Arachnoid cysts are developmental anomalies usually diagnosed in childhood. The most important complications of arachnoid cysts are subdural haematomas and hygromas and intracystic haemorrhage. In our case we present a 7-year-old boy whose arachnoid cyst ruptured into the subdural space following a mild head injury and disappeared after draining the subdural haematoma by burr-holes.

Surgical procedures design ed to decompress and stabilize unstable trauma-related thoracolumbar fractures are primarily anterior or posterior operative approaches combined with anterior or posterior instrumentation. Our goal is to identHy patients that are likely to benefit from either fixation system. Two treatment groups were studied. The first group of 20 patients underwent posterior instrumentation and fusion. Also, eighteen patients with evidence of neural compression were treated with posterior decompressive surgery. The second group, consisting of 10 patients with neurological deficits, was managed with single-stage anterior decompression, interbody strut grafting, and anterior instrumentation. There were no statistically significant differences between the groups with regard to postoperative neurological outcome (Mann-Whitney V, P>0.05),pain assessment and ability to return to work (Chisquare, P>0.05), rate of instrument failure (Chi-square, P>0,05), rate of solid fusion (Chi-square, P>0,05) and loss of reduction (Mann-Whitney U, P>0.05). When surgery is indicated, the operative approach (anterior or posterior) and type of instrumentation used (anterior or posterior) are determined by the location and characteristics of the fracture (e.g., neural compression and instability) and the surgeon's familiarity with the various techniques. Based on the results of this study, we conclude that posterior spinal instrumentation is as effective as anterior instrumentation in the treatment of unstable thoracolumbar fractures. Özet: Travma ile meydana gelen instabil torakolomber fraktürleri dekomprese ve stabilize etmek için planlanan cerrahi yöntemler esas olarak anterior veya posterior enstrümantasyonla kombine edilen anterior veya posterior operatif yaklasimlardir. Amacimiz anterior yada posterior fiksasyon sisteminden yararlanmasi olasi görünen olgulari tespit etmektir. Iki tedavi grubu çalisildi: 20 hastadan olusan birinci gruba posterior enstrümantasyon ve füzyon yöntemi uygulandi; nöral kompresyon bulgusu olan 18 hasta ayni zamanda posterior dekompressif cerrahi ile tedavi edildi. Nörolojik defisitli 10 hastadan olusan ikinci grup tek seans cerrahi girisimle anterior dekompresyon , interkorporal greft ve anterior enstrümantasyon uygulamasi ile tedavi edildi. Postoperatif nörolojik iyilesme (Mann-Whitney U, P>0.05), agri derecesi ve ise dönme kabiliyeti (Chi-Square, P>0,05), enstruman yetersizligi orani (Chi-Square, P>0,05), solid füzyon orani (Chi-Square, P>0,05) ve redüksiyon kaybi (Mann-Whitney U, P>0.05) degerlendirildigi zaman iki grup arasinda istatistikselolarak önemli bir fark bulunmadi. Cerrahi tedavi endikasyonu oldugunda, seçilecek yaklasim (anterior veya posterior) ve kullanilacak enstrüman (anterior veya posterior) fraktürün lokalizasyonuna, özelligine (fraktür tipi, nöral kompresyon ve instabilite gibi) ve cerrahin çesitli tekniklerdeki tecrübesine göre tayin edilir. Bu çalismada, instabil torakolomber fraktürlerin tedavisinde posterior spinal enstrümantasyonun anterior enstrümantasyon kadar yararli oldugu sonucuna varildi.

The purpose of this study is to evaluate the distribution, clinical features, and treatment modalities of arachnoid cysts (ACs) in our clinic. The study was carried out between January 1, 1996 and November 31, 2002 at the Neurosurgery Department of Çukurova University Hospital, Adana, Turkey. Thirty-five patients (13 female and 22 male) with ACs demonstrated by cranial magnetic resonance imaging or computed tomography during this period were enrolled and discussed in this study. The middle cranial fossa was the most common location of ACs; ACs were located in the middle cranial fossa in 22 (62.9%) cases, followed by the cerebellopontine angle in 4 (11.4%) cases, the cerebral convexity in 3 (8.6%) cases, the suprasellar region in 2 (5.7%) cases, the quadrigeminal cisterns in 2 (5.7%) cases, and the retrocerebellar region in 2 (5.7%) cases. All cysts were unilateral: 25 (71.4%) were located on the left side, and 10 (28.6%) were located on the right side. The mean age at onset of clinical manifestations was 3 years, 6 months (range: 1 month to 12 years). The mean age at diagnosis was 8 years (range: 1–32 years). The most frequent clinical features on presentation were epileptic seizures (42.9%) and headache (28.6%). A few patients (9 [25.7%]) underwent surgery. Surgical intervention with microsurgical excision and fenestration was performed in 7 patients, and cystoperitoneal shunting was performed in 2 patients. The major indications for surgery of ACs are intractable seizures, intracranial hypertension, and compression of neuronal tissues. Headache only is not a surgical indication. Microsurgical excision and fenestration are safe and effective for the surgical treatment of ACs.

