Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: A single center-experience.

INTRODUCTION AND OBJECTIVES: We aimed to assess the outcomes of patients with trigeminal neuralgia (TGN) who underwent Gamma Knife radiosurgery (GKRS). MATERIALS AND METHODS: Fifty-three patients with typical TGN underwent GKRS from May 2012 until December 2022. Among these patients, 45 patients who were follow-up for at least 12 months were included in the study. A mean dose of 87.5 Gy (range, 80-90) was administered to the trigeminal nerve. Postoperatively, outcome was considered excellent if the patient was pain- and medication-free. RESULTS: The mean symtpom duration was 9.53 years, and the mean patient age was 59.8 years (range, 34-85). The mean follow-up period was 46.8 months (range, 12-127 months). 46.7% of patients had a history of previous surgical interventions. A single nerve division was affected in 14 patients (31.1%), and multiple divisions were affected in 31 patients (68.9%). The rate of initial pain relief was 80%. Hypoesthesia in the area of trigeminal nerve developed in 30 (66.7%). Twenty patients (44.4%) exhibited excellent results within 72.4 months. Recurrence occurred in 11 patients (24.4%) with 27.6 months. CONCLUSIONS: Our results suggest that GKRS is a safe and effective procedure. Thus, it is an attractive first- and second-line treatment choice for TGN.

Flow diverter stents in the treatment of recanalized intracranial aneurysms.

BACKGROUND: We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly. MATERIALS & METHODS: Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded. RESULTS: Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero. CONCLUSION: The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.

The association between surgical characteristics and cognitive decline following deep brain stimulation of the subthalamic nucleus in Parkinson's disease.

OBJECTIVE: Despite optimal improvement in motor functioning, both short- and long-term studies have reported small but consistent changes in cognitive functioning following STN-DBS in Parkinson's disease (PD). The aim of the present study was to explore whether surgical characteristics were associated with cognitive decline one year following STN-DBS. METHODS: We retrospectively analyzed 49 PD patients who underwent bilateral STN-DBS. Cognitive change scores were related to the number of microelectrode recording (MER) trajectories, the STN length as measured by MER, and cortical entry points. Regression analyses were corrected for age at surgery, disease duration, education and preoperative levodopa responsiveness. Patients were then divided into a cognitive and non-cognitive decline group for each neuropsychological test and compared regarding demographic and surgical characteristics. RESULTS: One year postoperatively, significant declines were found in verbal fluency, Stroop Color-Word test and Trail Making Test B (TMT-B). Only changes in TMT-B were associated with the coronal entry point in the right hemisphere. The number of MER trajectories and STN length were not associated with cognitive change scores. When comparing the cognitive decline and non-cognitive decline groups, no significant differences were found in surgical characteristics. CONCLUSIONS: The electrode passage through the right prefrontal lobe may contribute to subtle changes in executive function. However, only few patients showed clinically relevant cognitive decline. The use of multiple MER trajectories and a longer STN length were not associated with cognitive decline one year following surgery. From a cognitive point of view, DBS may be considered a relatively safe procedure.

Management of Hardware Related Infections after DBS Surgery: A Cost Analysis.

AIM: To investigate the costs of treating the infection with antibiotics only with the risk of surgery when unsuccessful versus immediate removal followed by re-implantation in patients with deep brain stimulation (DBS) hardware infection. MATERIAL AND METHODS: We calculated the costs of the different strategies through a standard costing procedure. A decision model has been applied to establish the average treatment cost per patient representative for a clinical setting where both strategies are employed. Subsequently, a sensitivity analysis has been performed to assess the influence of clinical assumptions regarding the effectiveness of antibiotics treatment on average treatment costs. RESULTS: The costs of treating a case of DBS hardware infection with immediate internal pulse generator (IPG) replacement surgery were ?29,301 compared to ?9499 for successful antibiotic treatment. For antibiotic treatment followed by IPG replacement surgery the total costs were ?38,741. Antibiotic treatment alone was successful in 44% (4/9) of the included cases of DBS infection, resulting in average treatment costs per patient of ?25,745. Trying to resolve DBS hardware infections initially with antibiotics reduced treatment costs by 12.1%. CONCLUSION: Treatment with antibiotics with the risk of a later removal when unsuccessful was a more valuable strategy in terms of costs when compared to immediate surgical intervention in cases of hardware-related infections in DBS surgeries.

