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.

A different perspective on the dilemma of durotomy or duraplasty in Chiari type 1 malformation surgery.

PURPOSE: Symptomatic Chiari type 1 malformation (CIM) patients may elect to be treated; however, choosing the optimum surgical method remains problematic: posterior fossa decompression with duraplasty (PFDD) or without duraplasty (PFD). Many studies have compared these surgical methods from several perspectives. We looked at soft tissue density (STD) at the foramen magnum to add another perspective to the comparison of PFD with PFDD. MATERIALS AND METHODS: Eighty-six patients who underwent surgery in our clinic were included in the study. We examined preoperative and postoperative MR images taken in the 1st year. We obtained the foramen magnum area (FMA) and soft tissue at the level of the foramen magnum. The STD within the foramen magnum was calculated as the percentage ratio of soft tissue area (STA) to FMA. Anteroposterior diameters of the syrinx cavities in sagittal T2 sections were measured preoperatively and at 1-year postoperatively. Measurements were double-blind and were performed by the neurosurgeon and by the neuroradiologist. RESULTS: There was no statistically significant difference between the postoperative FMA increases, STA changes, STD changes in patients who underwent PFD and PFDD. In this study, there was no statistically significant difference between PFD and PFDD in terms of syrinx changes. CONCLUSIONS: The medium-term anatomical outcome following craniovertebral decompression for CIM, is no different whether performed PFD or PFDD.

Can Dynamic Susceptibility Contrast Perfusion Imaging be Utilized to Detect Isocitrate Dehydrogenase Gene Mutation in Gliomas?

AIM: To explore the ability of dynamic susceptibility contrast perfusion imaging (DSC-PI) to detect isocitrate dehydrogenase (IDH) gene mutation in gliomas. MATERIAL AND METHODS: Preoperative DSC-PI data on histopathologically proven gliomas obtained between January 2015 and December 2019 were reviewed retrospectively. All magnetic resonance imaging (MRI) examinations were performed using a 1.5-T scanner. The maximum relative cerebral blood volume (rCBVmax), percentage signal recovery (PSR), and normalized PSR of tumor cores were calculated. Differences in these values between IDH-mutant and wild-type gliomas were compared, and receiver operating characteristic curves were generated. RESULTS: The patients (32 females, 47 males) were aged 21-76 years (mean 50.7 ± 15 years). The rCBVmax and all PSR values differed significantly between patients with IDH-mutant and those with wild-type tumors (p < 0.01 for all comparisons). CONCLUSION: The rCBVmax and PSR values obtained by DSC-PI may facilitate noninvasive detection of the IDH mutation status of gliomas. PSR provided more reliable values for differentiation of IDH-mutant gliomas from wild-type gliomas.

Myelomeningocele and Kyphosis: Natural History of the Disease and the First Results of a New Surgical Technique.

AIM: To define the natural course of kyphosis, and to evaluate the efficiency of a new technique in surgical correction of kyphosis seen in myelomeningocele(MM) patients. MATERIAL AND METHODS: We retrospectively reviewed our patients with MM. The rate of kyphosis, mean angle of progression and mean angle of surgical correction were evaluated. Surgical correction was achieved with the same technique in all patients; kyphectomy, short segment instrumentation with plate system and long segment instrumentation with screw-rod system. RESULTS: A total of 14 patients were treated surgically and the mean age at the surgery was 39 months. The incidence of kyphosis rate was %21 in this study. The mean angle of kyphosis was 85.8°. Average angle of progression was 15.7° whereas it was 6.3° degree in patients whose kyphosis angle ?90 and > 90 degree, respectively, at birth. 14 patients were treated surgically and the mean age at the surgery was 39 months. The mean angle of correction of kyphosis was 86 degree. The most common complications were wound dehiscence and cerebro-spinal fluid leak. One patient died 3 months after surgery, and one patient was reoperated due to pull-out of screws. CONCLUSION: Effective surgical correction of kyphosis in MM patients can be achieved with the described surgical technique even in younger ages. Prospective studies in larger study population are necessary for more accurate definition of natural history of kyphosis in MM patients.

Pediatric Calvarial Tumors: 10 Years of Clinical Experience and Differences From the Literature.

ABSTRACT: Very few studies have focused exclusively on pediatric calvarial tumors. These studies have primarily addressed the similarities of the cases with those reported in the literature, as opposed to their distinctive features. In contrast, the present study is the most detailed study conducted in the last 10 years that includes only pediatric calvarial tumors and highlights their differences according to the literature. A total of 31 patients with pediatric calvarial tumor surgically treated in our center between 2010 and 2020 were included in the study. The patients' files were analyzed retrospectively and 17 different preoperative, intraoperative, and postoperative parameters were determined and compared with previous studies. Except for the tumors causing lytic or sclerotic lesions, there was at least one distinguishing aspect of our series in all parameters. Despite the many distinctive features, the consensus in the treatment of calvarial tumors is to perform complete resection of the tumor and, if possible, remove some of the adjacent healthy bone. Considering the age factor, however, closure of the resulting bone defects with cranioplasty to address issues of cosmesis and intracranial pressure is yet another aspect of pediatric calvarial tumors, because pediatric cranioplasty has its own specific complications. Using intraoperative neuronavigation and performing tumor resection alone without additional craniectomy are also methods the authors use to prevent major bone defects.