The purpose of this study is to evaluate the distribution, clinical features, and treatment modalities of arachnoid cysts (ACs) in our clinic. The study was carried out between January 1, 1996 and November 31, 2002 at the Neurosurgery Department of Cukurova University Hospital, Adana, Turkey. Thirty-five patients (13 female and 22 male) with ACs demonstrated by cranial magnetic resonance imaging or computed tomography during this period were enrolled and discussed in this study. The middle cranial fossa was the most common location of ACs; ACs were located in the middle cranial fossa in 22 (62.9%) cases, followed by the cerebellopontine angle in 4 (11.4%) cases, the cerebral convexity in 3 (8.6%) cases, the suprasellar region in 2 (5.7%) cases, the quadrigeminal cisterns in 2 (5.7%) cases, and the retrocerebellar region in 2 (5.7%) cases. All cysts were unilateral: 25 (71.4%) were located on the left side, and 10 (28.6%) were located on the right side. The mean age at onset of clinical manifestations was 3 years, 6 months (range: 1 month to 12 years). The mean age at diagnosis was 8 years (range: 1-32 years). The most frequent clinical features on presentation were epileptic seizures (42.9%) and headache (28.6%). A few patients (9 [25.7%]) underwent surgery. Surgical intervention with microsurgical excision and fenestration was performed in 7 patients, and cystoperitoneal shunting was performed in 2 patients. The major indications for surgery of ACs are intractable seizures, intracranial hypertension, and compression of neuronal tissues. Headache only is not a surgical indication. Microsurgical excision and fenestration are safe and effective for the surgical treatment of ACs.

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.

BACKGROUNDPerimesencephalic 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).METHODSThis report contains a retrospective analysis of 29 patients with PNSH who were followed from I 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.RESULTSThere 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).CONCLUSIONThis study provides evidence that patients with PNSH have an uncomplicated course and a particularly favorable outcome. (C) 2002 by Elsevier Science Inc.

Excessive calcium influx has been implicated in the pathophysiology of ischemic cerebral damage. The effects of nimodipine, a calcium antagonist, on the Na(+)-K+/MG+2 ATPase activity, Ca+2/Mg+2 ATPase, lipid peroxidation, and early ultrastructural findings were examined at the acute stage of ischemia in the rat brain. Ischemia was produced by permanent unilateral occlusion of the middle cerebral artery. In Group I, the rats which had no ischemia and not received medication were used for determining Na(+)-K+/Mg+2 ATPase, Ca+2/Mg+2 ATPase, the extent of lipid peroxidation by measuring the malondialdehyde content and normal ultrastructural findings. In Group II, the rats which had only subtemporal craniectomy without occlusion and received saline solution were used for determining the effect of the surgical procedure on the biochemical indices and ultrastructural findings. In Group III, the rats received saline solution following the occlusion in the same amount of nimodipine and in the same duration as used in Group IV. In Group IV, nimodipine pre-treatment 15 min before occlusion (microgram kg-1 min-1 over a 10 min period) was applied i.v. Na(+)-K+/Mg+2 ATPase and Ca+2/Mg+2 ATPase activities decreased significantly and promptly as early as 10 min and remained at a lower level than the contralateral hemisphere in the same group and at the normal level in Group I. Nimodipine pre-treatment immediately attenuated the inactivation of Na(+)-K+/Mg+2 ATPase (p < 0.05) but there was no change on Ca+2/Mg+2 ATPase activity (p < 0.05). Malondialdehyde content increased significantly in Group III following ischemia as early as 30 min. Nimodipine pre-treatment decreased the malondialdehyde level in Group IV (p < 0.05). This study supports the possibility that nimodipine pre-treatment effects the membrane stabilizing properties via inhibiting the lipid peroxidation and subsequently restoring some membrane bound and lipid dependent enzymes' activity such as Na(+)-K+/Mg+2 ATPase and the ultrastructural findings.

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.