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine mode

Background/aim: This study was undertaken to evaluate the effects of positive end-expiratory pressure (PEEP) levels on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to determine the appropriate PEEP level during steep Trendelenburg position combined with pneumoperitoneum.Materials and methods: Ten pigs were included in this study. Pneumoperitoneum and Trendelenburg position were maintained and PEEP titration was initiated. Arterial pressure, heart rate, arterial blood gas, ICP, and CPP were recorded at the following time points: baseline (T0), 30 min after positioning and pneumoperitoneum (T1), PEEP 5 (T2), PEEP 10 (T3), PEEP 15 (T4), and PEEP 20 (T5).Results: MAP significantly increased at T1 compared to T0 and decreased at T4 and T5 compared to T1. ICP was 9.5 mmHg and CPP was 69.3 mmHg at T0. CO2 insufflation and steep Trendelenburg position did not cause any significant difference in ICP and CPP. ICP increased and CPP decreased significantly at T4 and T5 compared to both T0 and T1. PaO2 and PaO2/FiO2 decreased significantly at T1 and T2 compared to T0, while both increased significantly at T3, T4, and T5 compared to T1.Conclusion: PEEP of 10 cmH2O was effective for providing oxygenation while preserving hemodynamic stability, ICP, and CPP in this model.

Management of Failed Cranioplasty.

AIM: Failed cranioplasty attempts may lead to numerous complications in a broad spectrum including cosmetic problems, infection, neurological deterioration and even death. Selection of the most appropriate surgical technique for second and further surgical attempts for these patients still remains a debate. We aimed to share our experience and technical pitfalls on management of failed cranioplasty, particularly for patients with large cranial defects. MATERIAL AND METHODS: A retrospective data analysis of cranioplasty cases in our series was performed including the time period between 2002 and 2012. Patients required recurrent cranioplasty were analyzed in detail. RESULTS: Totally, 101 patients underwent cranioplasty for bony defect. Of 101 patients, eleven required a revision surgery due to infection or spontaneous resorption of the bone flap. All patients underwent revision cranioplasty with pre-surgical plaster cast mold technique modified from previous studies and/or tissue expansion technique. Polymethyl-metacrylate (PMMA) was used as substitute for reconstructions. Mean follow-up was 36 months. Two out of eleven cases (18.1%) developed major complications, which led to further revision. At the end, a satisfactory reconstruction was achieved for all patients. CONCLUSION: Our modified molded plaster cast technique is a safe and cost-effective approach for the revision of failed cranioplasty. We believe that the tissue expanding techniques have also great contribution to achieve successful results.

Final Electrode Position in Subthalamic Nucleus Deep Brain Stimulation Surgery: A Comparison of Indirect and Direct Targeting Methods.

AIM: High frequency stimulation of the subthalamic nucleus (STN) is nowadays a widely performed surgery for patients with Parkinson's disease (PD). The field has witnessed a shift from indirect targeting to direct targeting. The question arises whether this change has influenced the final electrode position in STN deep brain stimulation surgery. To address this question, we compared the final electrode positions in atlas-based and magnetic resonance-based targeting methods in our series. MATERIAL AND METHODS: We performed a database review of the surgeries performed in three affiliated centers. RESULTS: We have found that with the shift to direct imaging, three key changes have taken place. The first is that the number of microelectrode recording trajectories has decreased by approximately 1 microelectrode. Secondly, the central trajectory has been chosen as the final position in more patients, and the third change is that direct targeting has improved the laterality of the targeting significantly. CONCLUSION: Direct targeting has changed routine clinical practice, thereby further refining the surgical approach.

A detailed analysis of intracerebral hemorrhages in DBS surgeries.

