Central nervous system hydatidosis in Turkey: a cooperative study and literature survey analysis of 458 cases

Progress of research on the diagnosis and treatment of bone cystic echinococcosis

Bone cystic echinococcosis (CE) is one of the most complex and dangerous of all echinococcoses. The lack of typical imaging features and clinical manifestations makes diagnosis and treatment of this disease difficult. X-ray and computed tomography (CT) images of bone CE are similar to those of bone cysts, giant-cell bone tumors, and bone metastases, but magnetic resonance imaging (MRI) shows good diagnostic value due to excellent soft-tissue imaging features. Serological tests cannot be used as a definitive diagnostic method for bone CE due to cross-reactivity, which can lead to false-positive or false-negative results. The development of novel antigens can open new frontiers in the diagnosis of the disease. Currently, views conflict on how to diagnose and treat bone CE. Both surgical and pharmacological treatments can be used, but determining which is appropriate is difficult due to the different sites and clinical manifestations of bone CE. Radical resection is not indicated for large-bone injuries, and Pharmacotherapy becomes important. This article reviews the progress of research into the pathogenesis and clinical manifestations of, and diagnostic strategies and treatment options for, bone CE. We aimed to provide a reference for clinical diagnosis and -treatment options.

Central nervous system hydatidosis around the world: a systematic review

INTRODUCTION

Echinococcosis is a chronic disease caused by Echinococcus species. The central nervous system (CNS) hydatidosis is still a major concern, especially in endemic countries, due to non-specific features and late diagnosis and treatment. This study aimed to provide a systematic review to elucidate the epidemiology and clinical characteristics of CNS hydatidosis worldwide over the past decades.

EVIDENCE ACQUISITION

PubMed, Scopus, EMBASE, Web of Science, Ovid, and Google Scholar were systematically searched. The gray literature and the references of included studies were searched as well.

EVIDENCE SYNTHESIS

Our results showed that the CNS hydatid cyst was more prevalent in the male gender, and it is known as a recurrent disease with a rate of 26.5%. CNS hydatidosis was more common in the supratentorial region and was also significantly common in developing countries, including Türkiye and Iran.

CONCLUSIONS

It was demonstrated that the disease would be more prevalent in developing countries. Also, there would be a trend toward a male predominance of CNS hydatid cyst, younger age involvement, and the recurrence rate of 25% in general. There is no consensus about chemotherapy unless in recurrent disease and the patients who experienced cyst rupture intraoperatively, recommended for a wide range of 3 to 12 months.

Primary cerebral cystic echinococcosis in a child from Roman countryside: Source attribution and scoping review of cases from the literature

BACKGROUND

Human cystic echinococcosis (CE) is a zoonotic parasitic infection caused by the larval stage of the species belonging to the Echinococcus granulosus sensu lato (s.l.) complex. Parasitic cysts causing human CE are mainly localized in the liver and in the lungs. In a smaller number of cases, larvae may establish in any organ or tissue, including the central nervous system (CNS). Cerebral CE (CCE) is rare but poses serious clinical challenges.

METHODS

This study presents a case of CCE in a child living in the countryside near Rome (Italy), along with a comparative molecular analysis of the isolated cyst specimens from the patient and sheep of local farms. We also systematically searched the literature to summarize the most relevant epidemiological and clinical aspects of this uncommon localization.

FINDINGS

The comparative molecular analysis confirmed that the infection was caused by E. granulosus sensu stricto (s.s.) (G3 genotype), and most likely acquired in the family farm. The literature search identified 2,238 cases of CCE. In 80.51% of cases, brain was the only localization and single CCE cysts were present in 84.07% of cases. Mean patients' age was 20 years and 70.46% were children. Cyst rupture was reported in 12.96% and recurrence of CCE after treatment in 9.61% of cases. Permanent disability was reported in 7.86% of cases, while death occurred in 6.21%. In case series reporting all CE localization, CCE represented 1.5% of all CE cases. In the few reports that identified at molecular level the CCE cyst, E. granulosus s.s. was found in 40% and E. canadensis in 60% of cases.

CONCLUSIONS

We report a rare case of CCE and evidenced the probable local origin of infection. The proportions of CE cases with uncommon localizations and with high impact on patients' lives have been globally neglected and should be included in the computation of the global burden of CE.

Stroke-Associating Acute Limb Ischemia Due to the Rupture of a Hydatid Cyst

(1) Background: Hydatidosis, or human cystic echinococcosis, is a zoonotic disease. Endemic in some areas, recently it has an increasing incidence in wider regions, determined by population migration. Clinical features depend on the localization and level of infection: asymptomatic or with signs related to hypersensitivity, organic functional deficiencies, expanding mass effects, cyst infection and sudden death. In rare cases, the rupture of a hydatid cyst causes emboli formation by the residual laminated membrane. (2) Methods: We performed an extensive literature review, starting from the case of a 25-year-old patient presenting with neurologic symptoms relevant for acute stroke, associating right upper limb ischemia. (3) Results: Imaging investigations revealed the source of the emboli as the rupture of a hydatid cyst, the patient presenting multiple pericardial and mediastinal localizations. Cerebral imaging confirmed an acute left occipital ischemic lesion, with complete recovery of the neurological deficit after therapy, while surgery for acute brachial artery ischemia had a favorable postoperative evolution. Specific anthelmintic therapy was initiated. An extensive literature review using available databases revealed the scarcity of data on embolism as a consequence of cyst rupture, highlighting the significant risk of clinicians overlooking this possible etiology. (4) Conclusions: An associated allergic reaction should raise the hypothesis of a hydatid cyst rupture as a cause of any level acute ischemic lesion.