Cerebral hydatidosis accounts for approximately 1 to 3% of all cases of hydatid disease. Generally, cerebral hydatid cysts are single lesions located in the watershed of the middle cerebral artery. Primary intracranial extracerebral hydatid cysts are extremely rare. Only 2% of hydatid cysts are localized in the skeleton, and of these 3 to 4% are found in the skull. The authors describe the case of a 10-year-old boy who was admitted to their clinic with headache and unilateral focal epileptic seizures. Computerized tomography scanning revealed a right parietal intraosseous hydatid cyst. A case of cranial intraosseous hydatid disease is presented, and the differential diagnosis and treatment are discussed in the light of literature.

OBJECT:The inflammatory cells that accumulate at the damaged site after spinal cord injury (SCI) may secrete interleukin-6 (IL-6), a mediator known to induce the expression of inducible nitric oxide synthase (iNOS). Any increased production of NO by iNOS activity would aggravate the primary neurological damage in SCI. If this mechanism does occur, the direct or indirect effects of IL-6 antagonists on iNOS activity should modulate this secondary injury. In this study, the authors produced spinal cord damage in rats and applied anti-rat IL-6 antibody to neutralize IL-6 bioactivity and to reduce iNOS. They determined the spinal cord tissue activities of Na+-K+/Mg++ adenosine-5'-triphosphatase (ATPase) and superoxide dismutase, evaluated iNOS immunoreactivity, and examined ultrastructural findings to assess the results of this treatment.METHODS:Seventy rats were randomly allocated to four groups. Group I (10 rats) were killed to provide normal spinal cord tissue for testing. In Group II 20 rats underwent six-level laminectomy for the effects of total laminectomy alone to be determined. In Group III 20 rats underwent six-level T2-7 laminectomy and SCI was produced by extradural compression of the exposed cord. The same procedures were performed in the 20 Group IV rats, but these rats also received one (2 microg) intraperitoneal injection of anti-rat IL-6 antibody immediately after the injury and a second dose 24 hours posttrauma. Half of the rats from each of Groups II through IV were killed at 2 hours and the other half at 48 hours posttrauma. The exposed cord segments were immediately removed and processed for analysis.CONCLUSIONS:The results showed that neutralizing IL-6 bioactivity with anti-rat IL-6 antibody significantly attenuates iNOS activity and reduces secondary structural changes in damaged rat spinal cord tissue.

Platelet-derived growth factor (PDGF) released from platelets is one of the mitogens in serum, which plays a major role upon the cell biology, namely enhancing cell division and controlling of the maturation, especially upon the glial cell growth and its differentiation. Trapidil, which is an anti-PDGF agent, inhibits the effect of PDGF, especially the proliferative effects on the glial and tumoral cells in vitro. Previous studies suggested that the astrocytic proliferation stimulated by PDGF was inhibited by trapidil via the selective antagonism. Trapidil was not found to have a considerable effect on the prevention of nonpermissive astrocytes in this study. It should be theorized that trapidil, administered immediately even after the trauma, could not reach the injury site in effective measure because of secondary events such as edema and impairment of blood circulation. This suggestion should be another subject for studies concerning trapidil which is administered prior to the trauma.

The results of percutaneous radiofrequency rhizotomy of lumbar spinal facets in 46 patients followed at least three months (mean 15 months) are reported and compared with those reported previously. Satisfactory pain relief three months after the procedure was achieved in 36.4 percent of patients without operations and in 41.7 percent of patients, with operations other than fusion. No patient had previously undergone fusion. Treatment of low-back pain by using radio-frequency thermocoagulation of spinal facets is a simple, safe, and well-tolerated procedure. It can be used to relief of pain in spite of decreasing rates of success within the follow-up period.

A 43-year-old woman complaining of severe pain of the right side of the face was admitted to the Department of Neurosurgery. It had been present for three months and diagnosed as trigeminal neuralgia. The CT scan without contrast material had been considered normal at that time. Three months later, after a favourable response to carbamazepine, she suddenly developed right occipital headache and drowsiness. On admission, she was alert, and neurological examination revealed only mild neck stiffness. Computed tomographic scan demonstrated an acute hematoma in the right cerebellopontine angle and in the fourth ventricle. Vertebral angiography revealed an aneurysm of the right anterior inferior cerebellar artery (AICA). A posterior fossa approach disclosed a large, nearly totally thrombosed, saccular AICA aneurysm, which showed minimal compression to the pons at the trigeminal root entry zone. The aneurysm was clipped and excised. She showed an excellent recovery and was free of pain in the early postoperative period and at the last examination 16 months later. Aneurysms in the distal AICA are very rare lesions. Only 31 cases have been published so far. Distal AICA aneurysm in an extremely unusual cause of trigeminal neuralgia secondary to aneurysmal compression. The literature concerning AICA aneurysms and their clinical manifestations is reviewed and discussed.

