An urban legend: Malignant transformation caused by radiotherapy in patients with presacral ganglioneuroma. The necessity and first-time administration of radiotherapy. Case report and literature review

Ganglioneuromas (GNs) are well-differentiated, rare benign tumors of neural crest origin and are, for the most part, considered to be the benign equivalent of neuroblastomas. There are very few cases of GN reported to be at presacral location in the literature. The standard form of treatment is the total surgical excision. However, total resection of GN is not always possible depending on the neuron, from which it originates, and its localization. Moreover, adjuvant radiotherapy (RT) or chemotherapy is not recommended even though patients are still symptomatic after subtotal resection. This view is based on the urban legend that it undergoes a malignant transformation although it is a benign tumor. Moreover, there are no data indicating that the GN cases reported in the literature have undergone RT. Therefore, articles about the suspicion that GN may undergo spontaneous or malignant transformation after RT are absolutely controversial. Based on our case, we present here, we believe that we will explain the valid necessity of application of RT that we administered for the first time and that with the clarification of this controversial topic, a significant gap will be closed in the literature.

Less Use of the Bipolar Cautery can Prevent Postlaminectomy Epidural Fibrosis: An Experimental Study in Rats

AIM

To investigate the role of bipolar electrocautery in the occurrence of epidural fibrosis following lumbar spine laminectomy in a rat model.

MATERIAL AND METHODS

Fourteen male Sprague-Dawley rats (age: 4-6 months, weight: 250-300 g) were randomly divided into two groups, a bipolar group (Group I) and a control group (Group II). Laminectomy was performed between the L1 and L3 levels. In Group I (n=7), a laminectomy was carried out and soft tissue around the spinal cord was coagulated by using a bipolar electrocautery. In the control group (n=7), only laminectomy was performed. The animals were sacrificed 4 weeks after surgery, and post-laminectomy epidural fibrosis (PLEF) was evaluated. Macropathological, qualitative and quantitative histological evaluations as well as immunohistochemical staining including transforming growth factor-β (TGF-β), collagen I and collagen III were performed.

RESULTS

The numbers of TGF-β positive cells staining (PCS) were 3.00 ± 0.46 for Group I and 1.00 ± 0.52 for Group II. The numbers of collagen I PCS were 2.00 ± 0.93 for Group I and 1.25 ± 0.46 for Group II. The numbers of collagen III PCS were 2.25 ± 0.76 for Group I, 1.25 ± 0.46 for Group II, and TGF-β PCS than Group II (p≤0.05). Compared with the control group, Group I's formation of epidural fibrosis was significantly increased.

CONCLUSION

Our study clearly demonstrated that the use of bipolar cauterisation is associated with increased PLEF in the experimental animal model. Thus, limiting the use of bipolar cauterisation may be effective in reducing this complication.

Artifacts in cranial MRI caused by extracranial foreign bodies and analysis of these foreign bodies

Purpose:

The purpose of our study was to conduct a chemical analysis of extracranial foreign bodies (FBs) causing artifacts in cranial magnetic resonance imaging (MRI) and to investigate the association between chemical composition, magnetic susceptibility, and artifact size.

Materials and Methods:

A total of 12 patients were included in the study. The FBs responsible for the artifacts were visualized using cranial computed tomography (CT). Artifact-causing FBs were removed from the scalps of 10 patients and analyzed using scanning electron microscope with energy dispersive spectroscopy (SEM-EDS), X-ray diffraction spectroscopy (X-RD), and Fourier-transform infrared spectroscopy (FT-IR). The magnetic susceptibility of the samples was determined using the reference standard material MnCl₂.6H₂O. The volume of the MRI artifacts was measured in cubic centimeters (cm³).

Results:

EDS results demonstrated that the mean Fe ratio was 5.82% in the stone samples and 0.08% in the glass samples. Although no phase peaks were detected in the X-RD spectra of the glass samples, peaks of Fe₂O₃, Al₂Ca (SiO₄) were detected in the X-RD spectra of the stone samples. The FT-IR spectra revealed metal oxide peaks corresponding to Fe, Al, in the stone samples and peaks confirming Al₂SiO₅ and Na₂SiO₃ structures in the glass samples. The mean volumes of the MRI artifacts produced by the stone and glass samples were 5.9 cm³ and 2.5 cm³, respectively.

Conclusions:

Artifacts caused by extracranial FBs containing metal/metal oxide components are directly associated with their chemical composition and the artifact size are also related to element composition and magnetic susceptibility.