OBJECTIVES: Deep brain stimulation is nowadays a frequently performed surgery in patients with movement disorders, intractable epilepsy, and severe psychiatric disorders. The most feared complication of this surgery is an intracerebral hemorrhage due to the electrode placement, either for intraoperative electrophysiology (microelectrode recording) and/or implantation of the final electrode (macroelectrode). Here, we have investigated the risk of developing an intracerebral hemorrhage in our cohort of deep brain stimulation patients over a period of 15 years. PATIENTS AND METHODS: We have collected demographic data and analyzed the effect of performing surgery with single-electrode versus multiple electrode guided DBS. The effect of using single-dose versus double-dose contrast enhanced MRI to visualize vessels for the electrode trajectory planning has been investigated as well. RESULTS: We have found that the overall calculated risk of an intracerebral hemorrhage in our series was 1.81% per patient, 0.3% per recording electrode and 0.23% per brain insertion. While three out of four patients recovered without neurological deficits, there was one mortality in a patient with cardiovascular comorbidities. Statistical comparisons between the groups of single-electrode versus multiple electrode guided surgery and single-dose gadolinium versus double-dose contrast enhanced MRI revealed no significant differences. In addition, there was no meaningful correlation between the age at surgery and the risk of bleeding. CONCLUSION: We have found that the risk of developing an intracerebral hemorrhage due to deep brain stimulation surgery is low. The clinical course of the patients with an intracerebral hemorrhage was generally favorable.

A Simple Technique for Bone Storage after Decompressive Craniectomy in Children.

Cranial vault reconstruction in the pediatric population is a specialized procedure, which requires additional considerations. Generally, inherent difficulties of bone storage and cranioplasty are neglected in the literature. We present a simple method of bone storage and autologous cranioplasty in a small child with severe head injury. The child underwent surgical treatment with decompressive craniectomy. A bone flap was transversally divided into two pieces and stored under the galea. Bone storage and reconstruction of the cranial vault with our surgical technique is a safe, easy and cost-effective choice excluding the surgical trauma to obtain a new subcutanous pocket for bone storage in pediatric decompressive craniectomy patients.

Vertebrojugular arteriovenous fistula and pseudoaneurysm formation due to penetrating vertebral artery injury: case report and review of the literature.

Vertebral artery injury including thrombosis, arteriovenous fistula (AVF), pseudo-aneurysm and hemorrhage may be iatrogenic or due to penetrating or blunt trauma. Although mostly asymptomatic, vertebral artery injury may also present with vertebrobasilar insufficiency findings, cephalgia, radicular pain or myelopathy due to blockade of arterial flow, arterial steal phenomenon and venous hypertension. The gold standard for diagnosis is digital subtraction angiography (DSA). Doppler ultrasonography, magnetic resonance-angiography and computerized tomography-angiography are also helpful. Endovascular treatment is now used more commonly. We present a case with sharp bread knife injury of the vertebral artery that was also complicated with a vertebrojugular fistula and pseudo-aneurysm together with the diagnostic and management options and a review of the current literature.

Surgery for intractable temporal lobe epilepsy: experience of a single institution.

BACKGROUND/AIM: In the treatment of epilepsy, encouraging results have been achieved with surgical treatment, especially for temporal lobe epilepsy (TLE). Drug resistance must be diagnosed as early as possible, because the ensuing seizures can be eliminated surgically via temporal lobe surgery in a high percentage (70%-90%) of patients. In this study we share our experience, in a single institution, of surgical treatment of intractable TLE. MATERIALS AND METHODS: Between March 2006 and November 2010 we performed 127 corticoamygdalohippocampectomy (CAH) procedures. All CAH surgical procedures were done as described by Niemeyer's technique. Resection lengths were 4-4.5 cm from the temporal pole. RESULTS: At the end of 24 months, 79.7% (n = 94) patients were still on antiepileptic medications, with 55 of them on a decreased number or dose of drugs, and 20.3 (n = 24) patients were antiepileptic drug-free. Postoperative Engel's classes were 1, 2, and 3 in 87.2%, 5.08%, and 7.6%, respectively. There was no mortality in follow-up, and dysphasia in 1 patient (0.84%) was the only morbidity. CONCLUSION: In our series we found that the outcome of surgery is associated with careful patient selection, which requires a detailed investigation of the patients. Our final conclusion is that outcome scores are independent of age, pathology, or sex but are dependent on correct patient selection.

Neuroprotective effects of quetiapine on neuronal apoptosis following experimental transient focal cerebral ischemia in rats.