Hydatid disease of the brain and spine

Hydatid disease of the central nervous system is relatively rare and comprises about 2-3% of all the hydatid cyst cases reported in the world. Spinal hydatid disease is an even rarer entity. It is endemic in sheep and cattle-raising regions, seen mainly in Mediterranean countries including Turkey and Syria. Pediatric neurosurgeons in non-endemic countries face a challenge when they encounter children with hydatid cysts of the central nervous system, mostly due to lack of awareness and the ensuing diagnostic dilemmas. It is also a significant socioeconomic problem in developing countries, due to improper hygiene and lack of dedicated veterinary practice. The clinical features are largely nonspecific and very according to location and severity of disease. However, with the advent of advances in MR imaging, the diagnostic accuracy of hydatic disease involving the brain and spine has increased. Intact removal of the cyst/s, without causing any spillage, and appropriate antihelminthic therapy is the goal and key to cure and prevention of recurrence. In this manuscript, the current literature on hydatid cyst of the brain and spine is reviewed to better understand the epidemiology, pathophysiology, diagnostic accuracy, and advances in therapeutic options. A heightened clinical suspicion, awareness of MR imaging features, improved surgical strategies, and options for prevention are discussed.

A rare case of recurrent primary dumbbell-shaped spinal hydatidosis

Spinal hydatidosis, which affects the thoracic vertebrae, is not only an extremely rare occurrence, but is also characterized by a high recurrence rate. Here, we reported a case of 67-years-old man who presented with recurrent spinal hydatid disease. The condition was originally misdiagnosed as Schwannoma via medical imaging, but eventually confirmed by postoperative pathology. He was subjected to surgery, combined with adjuvant drug therapy. Unfortunately, he experienced recurrent spinal hydatid disease and had to undergo hydatid cyst excision in over 5 years.

Hydatid cyst in the third ventricle of the brain: case report of an exceptionally rare condition

Hydatid disease is an endemic zoonotic disease caused by the cestode Echinococcus multilocularis and Echinococcus granulosus. Intra-ventricular hydatid cysts are extremely rare. Even more rarely, and to the best of our knowledge, only three cases of third ventricle involvement have been reported. Herein, we present the fourth case of an intraventricular hydatid cyst in a pediatric patient located in the third ventricle. It is about a 7-year-old girl, of a rural origin, admitted for intracranial hypertension, deterioration of the general status, and weakness on the right side of her body. A cerebral magnetic resonance imaging (MRI) showed the presence of a rounded cystic formation in the third ventricle. The patient was operated through a transfrontal transventricular approach, and the cyst was removed. Postoperative course was uneventful. Hydatid disease should be considered part of the differential diagnosis for cystic lesions of the central nervous system, especially in endemic regions. Total removal of the cysts without rupture is a challenge, but best treatment remains an active nationwide prevention.

Echinococcoses in Iran, Turkey, and Pakistan: Old Diseases in the New Millennium

Echinococcosis is considered a cosmopolitan zoonosis caused by different species of small taeniid tapeworms of the genus Echinococcus and is regarded as a neglected zoonosis. Cystic and alveolar echinococcoses are endemic diseases of Tibetan, Pamir, and Iranian plateaus. All of the countries within the Iranian plateau are affected by echinococcosis. Pakistan, Turkey, and Iran are the three most populous countries of the region, in which echinococcosis is highly endemic. The three neighboring countries share strong cultural and socioeconomic ties. The present study aimed to provide a broad review of the status of cystic and alveolar echinococcosis, summarizing the current knowledge about geographical distribution, molecular epidemiology, and transmission dynamics of Echinococcus granulosus sensu lato and Echinococcus multilocularis in this region. Additionally, we aimed to understand disease burden and risk factors as basic requirements for establishing a surveillance system and planning prevention and control programs. A considerable body of information is available on different aspects of echinococcosis in this region; however, several information and research gaps need to be filled before planning control programs. None of the countries in the region have an elaborate echinococcosis control program. Effective control programs require multi/intersectoral coordination within a One Health approach with a long-term political and administrative commitment and enhanced international collaboration among the three countries.

Diagnosis, treatment, and misdiagnosis analysis of 28 cases of central nervous system echinococcosis

BACKGROUND

To explore central nervous system (CNS) involvement in this disease, from the perspectives of diagnosis, treatment, and misdiagnosis METHODS: Twenty-eight patients with CNS echinococcosis were included in this retrospective study, including 18 males (64.3%) and 10 (35.7%) females. The average age of all the patients were 23.5 years (ranged 4-60 years). Twenty-three (23) patients (82.1%) received the first surgical resection in our hospital. Five (5) patients (17.9%) gave up surgical treatment for multiple-organ hydatidosis and previous surgery history at other hospitals, and albendazole was applied for a long-term (3-6 months) adjunct therapy for the 5 patients. The average follow-up time was 8 years.

RESULTS

For the 28 patients, 23 cases received surgical treatments, and the diagnosis was confirmed by pathological examinations. The diagnosis of 4 cases of brain echinococcosis and 2 cases of spinal cord echinococcosis could not be confirmed, resulting in a misdiagnosis rate of 21.4% (6/28). For the pathological examination, a total of 17 cases were infected with Echinococcus granulosus (including 2 cases of spinal cord echinococcosis), and 6 cases were infected with Echinococcus alveolaris.