Microsurgery versus Medical Treatment for Neuropathic Pain Caused by Foraminal Extraforaminal Lumbar Disc Herniation: An Observational Study

AIM

To investigate the incidence of neuropathic pain (NP) in patients with foraminal/extraforaminal lumbar disc herniation (FEFLDH), the prognosis of NP and the effect of microsurgery on patients treatment.

MATERIAL AND METHODS

Two patient groups with FEFLDH were investigated: the surgery group underwent surgical treatment, and the medical-treated group received medical treatment. Patients were diagnosed with NP when the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale was ≥ 12 points. The NP scores were evaluated during patient admission and at 1, 6 and 12 months postoperation or during medical treatment.

RESULTS

The surgery group included 37 patients (18 women, 19 men); FEFLDHs were localised at the L3-4 (n=9), L4-5 (n=23) and L5-S1 (n=5) levels. NP was detected in 16 patients before surgery (43%). The medical-treated group included 46 patients (19 women, 27 men); FEFLDHs were localised at the L2-3 (n=7), L3-4 (n=12) and L4-5 (n=27) levels. NP was detected in 20 patients before medical treatment (43%). The most common neuropathic symptom for patients was a burning sensation. NP was found more common in patients who were of at advanced age ( > 65 years) (p=0.019), had a longer clinical duration (p=0.007) or had a foraminal disc herniation (p=0.038).

CONCLUSION

Chronic compression of the dorsal root ganglion by FEFLDH is a significant cause of NP. If surgical treatment is delayed for FEFLDH, the risk of persistent NP may increase.

Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

Introduction

The treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems of neurosurgery. We report the rupture of a giant, lobulated, and almost completely thrombosed middle cerebral artery (MCA) aneurysm that is the ninth such report in the literature. We also investigated additional solutions used in the treatment of this patient.

Case Presentation

A 58-year-old man had been admitted with headache 8 years previously (in 2005), and a giant MCA aneurysm was detected. Two separate endovascular interventions were performed, and both failed. The patient began to live with the giant aneurysm. As there was a large thrombosis filling the aneurysm lumen during the previous endovascular procedures, the aneurysm was not expected to rupture. However, a rupture eventually occurred, in 2013. Even if an aneurysm is very large, lobulated, old, and almost completely thrombosed, it can suddenly bleed. During surgery on this patient, we observed severe cerebral vasospasm caused by a giant thrombosed aneurysmal rupture. Despite the complications, surgery is a life-saving treatment for this emergency when other strategies are not possible. Thrombectomy and clipping are approaches that require a great deal of courage for the neurosurgeon, in terms of entering the risky area within the aneurysm.

Conclusions

We believe that it would be more appropriate to plan for combined treatment with surgical and endovascular approaches before the emergency condition could occur.

Rapid onset mediastinal hematoma due to vertebral fracture and review of relevant literature

Patients with vertebral fractures are frequently encountered and those with thoracic and lumbar spine fractures are likely to have associated injuries. Detection of a widened mediastinum after trauma is very nonspecific and most of the time it is related to aortic injury or mediastinal hematoma. Vertebral or sternal fractures can also be the cause of mediastinal hematoma with or without aortic injury.

This report reviews an unusual case of rapid onset mediastinal hematoma due to vertebral fracture after a fall.

In the case, there was a mediastinal hematoma adjacent to a burst fracture of the T8 vertebral body. There was a rapid increase in identified hematoma during the emergency follow up and urgent erythrocyte transfusion was carried out.

We would like to raise awareness of this infrequent presentation of mediastinal hematoma, as it is insidious and possibly fatal. In the evaluation of mediastinal hematoma, the detection of osseous injuries is a requirement.

Split Rib Cranioplasty for Frontal Osteoma: A Case Report and Review of the Literature

INTRODUCTION

Osteomas are benign bone tumors. They generally lead to a local thickness on the frontal bone in calvarium. When they occur on the forehead, they often cause a cosmetic disorder without any neurological symptoms. The significant problem is the repair method of the cranium defect.

CASE PRESENTATION

The rib of a 34-year-old female was split and used for a small cranium defect of 3 × 3.5 cm. The preferred method and the obtained results were presented under the guidance of the literature.

CONCLUSIONS

Along with the technological advancement, different materials are employed according to the size of the cranium defect and the age of the case. The application of split costa cranioplasty for the small cranium defects in the region of patient's face is the method with the least possibility of complications, and its cosmetic and functional results are quite promising.