We produced retrobulbar hematoma in both orbits of 10 pigs in order to assess the effects of blood elements and pressure created by the hematoma on the optic nerves. Ten other pigs were used as a control group. Following decompression in the right orbits, ocular movements, fundi, and intraocular pressure were evaluated for 6 weeks. At the end of the 6th week the optic nerves of 20 pigs were dissected bilaterally for measurements of ATP-ase activity and ultrastructural examination. The results of the ultrastructural examination of the optic nerves of the control group were normal. Optic nerves with decompressed retrobulbar hematoma showed minimal degeneration, whereas the nerves subjected to retrobulbar hematoma with no decompression showed significant degenerative changes. For all groups ATP-ase activities were measured and evaluated. Na+, K+ ATP-ase activities decreased, while Ca++, Mg++ ATP-ase activities increased with the extent of degeneration. Optic nerve damage can develop after trauma. Decompression procedures are not among the causes of optic nerve degeneration but retrobulbar hematoma can result in optic neuropathy caused by the compression from the hematoma and the direct effect of blood waste products on the optic nerve.

The authors describe a case of giant fusiform aneurysm of the basilar artery presenting with ischemic symptoms. Angiography and CT revealed vertebro-basilar fusiform aneurysmal dilatation. Fusiform vertebro-basilar aneurysm is associated with various complications particularly brain stem infarction. Similar lesions in the literature are reviewed and the relationship between this clinical entity and cerebral ischemia, particularly brain-stem infarction are discussed.

BACKGROUND:Although use of corticosteroid in the management of head trauma has caused a great deal of controversy, corticosteroids have long been an adjunct in the management of severe closed head injury. The glucocorticoid steroid methylprednisolone (MP) has been proven to have significant antioxidant effect when administered in an antioxidant-high dose after central nervous system injury. METHODS:The sodium-potassium activated and magnesium dependent adenosine-5'-triphosphatase (Na(+)-K(+)/Mg(+2) ATPase EC.3.6.1.3.) activity, lipid peroxidation, and early ultrastructural findings were determined during the immediate posttraumatic period in rats. Mechanical brain injury was produced when a calibrated weight-drop device is allowed to fall on the skull's convexity over the right hemisphere, 1 to 2 mm lateral from the midline. In group I, rats were used to determine Na(+)-K(+)/Mg(+2) ATPase activity, the extent of lipid peroxidation, by measuring the level of malondialdehyde content and normal ultrastructural findings in two different brain areas (cerebral cortex and brain stem). In group II, physiologic saline was administered right after trauma in the same amount as methylprednisolone. In group III rats, methylprednisolone (30 mg/kg) was administered intravenously right after trauma. RESULTS:Na(+)-K(+)/Mg(+2) ATPase activity significantly decreased in the cerebral cortex and in brain stem within 2 hours after trauma (p < 0.05). There was significant difference in malondialdehyde content between groups II and III (p < 0.05). Methylprednisolone treatment reduced malondialdehyde content and induced the recovery of Na(+)-K(+)/Mg(+2) activity. CONCLUSIONS:These data suggest that inactivation of Na(+)-K(+)/Mg(+2) ATPase is closely correlated to changes of lipid peroxidation and the alteration of the ultrastructural findings in the early phases after head trauma. The glucocorticoid steroid methylprednisolone has been proven to have significant effect in activation of Na(+)-K(+)/Mg(+2) ATPase with significant reduction of malondialdehyde content.

Subependymomas are uncommon and relatively benign tumors with a distinctive histological appearance. They are generally asymptomatic and most of them are found incidentally at postmortem examination. These tumors are usually located in the fourth and lateral ventricle, and sometimes in the spinal cord. The authors present a series of 5 pure subependymomas of the central nervous system all of which were symptomatic and all of which were treated by microsurgical removal. The clinico-pathological findings and the results of microsurgical treatment in this series are presented.

Penetrating and perforating periorbital puncture wounds by lead pencils are not rare, but ones that reach the brain stem are extremely unusual. We recently treated a patient with of this type of injury. A newly sharpened lead pencil was accidentally introduced through the subconjunctiva at the inner canthus of the right eye. It passed along the medial border of the globe transorbitally and went through the superior orbital fissure into the temporal fossa, then continued through the lateral side of the sella and posterior clinoid, reaching the brain stem. The entire pencil was removed inch by inch without incident under CT control. Meanwhile, the operative team remained ready in case of emergency bleeding. The patient's postoperative course was uneventful, but the initial neurologic deficit of the patient remained fixed.