CONCLUSION

The diagnosis should be specifically considered in endemic regions. The clinical features of CNS hydatidosis were intracranial space-occupying lesions. For the treatment, the surgical removal of cysts should be necessary. In addition, the adjuvant therapy with drug and intraoperative prophylaxis is also suggested. The misdiagnosis may have resulted from atypical clinical features and radiographic manifestations, as well as the accuracy of hydatid immunologic test.

Echinococcosis of the spine

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine.More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord.As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely.Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization.This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients' outcomes.The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130.

Extra-hepatopulmonary cystic echinococcosis in Bulgaria: frequency, management and outcome of the disease

In the endemic countries, human cystic echinococcosis (CE) poses a serious medical and social problem. Because it most often affects the liver and lungs we aimed to define the proportion of cases with different organ localization, the diagnostic and therapeutic approaches in such cases, and the outcome of them. For a period 2010-2019, a total of 2863 cases of CE were registered in Bulgaria, of which 148 (5.17%) with organ localization other than liver and/or lung. The majority of patients with extra-hepatopulmonary localization of CE were adults. The distribution by gender showed predominance of female patients (57.43%) over those of males and primary cases (85.14%) exceeded the cases of recurrence. According to our study most common is the spleen involvement, followed by involvement of the abdominal cavity, kidneys and muscle/subcutaneous tissue. Other extra-hepatopulmonary organ localizations are significantly less common. This study shows that the extra-hepatopulmonary localization of CE is not so rare, and in most cases it is a primary disease. In respect of this, clinicians should consider hydatidosis in the differential diagnosis when cystic formation(s) is found, regardless of the organ involved.

Cerebral Cystic Echinococcosis

Cystic echinococcosis (CE) is a neglected helminthic disease and major public health problem in several regions of the world. The zoonosis is caused by the larval stage of different cestode species belonging to the genus Echinococcus. CE can affect any organ with the liver and lungs being most commonly involved. The brain is involved in less than 2% of the cases. We report a case of a CE1 echinococcal cyst of the brain in an Iranian patient.

Citation analysis of the most influential articles on traumatic spinal cord injury

Objective: We conducted a citation analysis in order to catalog and pay tribute to the 100 most influential clinical research articles in traumatic spinal cord injury.Design: The Thomson Reuters Web of Science was searched in a two-step process without time period limitations. Review articles were excluded. In the first stage of data extraction, a Boolean query was used to identify the top 100 most cited clinical papers on traumatic spinal cord injury. One hundred and seven keywords were manually chosen and extracted from titles and abstracts. A second Boolean query used these keywords to broaden search results. The top 100 articles from this second stage search comprised the final list.Outcome Measures: For each article, measures evaluated were number of citations, average number of citations per year, time elapsed before first citation, and time elapsed until the year in which each article received its respective highest number of citations in a one-year period.Results: 119,991 articles were found in the second stage search. The top 100 most cited articles meeting inclusion criteria were identified within the first 2,104 results. Archives of Physical Medicine and Rehabilitation was the most represented journal, with 20 of the top 100 articles. The top 100 list averaged 255 citations per article. The most highly cited article was the NASCIS 2 trial by Bracken et al., cited 1500 times, which investigated the efficacy of methylprednisolone or naloxone for spinal cord injury.Conclusion: Clinical research in traumatic spinal cord injury has grown over time, expanding to encompass rehabilitation and experimental therapies in addition to acute management trials. The list may serve as an archive and reference for further studies in this field.

VERTEBRAL HYDATIDOSIS: BIBLIOGRAPHICAL REVIEW AND CLINICAL CASE REPORT

ABSTRACT We will present a literature review of the vertebral location of hydatidosis. It is a rare, locally aggressive condition with a high recurrence rate that requires clinical treatment (antihelminthic drugs) and surgery, with decompression of the spinal canal. We report a case with more than 11 years of follow-up, which required surgical treatment on 4 occasions. Level of Evidence V; Therapeutic-investigational study of treatment results.

Mitochondrial-Based Therapeutics for the Treatment of Spinal Cord Injury: Mitochondrial Biogenesis as a Potential Pharmacological Target

Spinal cord injury (SCI) is characterized by an initial trauma followed by a progressive cascade of damage referred to as secondary injury. A hallmark of secondary injury is vascular disruption leading to vasoconstriction and decreased oxygen delivery, which directly reduces the ability of mitochondria to maintain homeostasis and leads to loss of ATP-dependent cellular functions, calcium overload, excitotoxicity, and oxidative stress, further exacerbating injury. Restoration of mitochondria dysfunction during the acute phases of secondary injury after SCI represents a potentially effective therapeutic strategy. This review discusses the past and present pharmacological options for the treatment of SCI as well as current research on mitochondria-targeted approaches. Increased antioxidant activity, inhibition of the mitochondrial permeability transition, alternate energy sources, and manipulation of mitochondrial morphology are among the strategies under investigation. Unfortunately, many of these tactics address single aspects of mitochondrial dysfunction, ultimately proving largely ineffective. Therefore, this review also examines the unexplored therapeutic efficacy of pharmacological enhancement of mitochondrial biogenesis, which has the potential to more comprehensively improve mitochondrial function after SCI.

Spinal Hydatid Cyst Disease

OBJECTIVE

A hydatic cyst (HC) is a zoonotic infection affecting the liver and lungs, with rare spinal involvement. We discuss the long-term results in 8 patients with spinal HC who were monitored at our clinic for 7 to 15 years.

METHODS

The demographic data and clinicopathologic characteristics of 8 patients with spinal HC diagnosed between 2000 and 2016 were evaluated for their contribution to recurrence, and the long-term follow-up results were examined.