Vascular endothelial growth factor gene polymorphisms in Turkish patients with sarcoidosis

Polymorphism at +813 locus of vascular endothelial growth factor (VEGF) gene is considered to decrease predisposition to sarcoidosis. Our study aimed to investigate the roles of this polymorphism in the development and extent of sarcoidosis. We examined polymorphisms of the VEGF gene in 90 cases with histopathological diagnosis of sarcoidosis and in 110 healthy subjects. VEGF +813 gene polymorphisms were determined using a polymerase chain reaction-based method after DNA isolation. A significant increase in the frequency of the T allele was found in healthy subjects (odds ratio 0.55; 95% confidence interval 0.32-0.97, P<0.05). Our results suggest that increase in rarer T allele at + 813 locus of VEGF gene may diminish susceptibility to sarcoidosis in Turkish population.

Prevalence of Helicobacter pylori vacA, cagA, cagE, iceA, babA2 genotypes and correlation with clinical outcome in Turkish patients with dyspepsia

BACKGROUND

Distinct virulence factors of Helicobacter pylori have been associated with clinical outcome of the infection; however, considerable variations have been reported from different geographic regions and data on genotypes of Turkish H. pylori isolates are sparse.

AIM

To determine the prevalence of specific genotypes of H. pylori in Turkish patients with dyspepsia.

MATERIALS AND METHODS

Ninety-three H. pylori-positive patients [30 with non-ulcer dyspepsia (NUD), 30 with duodenal ulcer (DU), and 33 with gastric cancer (GC)] who were admitted to our endoscopy unit due to dyspepsia were enrolled in the study. H. pylori infection was confirmed in all patients by histology and rapid urease test (RUT). The presence of vacA alleles, cagA, cagE, iceA, and babA2 genotypes were determined by polymerase chain reaction (PCR). Chi-squared test and Fisher's exact test were used for statistical comparisons and multivariate regression analysis was performed to find out independent predictors of different clinical outcomes.

RESULTS

Turkish strains examined predominantly possessed the vacA s1,m2 (48.4%) and s1,m1 (40.7%) genotypes. The vacA s1a genotype was detected in 66.7, 96.4, and 87.9% of isolates from patients with NUD, DU, and GC, respectively, and its presence was significantly associated with that of DU (p = .004), GC (p = .043), and cagA gene (p = .021). None of the cases was found to harbor the s1c genotype. The frequencies of the cagA and cagE genes among studied isolates were 73.6 and 59.3%, respectively. The cagA gene was significantly associated with the presence of DU (p = .004) and GC (p = .003), and the cagE gene, too, was significantly associated with the presence of DU (p = .002) and GC (p = .000). All H. pylori isolates possessed the iceA gene. In all, 68 isolates (74.7%) were positive for iceA1 and 23 (25.3%) for iceA2. The frequency of icea1 gene was significantly higher in cases with GC (85%) than in cases with NUD (60%) (p = .026). The frequency of babA2 gene was 23.3, 46.4, and 87.9% in isolates of patients with NUD, DU, and GC, respectively. When compared to cases with NUD (p = .000) and DU (p = .000), the presence of babA2 gene was significantly higher in cases with GC. Multivariate regression analysis disclosed cagE (p = .006) and vacA s1a (p = .027) genotypes to be independent predictors of DU and babA2 (p = .000) and cagE (p = .013) genotypes to be independent predictors of GC.

CONCLUSIONS

H. pylori vacA s1a, cagA, cagE genotypes have significant relations with the presence of DU and GC, and iceA1, babA2 with GC in Turkish patients with dyspepsia, whereas cagE and vacA s1a genotypes are independent predictors of DU, and babA2 and cagE genotypes are independent predictors of GC.

The relationship between arthritis and human parvovirus B19 infection

In order to evaluate the role of human parvovirus B19 in the etiopathogenesis of autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), synovial fluid and blood specimens were collected at 1-month intervals from 20 patients with early synovitis (ES) and 31 with RA. Blood specimens were also collected from 25 patients with SLE, 25 with osteoarthritis (OA) as the diseased control group, and 50 healthy blood donors (HBD) as the healthy control group. Detection of B19 IgM and B19 IgG were performed by enzyme-linked immunosorbent assay from serum specimens, and B19 DNA was detected by polymerase chain reaction from synovial fluid samples. B19 IgM, B19 IgG, and B19 DNA were found in the three patients of the ES group. Subsequently, two of them were diagnosed with RA and one with SLE. B19 DNA was also detected in the synovial fluid of eight patients in the RA group. Of them, all were positive for B19 IgG and half were positive for B19 IgM. B19 IgM was not detected in either of the control groups. To define the role of B19 in the etiopathogenesis and prognosis of undiagnosed arthritis and other chronic inflammatory diseases such as RA and SLE, we need broader serial and prospective studies based on clinical and laboratory collaboration. In conjunction with case reports, these studies would also serve to detect other possible factors in the etiopathogenesis of chronic inflammatory diseases.