Endonasal endoscopic approach for sellar metastatic pathologies: a national observation.

PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Comparison of Different Endoscopic Techniques for the Treatment of Hydrocephalus in Children.

AIM: To present a series of hydrocephalus cases treated with different endoscopic techniques, and to compare their surgical outcomes. MATERIAL AND METHODS: Sixty-one patients underwent endoscopic approach for treating hydrocephalus over a 5-year period. Forty-six patients were children. Three surgical techniques [i.e., endoscopic third ventriculostomy (ETV), ETV plus shunting, and simultaneous ETV plus aqueductoplasty] were used in these patients. Surgical results were statistically analyzed based on age, gender, and type of surgery. RESULTS: Of the 46 children, 24 (52.17%) were female with a mean age of 25.33 months. Twenty-one (45.65%) children underwent ETV alone, 19 underwent ETV plus ventriculoperitoneal shunting, and six underwent simultaneous ETV plus aqueductoplasty. Five (10.87%) children died during the follow-up period. No correlation was observed between surgery type and patient age. No statistically significant differences in sex and complications were found between the surgical techniques. CONCLUSION: ETV alone is the safest method for treating hydrocephalus in children. Mortality is higher in patients younger than 12 months who underwent combined surgical methods, instead of ETV alone.

Characteristics of the injuries of Syrian refugees sustained during the civil war.

BACKGROUND: During a war, many civilians are severely injured by firearms, bombs, and shrapnel. The triage of war injuries involves difficult and complicated processes requiring surgical procedures and patient monitoring in the Intensive Care Unit (ICU) of hospitals. In this study, we examine the demographic, traumatic, and critical care characteristics of cases injured during the civil war in Syria and requiring emergency surgery. METHODS: Electronic data of the traumatic, surgical, and ICU monitoring features of 707 patients admitted to Kilis Public Hospital between March 2012 and January 2013 were analyzed retrospectively RESULTS: Most of the patients reported having been injured due to firearms (83.75%). Of the 707 cases studied in this work, 93.2% was male. Male patients reported a mean age of 26.1±12.1 years, while pediatric cases reported a mean age of 11.7±3.41 years. The most frequently injured region of the body was the head-neck region (52.7%). The New Injury Severity Score (NISS) of the cases was 42.5±11.2 and their American Society of Anesthesiologists (ASA) score was 3.2±0.7. The number of cases with intraoperative exitus was 7, while the number of cases who had undergone damage control surgery was 204. The number of cases hospitalized in the ICU during the postoperative period was 233, and the average hospitalization duration in the ICU was 4.67±1.32 days. Among survivor patients, the first 24-hour invasive measurements (i.e., pH, hemoglobin, body temperature, and mean arterial blood pressure) and international normalized ratio were found to be high. The number of blood products used for surviving patients was fewer relative to that used for non-surviving patients, and these NISS of these patients was 29.7±10.1. The mortality rate of all patients followed up in the ICU after emergency surgery was 45%, and neurosurgical cases showed the lowest level of survival (24.1%). CONCLUSION: The results of this study indicated that head-neck, chest-abdomen, and multiple body injuries are the most widely seen among civilians brought to Turkey because of gunshot injuries sustained during the Civil War in Syria. The number of emergency operations performed in the study sample was high, and critical care follow-up durations were long. In addition, the NISS and ASA scores of mortal cases were fairly high.

Parieto-Occipital Interhemispheric Precuneal Approach to the Lesions of the Atrium: Experience with 66 patients.

AIM: The atrium (trigone) is the most common site for intraventricular lesions. The parieto-occipital interhemispheric precuneal approach (POIPA) is one of the particular ways to reach these lesions. The aim of this study was to draw specific attention to the surgical difficulties of these lesions and to present our experience with this operative approach. MATERIAL AND METHODS: Sixty-six patients with lesions located in the atrium of the lateral ventricles underwent surgical treatment in our institution using POIPA over a 13-year period. The clinical, radiological and surgical characteristics of these patients were retrieved and reviewed retrospectively. The histological diagnosis of the cases and postoperative complications were specifically focused on in this study. RESULTS: Thirty-six (54.5%) patients were male and 30 patients were female with a mean age 37.9 years (range between 8 and 74 years). The lesion was in the right atrium in 25 cases and in the left in 41 (62.1%) patients. POIPA was used in all cases to remove the lesions. The most common tumor was glioblastoma (34.8%), followed by glial tumors grade I, II and III and meningiomas. The other lesions were metastases, ganglioglioma, epidermoid cysts and arteriovenous malformations. Gross total resection of the tumors was achieved in 59 patients (89.4%) while subtotal removal was performed in 7 cases. Five (7.5%) patients died within the first month after surgery. Conclusion: POIPA provides a safe and effective way to reach lesions located in the atrium of the lateral ventricle. Knowledge of precise anatomy associated with the meticulous surgical techniques decreases the surgical morbidity and mortality of the patients.