RESULTS

Four male and 4 female patients with a median age of 30.75 years (range, 17-45 years) at the first surgery were included. Infections were localized in the thoracic (3), thoracolumbar (1), lumbar (1), sacral (1), cervicothoracic (1), and lumbosacral (1) regions. Two patients had secondary HCs that spread from another organ (lung and kidney). Patients underwent 2 to 5 surgeries during the study period, with an average follow-up time of 8.5 years (range, 7-15 years) after the first surgery. The surgical treatments included an anterior corpectomy and anterior plate for a patient with cervical localization and cystectomy for a patient with sacral localization; the other patients underwent cystectomy with corpectomy and stabilization with an anterior approach, cyst excision and laminectomy with a posterior approach, or additional posterior transpedicular screw stabilization. The patients were prescribed albendazole.

CONCLUSIONS

Spinal HC treatment is difficult, particularly in patients with vertebral and paraspinal involvement, spinal instability, and recurrence. Long-term follow-up is critical, and patients require medical and surgical treatment, with regular clinical, radiologic, and serologic examinations. The cysts must be removed without rupture during surgery, and the surgical area must be irrigated with hypertonic saline solution to reduce the risk of recurrence.

[Cerebral hydatid cysts in children: about 15 cases]

L’objectif de notre étude est d’illustrer l’intérêt de l’imagerie en coupe (TDM, IRM) dans le diagnostic positif et le suivi post-thérapeutique du kyste hydatique cérébral chez l’enfant et de mettre en lumière les particularités et les difficultés rencontrées dans la prise en charge de la localisation cérébrale de cette affection, par notre expérience basée sur 15 cas de kyste hydatique cérébral de l’enfant. Il s’agit d’une étude rétrospective de 15 cas d’hydatidose cérébrale de l’enfant colligés sur une période de 10 ans. La TDM cérébrale en coupes axiales de 5 mm d’épaisseur sans et avec injection de produit de contraste a été réalisée chez 15 patients. L’IRM encéphalique a été réalisée en séquences pondérées en T1 et en T2 chez un patient dans les trois plans de l’espace sans injection de Gadolinium. L’âge moyen de nos patients était de 9 ans. La symptomatologie clinique était dominée par le syndrome d’hypertension intracrânienne. Le kyste hydatique était solitaire et se situait au niveau de l’étage sus-tentoriel avec un important effet de masse sur le système ventriculaire et la ligne médiane dans la majorité des cas. Tous nos patients ont été opérés et l’évolution était favorable dans tous les cas. La TDM représente l’examen de choix pour le diagnostic et le suivi postopératoire du kyste hydatique cérébral. L’IRM trouve son intérêt essentiellement dans le diagnostic des formes multiples et des formes atypiques permettant une planification thérapeutique plus adaptée.

Our study aimed to highlight the role of cross sectional imaging techniques (CT, MRI) in positive diagnosis and post-therapeutic follow-up of cerebral hydatid cysts in children as well as to describe the peculiarities and the difficulties encountered in the management of these cysts based on our experience about 15 cases. We conducted a retrospective study of 15 cases of cerebral hydatidosis in children whose data were collected over a period of 10 years. CT scan of the brain with 5 mm slice thickness without and with injection of contrast product was performed in 15 patients. One patient underwent brain MRI creating either T1-weighted or T2-weighted images in all three planes without Gadolinium injection. The average age of patients was 9 years. Clinical symptoms were dominated by intracranial hypertension syndrome. Hydatid cyst was solitary and was located in the supratentorial level with an important mass effect on the ventricular system and the median line in most cases. All patients underwent surgery and patients’ evolution was favorable in all cases. CT scan is the test of choice for the diagnosis and the postoperative follow-up of patients with cerebral hydatid cysts. MRI is used essentially in the diagnosis of multiple and atypical type of cerebral hydatid cysts, enabling the design of more effective treatment strategy.

Orbital Hydatid Cyst Causing Papilledema and Proptosis in an Adult

Hydatid cyst is an infectious disease caused by Echinococcus granulosus, primarily involving the liver and lungs. The orbit is an extremely rare site for involvement with hydatid cyst. We present a 36-year-old man with unilateral visual loss, proptosis, and papilledema caused by an orbital hydatid cyst.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Primary Hydatid Cyst of the Brain in a Child: A Case Report

Background

Primary intracranial hydatid cyst is a rare location of human echinococcosis whose spontaneous, traumatic or even iatrogenic rupture, as in case of misdiagnosis, may cause anaphylactic reactions and dissemination.

Case Report

We discuss the management of a 9-year-old boy who was admitted to our Emergency Department with an intracranial hypertension syndrome. Head CT scan and brain MRI showed a huge intra-axial right temporo-parieto-occipital cyst with a marginal calcification, associated with left ventricular uncompensated hydrocephalus. DTI showed displacement of the ipsilateral corticospinal tract, whereas MR spectroscopy showed absence of normal brain metabolites and presence of succinate and lactate within the cyst. A diagnosis of hydatid cyst was then presumed on the basis of the neuroradiological findings. Empiric chemotherapy with albendazole was instituted and surgical en bloc removal of the cyst was obtained, allowing the patient to recover without complications. Diagnosis of brain echinococcosis was confirmed by laboratory tests.

Conclusions

HE is still an endemic manifestation in some rural areas of the world, and it should be included in the differential diagnosis of children living in or coming from an endemic country who present with an intracerebral cyst. Early diagnosis and complete surgical removal of the intact cyst are the main factors that determine a favourable outcome.

