Study Design:This was a retrospective study. Objective:The purpose of this retrospective study was to determine the radiologic outcome at the index and adjacent levels and clinical outcome of cervical total disk arthroplasty (TDA) using Prodisc-C after a minimum 24 months follow-up at a single center. Methods:Eighty-six levels of 59 (28 female, 31 male) cases with minimum 2 years follow-up were included in this study. Radiologic parameters including disk level height at the operated and adjacent levels, global cervical lordosis, segmental lordosis, range of motion, subsidence, facet arthrosis, adjacent segment degeneration (ASD), and heterotopic ossification were analyzed. All surgeries were performed by a single surgeon. Results:Average age was 39.5 (range, 27 to 56) years and average follow-up was 33.6 (range, 24 to 81) months. Operated levels were C3-4 (%4.6), C4-5 (%16.3), C5-6 (%48.8), C6-7 (%26.8), and C7-T1 (%3.5). All patients had clinical improvement. NDI was improved from 46 to 9. There was a significant improvement in segmental kyphosis, global lordosis, and disk height at the operated level with no significant change at the final follow-up. There was no radiographic facet joint arthrosis at the index and adjacent levels, 4 (%6.7) patients had radiographic signs of ASD at the cranial adjacent level, whereas 5 (%8.4) patients had ASD at the caudal adjacent level. Heterotopic ossification (HO) was observed in 4 patients (%6.7) with a complete fusion in 1 patient. Conclusions:This study demonstrates a satisfactory radiographic and clinical outcome after prodisc-C TDA with a minimum 24-month follow-up.
Giant cell glioblastoma is an extraordinary subtype of glioblastoma that merits mention as a distinct variant of glioblastoma in World Health Organization classification of gliomas. It represents for about 1% of brain tumors and about 5% of glioblastomas in general. It has no preferential region and may occur in various locations of the central nervous system, most commonly in the temporal lobe. To our knowledge, there have been a few cases involved in the unilateral lateral ventricle reported in the literature, but there have been no reports about the recurrent cases involved in bilateral lateral ventricles. We herein present a very rare case of recurrent giant cell glioblastoma that occurred across bilateral lateral ventricles.
Shrestha, Rajendra MBBS, MD; Pradhan, Reeka MBBS, MD; You, Chao MD, PhD Author Information
Background:Increasing literature data suggest that cranioplasty at early stage of skull defects may lead to better rehabilitation outcome. This study was conducted to explore the relationship between the timing of cranioplasty and neurological rehabilitation in patients with traumatic skull injury (TSI). Methods:A total of 77 patients were admitted as a result of TSI, assessed on rehabilitation measures, and grouped by the intervals between skull injury and cranioplasty. All patients underwent cranioplasty between 20 and 500 days after TSI. Neurological function and general wellbeing of the patients before and after cranioplasty were assessed as per National Institute of Health Stroke Score (NIHSS) and Karnofsky Performance Status (KPS) scales, respectively. Results:Cranioplasty led to significant improvement in functioning, with all the patients demonstrating clinically meaningful gains. There were approximately 80%, 50%, and 20% reduction in postcranioplasty NIHSS in patients who underwent cranioplasty within 90 days (group 1, P<0.01), 90 to 180 days (group 2, P<0.05), and beyond 180 days (group 3, P<0.05) after TSI, respectively. The postcranioplasty KPS scores significantly improved in all the patients compared with those before cranioplasty (P<0.05). The KPS improvement rate was significantly higher in group 1 compared with those in groups 2 and 3 (P<0.05), with no difference between groups 2 and 3. A reciprocal relationship between the intervals from TSI to cranioplasty and the KPS improvement rate was observed. Conclusions:Cranioplasty improved neurological rehabilitation and general wellbeing in patients with TSI, with the optimal surgical time no more than 90 days after skull injuries.
Hydatid cyst is a contagious disease formed by the pathogen Echinococus granulosus. Pulmonary and liver hydatidosis is the common form of the disease. However primary spinal hydatid cyst is rarely seen and compromise less than 1% of all hydatid cases. Primary spinal hydatid cyst and vertebral compression fracture association is very unusual. In this report we present a case of thoracic vertebral compression due to primary spinal hydatid cyst and discuss the important features of this rare disease.