Corpus Callosum Lipomas in Children.

AIM: To determine the clinical and radiographical aspects of six patients diagnosed with pericallosal lipomas (PCL). MATERIAL AND METHODS: A retrospective analysis of patients who presented to the neurosurgery outpatient clinics of Selcuk Faculty of Medicine between 2009 and 2019, revealed that six patients were diagnosed with PCL. The clinical and magnetic resonance imaging (MRI) data were obtained by reviewing patients? records. RESULTS: A total of six patients (two girls and four boys), with a mean age of 53.8 months (38?72 months), were included in this study. They were followed up for a mean period of 36.5 months (32?41 months). PCL were detected on MRIs, which were obtained to investigate headache in two patients, epilepsy in one patient, frontal dermal sinus tract and left frontal epidermoid tumor in one patient, and subcutaneous lipoma associated with PCL in one patient. Five patients displayed tubulonodular lipomas and one patient displayed curvilinear lipomas. Agenesis or dysgenesis of the corpus callosum (CC) was observed in four (66%) patients. Two patients received surgical treatment for cosmetic skin problem. CONCLUSION: Because of the benign course of PCL, i.e. no growth or very slow growth, and close proximity to the surrounding neurovascular structures, surgical removal should be considered only in symptomatic PCL. Furthermore, other malformations and anomalies may accompany PCL.

Comparison of Immunogenetic Properties of Glial Tumors with Advanced Magnetic Resonance Imaging Findings.

AIM: To investigate the immunogenetic properties of glial tumors according to the World Health Organization 2016 glial tumor classification and develop an accurate diagnosis and treatment strategy by comparing preoperative advanced magnetic resonance (aMRI) technique findings of these results. MATERIAL AND METHODS: This study was conducted at the Department of Neurosurgery at the Medical Faculty Hospital of Selcuk University between January 1, 2010 and January 4, 2017 and included 50 patients. MR spectroscopy (MRS), MR perfusion (PWI), and MR diffusion (DWI) were performed in 50 patients preoperatively. Patient data were obtained from the hospital’s information system. Pathological diagnosis of all patients was taken from the department of pathology at the same medical faculty. RESULTS: Among the patients included in the study, 11 were grade II (22%), 7 were grade III (14%), and 32 were grade IV (64%). All patients were IDH1 stained: 22 were IDH mutant (44%) and 28 were IDH wild-type (56%). A statistically significant difference in the survival time was observed between IDH mutant and wild-type. IDH-mutant tumors were commonly located in the frontal lobe and IDH wild-type tumors in the parietal and temporal lobes. A significant difference in PWI relative cerebral blood volume (rCBV) and DWI apparent diffusion coefficients (ADC) was noted among grade II, III, and IV tumor groups. The PWI rCBV cut-off value for grade IV tumors was 2.05 (90% sensitivity, 78% specificity). No difference in the Cho/Cr ratio among grade II, III, and IV tumor groups was noted. A significant difference was noted between the IDH mutant and wild type in terms of PWI rCBV. The PWI rCBV cut-off value of IDH mutantâ€"wild type was 2.15. No difference in the Cho/Cr, Cho/NAA, and DWI apparent diffusion coefficients (p > 0.05) was noted between the IDH mutant and wild type. CONCLUSION: PWI rCBV is the most important prognostic value of aMRI used in tumor grading. PWI rCBV values could be significant in distinguishing IDH wild and mutant.

Intraventricular microcystic meningioma in a child: a case report.

BACKGROUND: Microcystic meningiomas are extra axial masses that are extremely rare in the pediatric population. Intraventricular meningiomas are also rarely seen. CASE PRESENTATION: This case reports an 18-year-old boy who had an intraventricular mass on magnetic resonance imaging at the age of 12 years and had shown growth at a 6-year follow-up after subtotal resection. The mass was removed by total resection and pathological examination indicated microcystic meningioma. CONCLUSION: The present case is the first pediatric intraventricular microcystic meningioma in the literature. We believe that this unique case presented with its radiological, pathological and clinical features will contribute to the literature.

Iliac Artery Injury During Lumbar Disc Hernia Surgery.