Co-occurrence of Cardiac and Cerebral Hydatid Cysts: A Case Report

Cardiac and cerebral hydatid cysts are rarely encountered. In this case, we report a male patient admitted to our hospital with hemiparesis, headache and dysphasia which occurred as a result of complications of both 3,1x3,5 cm single hydatid cyst in the left cardiac ventricle and multiple cerebral hydatid cysts (approximately 18 particles, the largest being 3× 2,2cm). He had undergone surgery 17 month earlier due to a multiple brain hydatid cysts. Although he had been treated with albendazole, multiple cerebral hydatid cysts re-appeared 17 months after operation. This was a rare case in which left ventricular intracavitary hydatid cyst occurred together with brain multiple cysts at the same time. Physicians should be alert about the probability of cardiac involvement when a cerebral hydatid cyst is diagnosed and appropriate investigations should always be conducted.

Emergency Neurological Life Support: Traumatic Spine Injury

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Alhough the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, is also covered.

An orbital hydatid cyst involving inferior rectus muscle: A case report

The orbital hydatid cyst is a rare entity and although most of them are located in superolateral and superomedial angles of orbits, involvement of inferior sites is uncommon. We report a 12-year-old case of primary hydatid cyst situated in inferior rectus muscle which was undergone surgical removal. Magnetic resonance imaging (MRI) was used for differential diagnosis of hydatid cyst. Moreover, histological analysis was performed, after the cyst removal, to confirm the diagnosis. Early clinical and radiological evaluations and subsequent surgical excision is the mainstay of treatment and should be performed to prevent severe complications caused by the advanced and ruptured cysts.

Localized delivery of methylprednisolone sodium succinate with polymeric nanoparticles in experimental injured spinal cord model

With important social and economic consequences, spinal cord injuries (SCIs) still exist among major health problems. Although many therapeutic agents and methods investigated for the treatment of acute SCI, only high dose methylprednisolone (MP) is being used currently in practice. Due to the serious side effects, high dose systemic MP administration after SCI is a critical issue that is mostly considered controversial. In our study, it is aimed to develop a nanoparticle-gel combined drug delivery system for localization of MP on trauma site and eliminating dose-dependent side effects by lowering the administered dose. For this purpose, methyl prednisolone sodium succinate (MPSS) loaded polycaprolactone based nanoparticles were developed and embedded in an implantable fibrin gel. The effects of MPSS delivery system are evaluated on an acute SCI rat model, by quantification the levels of three inflammatory cytokines (interleukin-1β, interleukin-6 and caspase-3) and assessment of the damage on ultrastructural level by transmission electron microscopy. Developed NP-gel system showed very similar results with systemic high dose of MPSS. It is believed that developed system may be used as a tool for the safe and effective localized delivery of several other therapeutic molecules on injured spinal cord cases.

Defining the Pathway to Definitive Care and Surgical Decompression after Traumatic Spinal Cord Injury: Results of a Canadian Population-Based Cohort Study

Early access to specialized care after acute traumatic spinal cord injury (SCI) is associated with improved outcomes. However, many SCI patients do not receive timely access to such care. To characterize and quantify patients' pathway to definitive care and surgery post SCI, and to identify factors that may delay expeditious care, a population based cohort study was performed in Ontario. Using provincial administrative health data, adult patients with acute traumatic SCI who underwent surgery between 2002 and 2011 were identified using SCI specific ICD-10 codes. The relationship between predictor variables and a) time to arrival at the site of definitive care and b) time to surgery was statistically evaluated. Of 1,111 patients meeting eligibility criteria, mean times to arrival at the site of definitive care and to surgery were 8.1 ± 25.5 and 49.4 ± 65.0 hours respectively, with 53.3% of patients having surgery prior to 24 hours. While most patients (88.4%) reached the site of definitive care within 6 hours, only 34.2% reached surgery within 12 hours of arrival. Older age (IRR = 1.01; 95% CI: 1.01, 1.02), increased number of stops at intermediate health care centers (IRR = 7.70; 95% CI: 7.54, 7.86), higher comorbidity index (IRR = 1.43; 95% CI: 1.14, 1.72) and fall related SCI etiology (IRR = 1.16; 95% CI: 1.02, 1.29) were associated with increased time to arrival at definitive care. For surgery, increased age (OR = 1.02; 95% CI: 1.01, 1.03) and stops at intermediate health centers (OR = 2.48; 95% CI: 1.35, 4.56) were associated with a greater odds of undergoing late surgery (>24hrs). These results can inform policy decisions and facilitate creation of a streamlined path to specialized care for patients with acute SCI.

A difficult surgical approach for primary orbital hydatid cyst: transconjunctival medial orbitotomy

Hydatid cysts rarely appear isolated in the orbital cavity without involvement of other organs. The cysts are usually located in the retrobulbar region, and may be extraconal or intraconal. Herein we present a case of primary orbital cyst hydatid that is adjacent to the medial rectus muscle and optic nerve in the intraconal space and the difficulties during the surgical and medical treatment period.

Swollen eyelid reveals multiple intracranial hydatid cysts associated with a palpebral cyst

We report a case of a hydatid cyst of the eyelid in a 12-year-old boy associated with cerebral involvement. The patient was initially treated by neurosurgeons for brain cysts. The course after an interval of two months was marked by regression of the palpebral cyst on albendazole.