OBJECTIVE: This study was undertaken in the belief that the atypical antipsychotic drug quetiapine could prevent apoptosis in the penumbra region following ischemia, taking into account findings that show 5-hydroxytryptamine-2 receptor blockers can prevent apoptosis. METHODS: We created 5 groups, each containing 6 animals. Nothing was done on the K-I group used for comparisons with the other groups to make sure adequate ischemia had been achieved. The K-II group was sacrificed on the 1st day after transient focal cerebral ischemia and the K-III group on the 3rd day. The D-I group was administered quetiapine following ischemia and sacrificed on the 1st day while the D-II group was administered quetiapine every day following the ischemia and sacrificed on the 3rd day. The samples were stained with the immunochemical TUNEL method and the number of apoptotic cells were counted. RESULTS: There was a significant difference between the first and third day control groups (K-II/K-III : p=0.004) and this indicates that apoptotic cell death increases with time. This increase was not encountered in the drug groups (D-I/D-II : p=1.00). Statistical analysis of immunohistochemical data revealed that quetiapine decreased the apoptotic cell death that normally increased with time. CONCLUSION: Quetiapine is already in clinical use and is a safe drug, in contrast to many substances that are used to prevent ischemia and are not normally used clinically. Our results and the literature data indicate that quetiapine could help both as a neuronal protector and to resolve neuropsychiatric problems caused by the ischemia in cerebral ischemia cases.

Transoral protrusion of a peritoneal catheter due to gastric perforation 10 years after a ventriculoperitoneal shunting: case report and review of the literature.

Various complications following ventriculoperitoneal (VP) shunting have been reported but transoral protrusion of peritoneal catheter is a very rare situation. This case is the first adult with a transoral VP shunt protrusion in available literature. A 47-year-old female with pseudotumor cerebri admitted after the peritoneal catheter protruded from her mouth during retching. Endoscopic examination showed a catheter inside stomach entered through the anterior surface. The patient was treated via VP shunt extraction and remained stable. Extrusion of peritoneal catheter through vagina, anus, scrotal skin or gastrostomy wound is well-known. However transoral protrusion should be considered as a very rare complication of VP shunting, especially in an adult. We present a rare case of transoral protrusion of a peritoneal catheter 10 years after ventriculo-peritoneal shunting procedure and review of the literature through this article.

Neurosurgical training programme in selected European countries: from the young neurosurgeons' point of view.

AIM: In this paper we discuss the Neurosurgical Training Programme (NTP) in some European countries. MATERIAL AND METHODS: Although there is no official data on how many neurosurgeons are certified in Europe, our calculation shows that this number is somewhat lower than in the United States of America and even 3 times lower than in Japan (per 100.000 population). It is also evident that there is no consensus in the Programme duration or in the official NTP content, despite the recommendations of the EANS (The European Association of Neurosurgical Societies). Trainees from outside the European Union (EU) are under-represented in the EANS training courses. We believe that in the eastern part of Europe there is the most space for improvement in neurosurgical training. Solving of all these problems requires first and foremost their recognition and consideration - then devising a solution. CONCLUSION: The purpose of this paper is to compare and contrast several NTP's in Europe in order to promote a more coherent medical education. Some remarks and suggestions from the perspective of young neurosurgeons are given.

Effects of phenytoin sodium on dura mater healing in a rat model of CSF leakage.

AIM: Cerebro-spinal fluid (CSF) leakage caused by defects on the dura mater after trauma or some neurosurgical interventions is an important issue. In this study, we investigated the effects of local and systemic use of phenytoin sodium on dural healing. MATERIAL AND METHODS: Thirty-six male Wistar rats were divided into control, local phenytoin and systemic phenytoin groups with 12 rats in each. For each group, a dura defect was created at thoracic segment. Subjects were sacrificed at following 1st and 6th weeks and damaged segments were isolated. The results were compared histopathologically by Hematoxylin-Eosin and Masson-Trichrome staining. Criteria for the rate of collagen, neovascularization, and granulation formation were assessed semi quantitatively according to the histological assessment scale modified by Ozisik et al. RESULTS: Better healing was achieved in the systemic and local phenytoin groups than in the control group. The level of healing was significantly higher in the systemic group in both early and late periods than in other groups (p < 0.01). The level of healing in the late-local group was also statistically significantly higher than that in the control group. CONCLUSION: We observed that both systemic and local uses of phenytoin sodium (especially systemic) have positive effects on dura healing.

Radiological and histopathological comparison of microporous polysaccharide hemospheres and oxidized regenerated cellulose in the rabbit brain: a study of efficacy and safety.

