akinetic mute state. Brain magnetic resonance revealed ventriculomegaly; brain single photon emission computed tomography revealed bilateral reduction of perfusion in the frontal region. Because daily lumbar drainage did not result in clinical improvement, shunt placement was not considered. Bromocriptine therapy was begun at a dose of 2x2.5 mg; 24 hours later, the patient started to speak and move her upper extremities. Further improvement occurred over the following week when the dose was increased to 3x2.5 mg. Bromocriptine was replaced with a placebo to determine whether the neurologic improvement was caused by the medicine. The patients neurologic status deteriorated progressively; therefore, bromocriptine was restarted and she was discharged from the hospital. During the 6 months of follow-up, the patient has remained in good health. CONCLUSIONS The etiology of akinetic mutism is not clear. Monoaminergic pathways, particularly dopaminergic cell groups, are most probably involved in this syndrome, because bromocriptine has a dramatic effect on these patients, as demonstrated in our case.

Prognostic significance of third ventricle dilation in spontaneous intracerebral hemorrhage: a preliminary clinical study

Abstract Objective: Although numerous factors have been described that predict outcome after spontaneous intracerebral hemorrhage (ICH), very little is know about the role of hemorrhagic dilation of the third ventricle in development of hydrocephalus and prognosis. The objective of this study was to investigate whether the presence of hemorrhagic third ventricle dilation after ICH would predict development of hydrocephalus and outcome. Methods: We identified the patients with spontaneous ICH treated with external ventricular drainage (EVD) in this retrospective study. Computerized tomography (CT) was performed at admission within 24 hours of onset and retrospectively analysed to determine lesion size and location, status of third and fourth ventricle and frontal horn index (FHI). Glasgow coma scale (GCS) score, mean arterial pressure (MAP), etiology and demographic data were obtained from medical records. Outcome was determined using modified Rankin score at month 3. Patients with and without third ventricle dilation were compared in terms of hydrocephalus (FHI>0.38), initial GCS score, age and MAP, and analyses were performed to determine whether third ventricle dilation was a predictor of poor outcome. Results: Of the 22 patients studied, all had thalamic or basal ganglia hemorrhage with intraventricular hemorrhage (IVH) and all are treated with external ventricular drainage (EVD). Of the 22 patients, 12 had third ventricle dilation (width≥10 mm) and ten patients had non-dilated third ventricle (width<10 mm). Patients with third ventricle dilation had lower GCS scores (7.4 ± 1.8 versus 9.7 ± 2.1, p<0.005) and had higher FHI (0.46 ± 0.06 versus 0.38 ± 0.02, p<0.005) as compared to patients with non-dilated third ventricle. The differences in age (59.5 ± 9.4 versus 59.2 ± 11.2) and MAP (128.3 ± 16.0 versus 130.5 ± 13.6) of the patients were not significant statistically. Sixty-six percent of patients (8/12) with third ventricle dilation and 60% of patients (6/10) with normal third ventricle were dead 6 months post-operation and mortality rate did not differ significantly. Discussion: Although the roles of various factors are well described in the prognosis of spontaneous ICH, little is known about the role of third ventricle dilation. Based on our results, we concluded that third ventricle dilation is a poor prognostic factor.

Remote cerebellar haemorrhage after spinal surgery

Remote cerebellar haemorrhage (RCH) is a rare but potentially lethal complication of spinal surgery resulting from inadvertent opening of the dura. The precise mechanism of this type of haemorrhage remains undetermined. Magnetic resonance imaging (MRI) may show a ‘Zebra sign’ representing the horizontal curvilinear configuration of haemorrhage between the cerebellar folia.

Acute spontaneous spinal subdural hematoma in a patient with bilateral incarcerated inguinal hernia.

OBJECTIVE Acute spinal subdural hematoma is an infrequent and devastating condition that occurs mostly in patients with coagulopathy or receiving anticoagulants. It may also develop after trauma, spinal surgery or iatrogenically (lumbar puncture and/or spinal anaesthesia). Spinal vascular malformations or spinal tumours can also be the origins of subdural hematomas. However, acute spinal subdural hematomas, which are not associated with these risk factors, are seen even more infrequently. In this report, we have described a case of spontaneous acute spinal subdural hematoma that occurred in a patient with bilateral incarcerated inguinal hernia and discussed the possible pathomechanisms. METHODS A 50-year-old male was admitted to the emergency department for the acute onset of interscapular pain, slight weakness in both legs and urinary retention. Neurological examination revealed paraparesis (3/5 in left, 4/5 in right) and hypoesthesia below T5 dermatome. He had long-standing bilateral inguinal hernia and constipation for the last 5 days. Magnetic resonance imaging of the spine displayed an extramedullary acute hematoma at the T4-8 levels but it was impossible to identify whether the hematoma was extradural or intradural exactly. The patient underwent an urgent operation via T4-6 laminectomy. After opening the dura, an extensive, partially organized hematoma was completely removed by aspiration. Muscle strength was improved immediately; urinary retension was recovered on postoperative day 7. Constipation was relieved on postoperative day 4. CONCLUSION Acute spinal subdural hematoma is an emergency condition in case of neurological compromise. Urgent surgical evacuation of hematoma results in good outcome. In the case of unidentified etiologies, the conditions that could play a role in increased intraabdominal and/or intrathoracic pressure should be considered always.