A rare and unexpected clinical progress and location on a primary extradural spinal hydatid cyst in a pediatric patient: a case report

BACKGROUND

Involvement of spine in patients with hydatid disease (HD) is less than 1% and primary intra-spinal extradural HD is extremely rare. Although this disease is introduced as benign pathology according to its clinical presentation and biological behavior, intraoperative rupture of the cyst may aggravate the patients' outcome in the long-term especially in pediatric patient population.

CASE PRESENTATION

We report a 9-year-old girl who presented a progressive neurological deterioration due to an enlargement of a ventrally located extradural hydatid cyst within the thoracic spinal canal. Total removal of the cyst was achieved by preserving the capsule integrity for preventing potential seeding. Our preoperative initial diagnosis based on the radiological findings was confirmed as cyst hydatid histopathologically.

CONCLUSION

Cyst hydatid should be considered in the differential diagnosis of the presence of homogenous cystic lesions with regular shape inside the spinal canal especially in patients from endemic region. To our knowledge, this pediatric patient is the first case of cyst hydatid located ventral side of the spinal cord extradurally located inside the spinal canal showing no extension.

Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry

In prior analyses of the effectiveness of methylprednisolone for the treatment of patients with acute traumatic spinal cord injuries (TSCIs), the prognostic importance of patients' neurological levels of injury and their baseline severity of impairment has not been considered. Our objective was to determine whether methylprednisolone improved motor recovery among participants in the Rick Hansen Spinal Cord Injury Registry (RHSCIR). We identified RHSCIR participants who received methylprednisolone according to the Second National Spinal Cord Injury Study (NASCIS-II) protocol and used propensity score matching to account for age, sex, time of neurological exam, varying neurological level of injury, and baseline severity of neurological impairment. We compared changes in total, upper extremity, and lower extremity motor scores using the Wilcoxon signed-rank test and performed sensitivity analyses using negative binomial regression. Forty-six patients received methylprednisolone and 1555 received no steroid treatment. There were no significant differences between matched participants for each of total (13.7 vs. 14.1, respectively; p=0.43), upper extremity (7.3 vs. 6.4; p=0.38), and lower extremity (6.5 vs. 7.7; p=0.40) motor recovery. This result was confirmed using a multivariate model and, as predicted, only cervical (C1-T1) rather than thoracolumbar (T2-L3) injury levels (p<0.01) and reduced baseline injury severity (American Spinal Injury Association [ASIA] Impairment Scale grades; p<0.01) were associated with greater motor score recovery. There was no in-hospital mortality in either group; however, the NASCIS-II methylprednisolone group had a significantly higher rate of total complications (61% vs. 36%; p=0.02) NASCIS-II methylprednisolone did not improve motor score recovery in RHSCIR patients with acute TSCIs in either the cervical or thoracic spine when the influence of anatomical level and severity of injury were included in the analysis. There was a significantly higher rate of total complications in the NASCIS-II methylprednisolone group. These findings support guideline recommendations against routine administration of methylprednisolone in acute TSCI.

Recurrent primary retro-bulbar hydatid cysts

Retro-bulbar hydatid cysts are extremely uncommon, while nonorbital forms are frequently encountered disease in underdeveloped countries. Most of these are situated in the superolateral and superomedial angle of the orbit. We report a case of recurrent primary hydatid cysts of the orbit, situated in different locations in the orbit. A 35-year-old female patient was admitted to Department of Neurosurgery with proptosis, ptosis and watering from left eye. She also complained for headache with excruciating pain in left eye and loss of vision in left eye. Neurological examination revealed limited ocular mobility in all directions. Visual acuity was reduced to finger counting at 2-feet distance. Papilledema was found in ophthalmic examination. This case was considered as recurrence of primary infection because there was no previous history of hydatid disease and no finding of liver and lung cysts on radiological examinations. Treatment of orbital hydatid cyst, early diagnosis, surgical excision and systemic use of albendazole are suggested.

Clinical characterization of unusual cystic echinococcosis in southern part of Turkey

BACKGROUND AND OBJECTIVES

The incidence of primary extrahepatic cystic echinococcosis (CE) is rare. Generally, radiological and serological findings can help establish the diagnosis of hepatic and pulmonary CE, but a CE in an unusual location with atypical radiological findings may complicate the differential diagnosis. The objective of this study is to present the characteristics of cases with extrahepatic CE in respect of sites of involvement, clinical presentations, radiological findings, serological diagnostic evaluations, and outcomes of infected patients.

DESIGN AND SETTINGS

A retrospective analysis of surgically treated CE was conducted between January 1993 and January 2014 in the General Surgery, Pediatric Surgery, Urology, Cardiovascular Surgery, Neurosurgery, and Orthopedics departments of University of Cukurova, Faculty of Medicine, Balcal Hospital.

PATIENTS AND METHODS

Among the 661 patients managed for CE, 134 had unusual sites of involvement. Radiological and serological examinations were used to differentiate CE from alveolar echinococcosis.

RESULTS

Of 134 cases with unusual sites of involvement, 32 cases had liver CE (23.9%), 7 cases had lung CE (5.2%), and 2 cases had concomitant liver and lung CE (1.5%). In 93 (69.4%) cases, unusual organ involvement was isolated without any liver or lung involvement. The mean age was 45 years. Abdominal pain was the main symptom and was found in 104 patients. Thirty-one (23.1%) of 134 extrahepatic CE cases were evaluated as negative with indirect hemagglutination (IHA). However, positive results were obtained in 54 cases evaluated with Echinococcus granulosus IgG Western blot (WB), including 10 IHA-negative cases.

CONCLUSION

CE with unusual localizations may cause serious problems of diagnostic confusion. The combination of clinical history, radiological findings, and serological test results (especially the WB) are valuable in diagnosing extrahepatic CE.