Object: To investigate the clinical features and radiologic findings in misdiagnosed intracranial infection. Methods: A series of 12 uncommon patients with misdiagnosed intracranial infection were enrolled in the present study from January 2004 to December 2013. Results: All patients with rare intracranial infections were confirmed by histopathologic examination; the misdiagnosis rate is 100% in the present series. The initial diagnosis included metastatic tumor, glioma, meningioma, cyst disease, hematoma, and epidermoid cysts. The features of magnetic resonance imaging were isointense (5/12), hyperintense (5/12), hypointense (2/12) on T1 weight, and hypointense (4/12) and hyperintense (8/12) on T2 weight, respectively, as well as nonspecific enhanced findings in the present study. The most common etiology of misdiagnosed intracranial infections was fungal abscess and neurocysticercosis that account for 25% (3/12) of the infections. Uncommon intracranial toxoplasmosis in 1 case and 1 case of cerebral alveolar echinococcosis in 1 case were also observed, respectively (8.3%). In addition, 2 cases (16.7%) of all patients were proved to have intracranial abscess with specific pathogen: one is Staphylococcus aureus, and the other is Serratia marcescens. Two intracranial abscesses (16.7%) with nonspecific pathogen were also found in the present study. The follow-up was conducted on all patients during a period of 3 to 96 months (average, 48 mo), of which 91.7% patients had a favorable outcome (Glasgow Outcome Scale 5 and 4) and 8.3% had an unfavorable outcome (Glasgow Outcome Scale ≤3). Conclusions Primary diagnosis of rare intracranial infections should be emphasized; favorable outcome could be achieved by early microsurgical intervention and timely effective antibiotics.
Objective:We report on late period results in 70 lumbar and cervical patients, who underwent percutaneous plasma disk coagulation treatment in our clinic, evaluated using a visual analogue scale (VAS). Methods:In our study, we evaluated 70 patients who had Macnab grade 1-2-3 lumbar and cervical disk herniation in the lumbar 4-5 and cervical 5-6 levels, without posterior longitudinal ligament tear but with radiculopathy. Data took the form of early-period and late-period VAS scores. Two groups of patients were evaluated: group 1 comprised 35 patients who had L4-L5 lumbar disk herniation with Pfirrmann grade 1-2-3 degeneration, whereas group 2 comprised 35 patients who had C5-C6 cervical disk herniation with Pfirrmann grade 1-2-3 degeneration. Results:A total of 70 patients presented to our clinic between January 2010 and April 2013, who had Macnab grade 1-2-3 disk herniation and radiculopathy, and had previously undergone conservative treatment and physical treatment methods, and those with no improvement were given percutaneous plasma disk coagulation treatment. The youngest patient was 19 years old, and the oldest was 50, yielding an average age of 28 years. The average preoperative VAS score of patients in the Pfirrmann grade 1-2-3 group was 7.1, whereas the postoperative scores were 3.8 in month 1; 4.1 in month 6; 4.3 in year 1; and 4.4 in year 2. The preoperative VAS score of group 2 was 7.2, whereas the postoperative scores were 3.5 in month 1; 2.5 in month 6; 2.1 in year 1; and 2.4 in year 2. Conclusions:It was found that percutaneous plasma disk coagulation (D30) treatment in patients with Macnab grade 1-2-3 and Pfirrmann grade 1-2-3 degeneration was useful in lumbar and cervical herniations, but the results were more significant in cervical disk herniations.
Acute onset hemiparesis is a common initial presentation of cerebral ischemic stroke. However, other possibilities should be considered as well before final diagnosis. Motor deficits resulting from spontaneous spinal epidural hematoma (SSEH) are usually paraparesis or quadriparesis, but a few cases of SSEH that presented hemiparesis have been documented and misdiagnosed as cerebral ischemic stroke. Herein, we present a rare case of SSEH with acute hemiparesis, which was initially misdiagnosed.
This report describes a very rare Dandy-Walker malformation (DWM) and emphasizes the follow-up for asymptomatic DWM. This case reports a man with undiagnosed DWM who was asymptomatic until the age of 59 years when he presented with headache. Computed tomography and magnetic resonance imaging revealed DWM. To our knowledge, this is the first report that describes a patient who was diagnosed with DWM presenting with headache without any other symptoms.
Low-pressure hydrocephalus (LPH) after skull base surgery is rare. We report a 52-year-old man with sphenoidal planum meningioma who underwent a pterional approach for tumor excision. After surgery, consciousness disturbance and intraventricular hemorrhage with associated hydrocephalus were observed. Clinical expression revealed poor response to apparently adequate cerebrospinal fluid drainage through external ventricular drain and functioning ventriculoperitoneal shunt with persisted ventriculomegaly on brain computed tomography scans. A diagnosis of LPH was made, and then combination of external ventricular drain with subatmospheric drainage and endoscopic third ventriculostomy were performed. Finally, the patient recovered clear consciousness with recovery of normal ventricular size. This report highlights the postulated mechanism of LPH formation after skull base surgery and advocates some treatment options for this rare entity.