Dysphagia due to diffuse idiopathic skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH), known as Forestier disease, is a non-inflammatory condition characterized by large bridging anterior osteophytes of the cervical spine caused by ossification of the anterior longitudinal ligament and surrounding extraspinal ligaments. Common symptoms of this disease are cervical pain and stiffness; however, it can manifest itself by respiratory compromise due to upper respiratory airway compression and dysphagia due to mechanical obstruction.

Six months post-operative clinical and 24 hour post-operative MRI examinations after nucleoplasty with radiofrequency energy

SummaryBackground. Minimally invasive techniques are gaining popularity for the treatment of discogenic low-back pain. Nucleoplasty is a relatively new procedure that uses radiofrequency energy to disintegrate and evacuate the disc material. The purpose of this study is to examine the early post-operative radiological changes after lumbar nucleoplasty and to assess the short-term effects of this procedure on discogenic lower back pain and leg pain. Methods. Twenty nine patients between the ages of 32 and 59 years (mean 44.14, SD 7.11 years) were included in the study. Visual Analogue Scale (VAS) scores of the patients were recorded in the pre-operative period and 24 hours, 3 months and 6 months after the procedure. Additionally, pre-operative and post-operative lumbar magnetic resonance imaging (MRI) examinations of these patients were compared. Findings. The mean pre-operative VAS score was 6.95 (range 3.0–10.0, SD 1.87) and the mean post-operative VAS scores at 24 hours, 3 months and 6 months were 2.46 (range 0–8.0, SD 2.07), 4.0 (range 0–10.0, SD 3.09) and 4.53 (range 0–10.0, SD 3.6), respectively. There were statistically significant reductions (p < 0.001) in VAS scores for all post-operative time points when compared to pre-operative values. Nucleoplasty did not produce obvious changes at least on the early post-operative MRI examination. Conclusions. Although, nucleoplasty appeared to be a safe minimally invasive procedure, the value of this new technique for the treatment of discogenic low-back pain remains as yet unproven. Further randomised placebo-controlled studies with longer follow-up are needed to elucidate the effects of nucleoplasty on discogenic low back and leg pain.

Problems in the management of intracranial meningiomas.

Meningiomas account for approximately 15–20% of all brain tumors, and are the most common benign intracranial tumor. These neoplasms develop from cap cells in the arachnoidea; thus, they can be found anywhere that dura mater exists. Meningiomas are usually diagnosed in middle age, and are significantly more frequent in females than in males. Atypical and anaplastic malignant forms also exist. Some types of meningiomas are difficult to manage and require special considerations. The first-line therapy for meningioma is surgery aimed at total excision; however, limitations of surgery must be fully evaluated in order to achieve better results. Conventional radiotherapy and gamma-knife radiosurgery can be used as adjuvant therapeutic modalities under certain conditions. The issues that we consider important in the management of intracranial meningiomas can be discussed under the headings of diagnosis, surgery, multiplicity, pathology, and recurrence.

Simple decompression of the ulnar nerve at the elbow via proximal and distal mini skin incisions.

The purpose of the present study was to describe a new minimally invasive surgical technique for decompression of the ulnar nerve at the elbow for treatment of cubital tunnel syndrome. Four patients underwent surgical treatment for cubital tunnel syndrome. Preoperative clinical states were classified by using the McGowan grading system and the postoperative states were recorded by using the Wilson and Krout grading system. Preoperative and last follow-up electromyographic results were also recorded. At the last follow-up, three patients were recorded as excellent and one patient was recorded as good according to Wilson and Krout grading system. One patient showed improvement in sensory nerve conduction velocity another showed improvement in motor nerve conduction velocity at the last follow-up. We conclude that simple decompression of the ulnar nerve at elbow via proximal and distal mini skin incisions is an effective, technically simple and safe surgical method in the treatment of cubital tunnel syndrome.

INTRAVENTRICULAR DYSEMBRYOPLASTIC NEUROEPITHELIAL TUMOR : CASE REPORT

OBJECTIVEThe most common localization of dysembryoplastic neuroepithelial tumors (DNTs) is the supratentorial cortex, often in the temporal lobe. However, intraventricular localization of a DNT is extremely rare. CLINICAL PRESENTATIONA 30-year-old woman presented with a 1-year history of epileptic seizures. The seizures had not been controlled despite standard doses of antiepileptics. INTERVENTIONNeuroimaging results demonstrated a lesion located in the occipital horn of the right lateral ventricle. The lesion was totally removed. Based on histopathological and immunohistochemical evaluation, a DNT was diagnosed. Over the course of the next 8 months, the patients epileptic seizures were under control. The most recent neuroimaging examinations revealed neither residual nor recurrent tumor. CONCLUSIONBecause DNTs are surgically curable and neither radiotherapy nor chemotherapy is required after surgery, recognition of an intraventricular DNT in this location is extremely important.

Compression of the ulnar nerve in Guyon's canal by an arteriovenous malformation.

revealed a divided palmaris longus tendon, the distal portion of which had reattached itself to the flexor carpi radialis tendon to lie across the median nerve (Fig 1). The distal part of the palmaris longus tendon was mobilised and excised, freeing the nerve from compression. At follow-up a month later, his symptoms had completely resolved. Literature review identified three cases of anatomical anomalies of the palmaris longus tendon responsible for median nerve compression proximal to the carpal tunnel (Green, 2006; Schuurman and van Gils, 2000; Yildiz et al., 2000) but no cases of tendon bridging over the nerve after previous injury, such as had occurred in this patient.