AIM: Topical hemostatic agents are widely used in brain surgery but they have some disadvantages such as foreign body reaction, being a focus for infection and causing artifacts in radiological examinations. The purpose of this study is to compare the effectiveness and safety of microporous polysaccharide hemospheres (MPH) with a well known agent, oxidized regenerated cellulose (ORC), histopathologically and radiologically. MATERIAL AND METHODS: Standard brain lesions (4x1mm) were created in 24 hemispheres in 12 New-Zealand rabbits. Animals were divided into three groups; control, ORC and MPH. Twenty-four hours later, all rabbits magnetic resonance brain imaging. After imaging, the animals were sacrificed and the brains were removed for histopathological analysis. RESULTS: Histopathological analysis showed no significant difference between the groups. Radiological examination showed no significant difference between the MPH and ORC groups in terms of edema but the edema in control group was significantly prominent than MPH and ORC groups (p < 0.001). CONCLUSION: A new agent (MPH) provides safe and effective hemostasis in the brain in this study. The most important advantage of microporous polysaccharide hemospheres is their rapid clearance from the surgical field and therefore having the potential of causing less imaging artifacts.

Two meningiomas with different histological grades in the same patient. Case report.

A 56-year-old female presented with two intracranial meningiomas with different grades manifesting as speech disorder for one week. Neurological and radiological evaluations showed two distinct tumors suggestive of multicentric meningiomas. Surgical resection of both masses was performed in the same procedure. Histological examination found both meningothelial and atypical meningiomas. Concurrency of meningiomas with different grades in same patient is extremely rare. The present case emphasizes the need for follow up of all patients with meningioma even if the neuroimaging features indicate benign character.

Anti-apoptotic and neuroprotective effects of α-lipoic acid on spinal cord ischemia-reperfusion injury in rabbits.

PURPOSE: Radical oxygen species produced after injury counteracts antioxidant activity and frequently causes severe oxidative stress for the tissues. Alpha-lipoic acid is a powerful metabolic antioxidant with immunomodulatory effects which provides neuroprotection. The aim of this study is to investigate the neuroprotective and anti-apoptotic effects of alpha-lipoic acid on spinal cord ischemia-reperfusion. METHODS: Twenty-four adult, male, New Zealand rabbits were divided into sham (n = 8), control (n = 8), and treatment groups (n = 8). The abdominal aorta was clamped for 30 min by an aneurysm clip, approximately 1 cm below the renal artery and 1 cm above the iliac bifurcation in control and treatment groups. Only laparotomy was performed in the sham group. Twenty-five cubic centimeters of saline in control group and 100 mg/kg lipoic acid were administered intraperitoneally in the treatment group after closure of the incision. The animals were killed 48 h later. Spinal cord segments between L2 and S1 were harvested for analysis. Levels of nitric oxide, glutathione, malondialdehyde, advanced oxidation protein products, and superoxide dismutase were analyzed as markers of oxidative stress and inflammation. Caspase-3 activity was analyzed to detect the effect of lipoic acid on apoptosis. RESULTS: In all measured parameters of oxidative stress, administration of lipoic acid significantly demonstrated favorable effects. Both plasma and tissue levels of nitric oxide, glutathione, malondialdehyde, and advanced oxidation protein products significantly changed in favor of antioxidant activity. There was no significant difference between the plasma superoxide dismutase levels of the groups. Histopathological evaluation of the tissues also demonstrated significant decrease in cellular degeneration and infiltration parameters after lipoic acid administration. However, lipoic acid has no effect on caspase-3 activity. CONCLUSIONS: Although further studies considering different dose regimens and time intervals are required, the results of the present study prove that alpha-lipoic acid has favorable effects on experimental spinal cord ischemia-reperfusion injury.

Fractionated gamma knife radiosurgery for optic nerve tumors: a technical report.

AIM: The main purpose of this report is to demonstrate the effects of fractionated radiosurgery regimens in the management of optic gliomas MATERIALS and METHODS: Two patients suffering from progressive loss of vision due to optic nerve gliomas were treated with Gamma Knife radiosurgery in three fractions within three consecutive days instead of a single dose regimen. Patients were followed for 42 and 39 months respectively. RESULTS: The treatment modality was well tolerated by the patients with radiological and neurological tumor control after 42 and 39 months of follow up. There were no additional complications. CONCLUSION: Fractionated regimens of Gamma Knife surgery offer a very good alternative for lesions such as optic glioma and optic nevre sheath meningioma.