Preventing Sciatic Nerve Injury due to Intramuscular Injection: Ten-Year Single-Center Experience and Literature Review.

AIM: Sciatic nerve injury is the most frequent and serious complication of intramuscular gluteal injection. This study aims to highlight the incidence and causes of this continuing problem and to discuss the relevant literature. < p < MATERIAL and METHODS: A total of 217 subjects who were diagnosed with sciatic nerve injury in our neurophysiology laboratory between 2003 and 2013 were examined. Sensory and motor transmission studies and needle electromyography were performed by conventional methods in the two lower legs and the results were compared between each leg. RESULTS: Of the subjects who experienced a sciatic injury secondary to intramuscular injection, 59 (27.2%) were female and 158 (72.8%) were male. In all subjects, the dorsogluteal site of the buttocks was selected for intramuscular injection. Sciatica occurred on the right side in 91 subjects, on the left side in 125, and bilaterally in one. The peroneal nerve was more affected than the tibial nerve. The most used agents were non-steroidal anti-inflammatory drugs. According to follow-up electromyography findings of 103 subjects, significant sequelae remained in 2/3 of cases. CONCLUSION: The occurrence of sciatic neuropathy after gluteal injection causing permanent sequelae and leading to medicolegal problems is relatively rare. We suggest a double quadrant drawing technique in each gluteal region. We also draw attention to this issue with postgraduate and in-service training programs of medical staff, and providing continuity in education can reduce this serious complication.

Anterior Skull Base Defects Reconstructed Using Three-Layer Method: 78 Consecutive Cases with Long-Term Follow-Up.

Objectives Anterior skull base defects are potentially lethal and surgical treatment must be performed as soon as possible. The purpose of this study was to evaluate whether our technique is effective or not in long-term period. Design Retrospective chart review of all patients whose data were entered into the Hospital Registry System between 1995 and 2015. Setting/Participants This study was performed at the Gaziantep University School of Medicine, Gaziantep, Turkey, in 2015 and included 78 patients who in the past 20 years underwent three-layer reconstruction surgery for anterior skull base defects at the same university. Main Outcome Measures Among the patients, defects repaired by transcranial approach had the lowest recurrence rate. Overall, successful repair was achieved in 100% of the patients. Results Pure transbasal approach was used as a single procedure on 71 (91%) patients. Combined approaches were used in seven (9%) cases. The extended transbasal approach was combined with a transfacial approach in four patients and with a pterional approach in three patients. Conclusion We encourage the use of three-layer reconstruction and recommend free fascia lata grafts and galeal flaps with vascularized pedicle as sealing material of choice in all types of cases such as tumor and trauma.

Urodynamic outcomes of detethering in children: experience with 46 pediatric patients.

AIM: Tethered cord syndrome (TCS) manifests with neurological and urological complaints. Surgical detethering is the main treatment for TCS. Children with urological symptoms are required objective pre- and postoperative evaluations in order to predict urological outcome. The aims of this study are to investigate the effects of detethering procedure on the urodynamic tests and to determine the relationship between the changes of urodynamic tests and the patients' age and gender. MATERIAL AND METHODS: The data of urodynamic tests in 46 pediatric patients, who underwent surgery for TCS, were retrospectively evaluated. Bladder capacity, post-voiding residual urine volume, maximum intravesical pressure, and bladder compliance of each patient were measured in preoperative period and at the third month after surgery. These parameters were statistically compared, and the correlations of these parameters with age, gender, and etiology of the TCS were also investigated. RESULTS: Bladder capacity and post-voiding residual urine volume were decreased and maximum intravesical pressure and bladder compliance were increased after surgery for TCS. The decrease in bladder capacity was significant in patients older than 10 years (p < 0.05). The increase in maximum intravesical pressure was also positively correlated with age (p < 0.05). But the increase in bladder compliance was negatively correlated with age (p < 0.05). CONCLUSION: Bladder capacity, post-voiding residual urine volume, and bladder compliance are mainly affected by surgery in patients with TCS. From the urological viewpoint, children older than 10 years are most likely to benefit from surgery for TCS.

Tethered cord syndrome in children: a single-center experience with 162 patients.