Secondary adrenal insufficiency after glucocorticosteroid administration in acute spinal cord injury: a case report

CONTEXT/BACKGROUND

A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI.

FINDINGS

AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI.

CONCLUSION

The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.

Repair of injured spinal cord using biomaterial scaffolds and stem cells

The loss of neurons and degeneration of axons after spinal cord injury result in the loss of sensory and motor functions. A bridging biomaterial construct that allows the axons to grow through has been investigated for the repair of injured spinal cord. Due to the hostility of the microenvironment in the lesion, multiple conditions need to be fulfilled to achieve improved functional recovery. A scaffold has been applied to bridge the gap of the lesion as contact guidance for axonal growth and to act as a vehicle to deliver stem cells in order to modify the microenvironment. Stem cells may improve functional recovery of the injured spinal cord by providing trophic support or directly replacing neurons and their support cells. Neural stem cells and mesenchymal stem cells have been seeded into biomaterial scaffolds and investigated for spinal cord regeneration. Both natural and synthetic biomaterials have increased stem cell survival in vivo by providing the cells with a controlled microenvironment in which cell growth and differentiation are facilitated. This optimal multi‒disciplinary approach of combining biomaterials, stem cells, and biomolecules offers a promising treatment for the injured spinal cord.

Survey of Cervical Spine Research Society members on the use of high-dose steroids for acute spinal cord injuries

STUDY DESIGN

A questionnaire survey.

OBJECTIVE

To characterize surgeons' current perspectives on the administration of methylprednisolone for acute spinal cord injury (SCI) and determine how this has changed during the last 7 years.

SUMMARY OF BACKGROUND DATA

The determinants of and complications associated with off-label steroid use for acute SCI remain controversial.

METHODS

A survey was sent to surgeon members of the Cervical Spine Research Society requesting information regarding their use of steroids for acute SCI. Determinants included surgeons' specialty, trauma center level, number of SCIs treated per year, severity of injury, and location of injury. These results were compared across groups as well as with a historical control.

RESULTS

In the case of cervical complete and incomplete SCIs, 47.4% and 56.4% of respondents, respectively, reported using steroids. For complete and incomplete thoracolumbar spine injuries, the usage rate was 46.2% and 55.1%, respectively. There has been a significant (P < 0.0001) decrease in the number of surgeons using high-dose steroids in the treatment of acute SCIs when compared with a previous report in 2006 (56% vs. 89%).More than 80% of respondents reported sepsis, active gastrointestinal bleeding, and SCI occurring earlier than 8 hours as contraindications. Seventy-one percent of respondents reported observing complications from the use of steroids, and 76.3% thought that the complications were severe enough to limit steroid use. Of the surgeons who used steroids for SCI, 26% thought that steroids improved neurological recovery, 19.2% used steroids to adhere to institutional protocol, and 25.6% stated they did not think steroids were beneficial but used them because of medicolegal concerns.

CONCLUSION

There has been a significant decrease in the number of surgeons using high-dose steroids for acute SCIs. Sepsis, gastrointestinal bleeding, and an injury occurring more than 8 hours prior to presentation were agreed upon as contraindications to steroid use.

Multicenter prospective nonrandomized controlled clinical trial to prove neurotherapeutic effects of granulocyte colony-stimulating factor for acute spinal cord injury: analyses of follow-up cases after at least 1 year

STUDY DESIGN

An open-labeled multicenter prospective nonrandomized controlled clinical trial.

OBJECTIVE

To confirm the feasibility of using granulocyte colony-stimulating factor (G-CSF) for treatment of acute spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

We previously reported that G-CSF promotes functional recovery after compression-induced SCI in mice. On the basis of these findings, we conducted a multicenter prospective controlled clinical trial to assess the feasibility of G-CSF therapy for patients with acute SCI.

METHODS

The trial ran from August 2009 to March 2011, and included 41 patients with SCI treated within 48 hours of onset. Informed consent was obtained from all patients. After providing consent, patients were divided into 2 groups. In the G-CSF group (17 patients), G-CSF (10 μg/kg/d) was intravenously administered for 5 consecutive days, and in the control group (24 patients), patients were similarly treated except for the G-CSF administration. We evaluated motor and sensory functions using the American Spinal Cord Injury Association score and American Spinal Cord Injury Association impairment scale at 1 week, 3 months, 6 months, and 1 year after onset.

RESULTS

Only 2 patients did not experience American Spinal Cord Injury Association impairment scale improvement in the G-CSF group. In contrast, 15 patients in the control group did not experience American Spinal Cord Injury Association impairment scale improvement. In the analysis of increased American Spinal Cord Injury Association motor score, a significant increase in G-CSF group was detected from 1 week after the administration compared with the control group. After that, some spontaneous increase of motor score was detected in control group, but the significant increase in G-CSF group was maintained until 1 year of follow-up.

CONCLUSION

Despite the limitation that patient selection was not randomized, the present results suggest the possibility that G-CSF administration has beneficial effects on neurological recovery in patients with acute SCI.

LEVEL OF EVIDENCE

3.

Intracranial hydatid cyst is a rare cause of midbrain herniation: A case report and literature review

Hydatid disease is a parasitic infection affecting the brain in about 2% of the cases. Brain involvement is most commonly observed in children. Here, we report a 13-year-old male patient who presented with headache, nausea, and vomiting. Before cranial computed tomography (CT) was performed, the patient had generalized epileptic seizures. He was disoriented, and had anisocoria with dilatation of the right pupilla. CT showed a cystic lesion of 10-cm diameter in the right temporoparietal region that had caused a shift of the midline structures to the contralateral side; an urgent operation was performed as there were signs of midbrain herniation.