Objective:The keyhole concept in neurosurgery has remained mostly limited to transcranial endoscope-assisted microsurgery or limited-sized keyhole craniotomies. In contrast, documentation of keyhole surgery, as described by Yaşargil, regarding no traumatization to the normal neural, arterial, and venous structures has appeared relatively less in the medical literature, under the term keyhole neurosurgery. Microsurgical resection of falcine meningiomas, although not infrequent, poses technical challenges related to the tumor’s anatomic relationships with the superior sagittal sinus, inferior sagittal sinus, callosomarginal arteries, pericallosal arteries, and neural structures of the medial aspects of the hemispheres. Case Description:A 35-year-old female patient with an anterior inner falcine meningioma and frontal multiple cortical veins draining into superior sagittal sinus is presented. The tumor was totally removed using a very small gap without scarifying any cortical vein. Postoperatively, the patient did very well. Conclusions:The microneurosurgical technique of navigation through aquatic cisternal corridors for surgical access is a minimally invasive technique permitting surgical manipulations through very small gaps and preserves normal neural and vascular structures.
Patients undergoing lumbar laminectomy experience severe pain in the postoperative period, which may increase the incidence of postoperative morbidity and complications. This study determined the effect of bupivacaine on postoperative back pain after lumbar laminectomy. Sixty consecutive patients who underwent posterior approach laminectomy were randomly allocated to control and study groups. Anesthesia was induced with intravenous midazolam, fentanyl, and morphine. Tracheal intubation was facilitated by Atra, and patients’ lungs were ventilated with a mixture of 66% nitrous oxide and 0.5% to 1% halothane in oxygen. Anesthesia was continued with panthotal. Before wound closure in the study group, the surgeon injected 30 mL of 0.25% bupivacaine in paravertebral muscle and 30 mL of normal saline at the same site in the control group. Pain was assessed at rest on a linear visual analog scale at 6 and 12 hours after surgery. Also, the size of incision was recorded in all patients. No difference was noticed for pain intensity scores in different age groups. Level of education did not influence the pain tolerance and there was no relation between increases in size of incision and pain intensity. In the study group, after 6 and 12 hours postoperatively, female patients had more visual analog scale values than male patients, which was more significant statistically after 6 hours postoperatively when compared with 12 hours postoperatively. Regarding education and pain perception, there was no significant correlation. There was no statistical difference for age between groups. As injection of bupivacaine in paravertebral muscles did not diminish the postoperative back pain experienced by the patients and no difference was noticed in pain intensity scores between groups, our findings denote to ineffectiveness of local bupivacaine in postoperative back pain.
Thyroid carcinoma associated with Moyamoya disease has not been reported in the literature. We first described a 46-year-old woman of Moyamoya disease after 10 years of thyroidectomy due to papillary adenocarcinoma of thyroid. During the 10-year medicine history, the patient was treated with levothyroxine (100 µg/d), and thyroid antibody tests demonstrated that elevated thyrotropin receptor antibody sustained for long time. After 10 years, the patient was diagnosed with Moyamoya disease according to digital subtraction angiography findings. The case suggested that thyroid autoimmune stimuli of papillary thyroid carcinoma with thyroid-stimulating hormone receptor antibody may be associated with pathogenic mechanism of Moyamoya disease.
Objective and Importance: Sylvian aqueduct syndrome (SAS) is associated with a complex clinical picture, which suggests global rostral midbrain dysfunction. Clinical Presentation: A 34-year-old woman developed SAS and Parkinsonism secondary to aqueductal stenosis and was treated by endoscopic third ventriculostomy (ETV) as an initial treatment, which led to the successful resolution of the symptoms. At admission, she exhibited only memory disturbance, slight cognitive impairment and urinary incontinence after recent childbirth. Magnetic resonance imaging (MRI) revealed aqueductal stenosis with the enlargement of the third and lateral ventricle with normal sized fourth ventricle. Several days later, the patient displayed upward gaze paralysis (Parinaud’s syndrome), Parkinsonian hands tremor, and somnolent confusional state. An MRI revealed abnormal intensity in the midbrain and upper pons as well as bulging of the posterior portion of the third ventricle. The dramatic resolution of the patient’s Parinaud’s syndrome, Parkinsonian tremor, and drowsy state after ETV was accompanied by the disappearance of the abnormal intensity in the midbrain and posterior bulging of the third ventricle. This characteristic change, which occurred simultaneously in both the clinical and MRI findings, revealed the lesion responsible for the SAS and Parkinsonism. A drastic change in the ventricular size or transtentorial pressure gradient might have also caused distortion and stretching of the midbrain. Conclusions: The simultaneous resolution of the clinical symptoms and abnormal MRI findings after ETV revealed the lesion responsible for this patient’s SAS and Parkinsonism. Early ETV allowed the reversal of the SAS and Parkinsonism and should be considered as the first-line treatment.