PURPOSE: Tethered cord syndrome (TCS) is not an uncommon clinical problem in children. The aim of this retrospective study is to document our experience on the surgical treatment of TCS in childhood. METHODS: The data of 162 children who underwent surgical treatment for TCS in a 15-year period were reviewed retrospectively. Their demographic, clinical, radiological, and surgical features were documented. They were divided into two groups as primary and secondary TCS, and the surgical technique for each group was demonstrated. Untethering the spinal cord and correction of the associated malformation were the standard surgical technique for each patient. The results of the treatment were summarized. RESULTS: Among the 162 children, 101 (62.3%) of them were female and 61 were male with a mean age of 62 months. Primary TCS was detected in 43 patients while secondary TCS was found in 119 (73.4%) patients. Hypertrichosis was the most common physical finding while back pain was the common complaint. Lipoma, split cord malformation, dermal sinus tract, and myelomeningocele were the associated malformations for secondary TCS. CONCLUSIONS: Children should be individualized for the treatment of TCS. Each patient must be evaluated neurologically and radiologically for the accurate diagnosis. Surgical untethering is the safe and effective method of treatment for children with TCS.

Histological structure of the medial and lateral walls of cavernous sinus in human fetuses.

PURPOSE: The aim of this study is to elucidate the architecture of these fine structures in human fetuses. METHODS: The histological examination of medial wall (MW) and lateral wall (LW) was performed in 15 normal human fetuses. Eleven fetuses were female and four were male. The gestational age ranged between 14 and 35 weeks. The weight ranged between 180 and 1750 g. The wall samples (two MW and two LW from each fetus) were obtained by microsurgical technique and underwent histological examination. Each wall was examined for the structure and composition of collagen and elastic fibers, ganglions, peripheral nerves, and vessels. RESULTS: A total of 60 wall samples (30 MW and 30 LW) were examined in 15 fetuses. Loose connective tissue composed of type III collagen was observed in both of the walls. Elastic fibers were observed only in three wall samples (two MW and one LW). Ganglion was detected in 11 samples (nine in LW and two in MW), and peripheral nerve was found in 28 walls (18 LW and 10 MW). Vessels were observed in 51 samples (26 LW and 25 MW). None of the walls was stained with type I collagen. CONCLUSIONS: The structure of LW and MW of the cavernous sinus (CS) in fetuses is mainly composed of collagen tissue while some elastic fibers are supported by this tissue. Type III collagen is the main component of fetal CS walls. Because of the weak histological structure, CS may be more prone to tumor invasion in infants.

Unusual penetration of a construction nail through the orbit to the cranium: a case report.

Penetrating head and neck trauma with construction nails are uncommon life-threatening injuries and an important problem in developing countries. Assessment of the neurovascular and systemic physical status is a first requirement, and the decision concerning which surgical approach to perform for the removal of the nail is of critical importance. A 10-year-old girl was presented one hour after a fall injury with complaint of a swelling and foreign body lodgment on the left forehead. Neurological and systemic physical examinations were normal except for weak direct pupillary light reflex on the left side and the patient's state of uneasiness. Radiological investigations showed that the head of the nail had entered from the left infra-orbital region and become lodged through the orbital roof, below the frontal bone. Surgical extraction of the nail in the operating room was performed successfully using left pterional craniotomy and lateral orbitotomy technique, and there was no complication after surgery. Here, we report a case with a rare craniocerebral penetrating wound and type, with the head of the nail lodged in the anterior fossa through the orbital roof, which may be defined as 'reverse penetration of the nail'.

Efficacy of fentanyl and/or lidocaine on total antioxidants and total oxidants during craniotomy.

OBJECTIVE: The aim of this study was to investigate the oxidative, hemodynamic, and analgesic effects of local lidocaine infiltration, or intravenous (IV) fentanyl injection, or a combination of lidocaine and IV fentanyl during head fixation in a 3-pin headrest in patients undergoing elective craniotomy. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: Gaziantep University Medical Faculty, Department of Anesthesiology and Reanimation. METHODS: Eighty patients were randomly assigned to one of four groups. Five minutes before pin fixation, patients in group L received 1 mg/kg of lidocaine 2% for scalp infiltration (n=20), group F received 1 µg/kg of IV fentanyl (n=20), group FL received 1 mg/kg of lidocaine 2% and 1 µg/kg of fentanyl (n=20), and group P received a placebo (n=20). Following standard anesthesia, basal, pre- and post-fixational hemodynamic data were recorded. Blood samples were taken for evaluation of oxidant and antioxidant levels before and after pin fixation. RESULTS: The total antioxidant levels after pin fixation were highest in group FL followed by group F, then group L and finally group P (ie, FL>F>L>P) (P<0.05). The mean arterial blood pressure (MAP) after pin fixation was higher than the MAP before pin fixation in groups L and P (P<0.05), but was lower in groups F and FL (P<0.05). CONCLUSION: The combination of fentanyl and lidocaine before pin fixation is useful in preventing severe hemodynamic response to pain stimuli, such as pin fixation, and in increasing total antioxidant levels in the post-fixational period during craniotomy in adults.