Primary hydatid cyst of pineal region of brain: A case report from Saudi Arabia

Preoperative diagnosis of cerebral echinococcosis in an unusual location is always difficult. Nonetheless, this possibility should be kept in mind in all cystic lesions of the brain. Although total excision of the cyst without rupture is a time - tested treatment, but in order to prevent recurrence, adjuvant medical treatment should also be started. Albendazole, mebenadazole and praziquental are commonly used drugs. Albendazole is a drug of choice. Its usual dose for adults is 400 mg twice daily. Exact duration of treatment is still uncertain, but it should not be <6 months. This case report shows primary presentation of hydatid cyst in the pineal region which later disseminated intracranially. However complete excision of the cyst at site of recurrence, combined with medical treatment, proved quite successful. Patient was found recurrence free 3 years after surgery. Last but not least, endoscopic third ventriculostomy and biopsy should be performed very carefully in cystic lesions of posterior third ventricular region.

Primary intracranial and spinal hydatidosis: a retrospective study of 21 cases

OBJECTIVE

To analyse the epidemiological characteristics, clinical symptoms, radiological aspects, treatments, and outcomes of primary central nervous system (CNS) hydatidosis and compare our results with those observed for secondary intracranial hydatidosis.

PATIENTS AND METHODS

We retrospectively reviewed 21 cases of primary CNS hydatid cysts operated on at the First Affiliated Hospital of Xinjiang Medical University between 1996 and 2010.

RESULTS

Of the 21 primary cases, the vast majority were intracranial hydatidosis patients (20 cases, 95·24%). Only one patient had spinal hydatidosis. Unlike previously published reports, we found that intracranial hydatid cysts were more common in adults (80·96%) than in children (19·04%), with a slight male predominance (M/F = 1·1). All symptoms, including vomiting, nausea, and focal neurological signs, resulted from the increased intracranial pressure, which was closely associated with the cyst location. For the spinal hydatidosis patient, the primary symptom of back pain was indicative of spinal cord compression syndrome. All cysts in the 21 primary cases were pathologically similar. The recurrence percentage was 28% over 12 years. Two patients with multiple intracranial hydatid cysts died due to foramen magnum herniation.

CONCLUSION

Despite imaging and therapeutic advances, CNS hydatidosis remains difficult to treat, and severe complications and the high incidence of recurrence result in unsatisfactory outcomes.

Intra cranial hydatid cyst: A case report of total cyst extirpation and review of surgical technique

Hydatid cysts commonly affect liver and lung but it can also affect the brain in rare cases. We report a case of 22 year female with history of headache for one and half years. Intracranial hydatid cyst was diagnosed on computed tomography scan and magnetic resonance imaging. The cyst was delivered without rupture using hydrostatic dissection followed by post-operative anthelminthic medication. Surgery remains to be the standard management. Amongst the surgical techniques described, Dowling's technique is the most acceptable. However, care must be taken in to avoid rupture of the cyst peroperatively which can result in subsequent complications and recurrence. Albendazole and corticosteroids can be used as adjunct to surgical treatment in selective cases.

Nanomedicine for treating spinal cord injury

Spinal cord injury results in significant mortality and morbidity, lifestyle changes, and difficult rehabilitation. Treatment of spinal cord injury is challenging because the spinal cord is both complex to treat acutely and difficult to regenerate. Nanomaterials can be used to provide effective treatments; their unique properties can facilitate drug delivery to the injury site, enact as neuroprotective agents, or provide platforms to stimulate regrowth of damaged tissues. We review recent uses of nanomaterials including nanowires, micelles, nanoparticles, liposomes, and carbon-based nanomaterials for neuroprotection in the acute phase. We also review the design and neural regenerative application of electrospun scaffolds, conduits, and self-assembling peptide scaffolds.

Spinal cystic echinococcosis--a systematic analysis and review of the literature: part 2. Treatment, follow-up and outcome

Bone involvement in human cystic echinococcosis (CE) is rare, but affects the spine in approximately 50% of cases. Despite significant advances in diagnostic imaging techniques, surgical treatment and introduction of pharmacological therapy, spinal echinococcosis remains associated with a high degree of morbidity, disability and mortality. We systematically reviewed the published literature of the last five decades to update and summarize the currently existing data on treatment, follow-up and outcome of spinal CE.

Spinal cystic echinococcosis--a systematic analysis and review of the literature: part 1. Epidemiology and anatomy

Bone involvement in human cystic echinococcosis (CE) is rare, but affects the spine in approximately 50% of cases. Despite significant advances in diagnostic imaging techniques as well as surgical and medical treatment of spinal CE, our basic understanding of the parasite's predilection for the spine remains incomplete. To fill this gap, we systematically reviewed the published literature of the last five decades to summarize and analyze the currently existing data on epidemiological and anatomical aspects of spinal CE.

Spinal cystic echinococcosis (CE) is a rare but malignant form of a truly neglected tropical disease. Despite significant advances in diagnostic imaging techniques as well as surgical and medical treatment of spinal CE, our basic understanding of the parasite's predilection for the spine remains poor at best. Information on the influence of parasite and host specific factors on anatomical manifestations and evolution of CE is currently lacking. We systematically reviewed all published case reports and case series of spinal CE from 1965 until 2012 to summarize and analyze the epidemiological and anatomical aspects of the disease and discuss the findings in light of the existing data.