Objective: The aim of our study was to evaluate the frequency of angiographic vasospasm and computed tomography (CT) detectable cerebral ischemia after subarachnoid hemorrhage, the relationship between these events, and the impact on outcome. Patients and Methods: We prospective enrolled 54 patients with subarachnoid hemorrhage treated from March 2011 to January 2013. CT and CT angiography of brain were obtained on the ninth day of rupture regardless of neurological status. The control brain CT and CT angiography were obtained earlier if clinical symptoms implied delayed cerebral ischemia. The outcome was assessed after 6 months using the extended Glasgow Outcome scale scale. Results: Fifty-four percent of the patients recruited had CT angiography vasospasm and 46% had cerebral ischemia on CT scans. Our study shows a strong correlation between angiographic vasospasm and cerebral ischemia visible on CT (P=0.001) and severity of vasospasm and frequency of ischemia (P=0.03). Twenty percent of the patients showed ischemia with no demonstrable vasospasm confirming multiple cause of delayed cerebral ischemia. Logistic regression model has shown the strong impact of angiographic vasospasm (P=0.004, odds ratio=6.85; 95% confidence interval, 1.83-26.65) and arterial hypertension (P=0.02, odds ratio=4.32; 95% confidence interval, 1.16-16.01) on the development of cerebral ischemia. Angiographic vasospasm (P=0.01) and cerebral ischemia (P=0.005) were associated with worse 6-month outcome. Conclusion: A strong association exists between angiographic vasospasm and cerebral ischemia on CT although some ischemia occurs in area without vasospasm.
This study included 67 patients who underwent dynamic stabilization of the lumbar spine with the polyetheretherketone (PEEK) and Ti-alloy-cable composite. Patient participation was based on the presence of degenerative spondylolisthesis (grade I), lateral or central spinal stenosis, and their physician’s recommendation that the patient required decompression and instrumented fusion for 1 or 2 contiguous spinal levels between L1 and S1. Participants were evaluated preoperatively and postoperatively at 3, 6, 12, and 24 months. The ratio of intervertebral disk space to vertebral body height (IVS) and segmental and lumbar lordosis were evaluated preoperatively and postoperatively. Pain scores were evaluated by Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) preoperatively and postoperatively. The mean pain and function scores improved significantly from the baseline to 24-month follow-up evaluation, as follows: ODI score from 53.4% to 27.3% and back pain VAS from 63.2 to 31.9. The ODI and VAS scores decreased significantly from preoperative to postoperative. The IVS ratio remained unchanged between preoperative and postoperative conditions. The lumbar and segmental lordotic angles increased insignificantly from preoperative levels in the months following surgery. In conclusions, the early clinical outcomes of treatment with the dynamic rod composed of PEEK and Ti-alloy cable are promising in terms of maintenance of segmental lordosis and intervertebral space ratio, and improvement in pain and disability. Future clinical studies would be needed to examine and provide information regarding the impact of this dynamic pedicle screw system on the incidence of adjacent-level disease.
Objective: The aim of the study was to systematically review which factor of serum, assessed in traumatic brain injury (TBI), predicts patient’s outcome. Materials and Methods: Databases were searched for relevant publications between 2005 and January 2013, and those fulfilling the following selection criteria were included: (1) studies conducted from 2005 until February 2013; (2) studies in which factors affecting the outcome after TBI were evaluated; (3) studies that defined TBI as “acute changes in brain function resulting in a strong external force to the head”; (4) studies in which the result was measured by the Glasgow Outcome Score (GCS) or by means of a comparable measure describing the activity limitation and neurological state; (5) studies in which the correlation between the measured factors in the first month after injury and prognosis was addressed; and (6) studies involving patients with moderate and/or severe TBI (GCS<13). All of the papers shortlisted were checked and approved by a specialist and expert in that field. A systematic review and analysis was performed for the prognostic factors assessed in the studies. Results: A total of 71 studies were included, 58 of which were of high quality. Most studies used the GCS at 6 months after injury as the outcome measure, sometimes in combination with other outcome measures. Strong evidence for predicting outcome was found for serum concentration of S100 protein, NSE, MBP, NF-H, GFAP, UCH-L1, blood glucose levels, serum levels of LDH, sodium level, prothrombin time, partial thromboplastin time, platelet count, D-dimer, HSP 70, serum levels of IL-8, number of circulating endothelial progenitor cells (EPCs), and DNA levels in serum. Moderate evidence for predicting outcome was found for high serum MMP9. Strong evidence of no association was found for WBC count and serum cortisol levels, and moderate evidence of no association was found for serum total cholesterol. For other determinants, inconclusive or no evidence or limited evidence was found. Conclusions: S100 protein, NSE, MBP, NF-H, GFAP, UCH-L1, blood glucose levels, serum levels of LDH, sodium level, prothrombin time, partial thromboplastin time, platelet count, D-dimer, HSP 70, serum levels of IL-8, number of circulating EPCs, and DNA levels in serum predicted outcome after TBI. WBC count, serum cortisol levels, total cholesterol, and MMP9 did not have predictive values.