BACKGROUND: Vascular injury complications during lumbar discectomy are rare but potentially life-threatening. Therefore, an early diagnosis and effective treatment management is required for these complications. CASE DESCRIPTION: A 50-year-old female patient was admitted to our outpatient clinic with severe back and right leg pain. She underwent surgery for right L4-5 extruded disc herniation with general anesthesia. Sudden arterial hemorrhage occurred during discectomy performed with straight disc forceps and was controlled using hemostatic materials, with no significant decrease in blood pressure. However, the patient became hypotensive near the end of the operation. The incision was quickly closed, and she was turned to supine position. Emergency abdominal ultrasound, computed tomography, and computed tomography angiography revealed an injury of the left main iliac artery, which was repaired by endovascular stenting. Laparotomy and Bogota bag were applied because of increased intrabdominal pressure at 3 hours postoperative. In addition, a retroperitoneal catheter was placed into the area of the right retroperitoneal hematoma on the first postoperative day. Tissue plasminogen activator was administered through the catheter. On postoperative day 3, the Bogota bag was removed, and the abdomen was closed. The patient was discharged without neurodeficit on day 27. Her abdominal fascial defect was closed with a synthetic graft after 5 months. CONCLUSIONS: Although lumbar discectomy is one of the most commonly performed neurosurgical procedures, the routine rules of discectomy should not be neglected. Early detection and a multidisciplinary approach can help prevent mortality in the event of vascular injury.

Small Cell Lung Carcinoma Metastasis to Atypical Meningioma: Importance of Perfusion Magnetic Resonance Imaging Graphics in Differential Diagnosis.

We described the imaging findings of small cell lung carcinoma metastasis to atypical meningioma and the importance of magnetic resonance imaging perfusion graphics at the differential diagnosis. To be able to determine subtypes of meningiomas and differentiate whether they are malignant or benign may provide a preoperative idea to determine prognosis and surgical procedure.

Fluorodeoxyglucose positron emission tomography/computed tomography findings in a patient with cerebellar mutism after operation in posterior fossa.

Cerebellar mutism is a transient period of speechlessness that evolves after posterior fossa surgery in children. Although direct cerebellar and brain stem injury and supratentorial dysfunction have been implicated in the mediation of mutism, the pathophysiological mechanisms involved in the evolution of this kind of mutism remain unclear. Magnetic resonance imaging revealed dentatothalamocortical tract injuries and single photon emission computed tomography showed cerebellar and cerebral hypoperfusion in patients with cerebellar mutism. However, findings with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this group of patients have not been documented previously. In this clinical case, we report a patient who experienced cerebellar mutism after undergoing a posterior fossa surgery. Right cerebellar and left frontal lobe hypometabolism was shown using FDG PET/CT. The FDG metabolism of both the cerebellum and the frontal lobe returned to normal levels after the resolution of the mutism symptoms.

Intramedullary schwannoma of conus medullaris with syringomyelia.

Intramedullary schwannomas of the spinal cord are rare tumors. They are most commonly observed in the cervical region; however, few have been described in the conus medullaris. The association of intramedullary schwannomas with syringomyelia is also rare. In this report, we present a case of intramedullary schwannoma of the conus medullaris with syringomyelia, which was treated surgically.

The Effects of Electrocautery on Peripheral Nerve: An Experimental Study.

BACKGROUND The aim of this study was to assess the usability of an electrocautery device as nerve stimulator and to investigate histopathologically the adverse effects of electrocautery at low power on rat sciatic nerves. METHODS A total of 36 female Sprague-Dawley albino rats were divided into six groups according to the power applied to their sciatic nerves (1, 2, 3, 4, 5 and 6 W, respectively). Pathologic changes were studied by microscopic examination and scored (no change = 0, mild = 1, moderate = 2, severe = 3). Multiple comparisons were provided for all groups by the Bonferroni test (one-way analysis of variance). A p value < 0.05 was accepted as statistically significant. RESULTS The average scores were 2.66 ± 0.51, 3.66 ± 0.51, 5.83 ± 1.83, 10.0 ± 1.78, 11.0 ± 1.54, and 13.8 ± 0.89 in groups 1 to 6, respectively. Significant differences were found between all groups (p < 0.01), except between groups 1 and 2, groups 2 and 3, and groups 4 and 5 (p > 0.05) Variable motor responses and foot deformities were observed at the different power levels. CONCLUSION Although electrocautery devices provoke motor responses if getting in contact with peripheral nerves as do nerve stimulators, their use induces histopathologically adverse effects even at the lowest power. Their use around peripheral nerves should be avoided.

Solitary Metastasis of Renal Cell Carcinoma to the Third Ventricle Mimicking a Colloid Cyst: Case Report.

Colloid cysts are the most common third ventricle lesions and metastasis to this area is rare. We presented a case of solitary metastasis from a renal cell carcinoma to the third ventricle choroid plexus mimicking a colloid cyst. A 53-year-old man, who had a history of renal cell carcinoma 12 years ago, was operated for single third ventricle lesion and hydrocephalus via a transcallosal approach. Total removal could not be performed due to intraoperative massive bleeding. Histological examination revealed a metastatic renal cell carcinoma. The patient died on the postoperative 13th day because of bleeding from the residual tumor. Stereotactic radiosurgery and ventriculoperitoneal shunting might be favorable in such cases in order to avoid serious complications.

Intracranial giant tuberculoma mimicking brain tumor: a case report.

Tuberculomas are small tumor-like lumps that can be seen, usually in large numbers, in central nervous system involvement of tuberculosis. Giant tuberculomas that are big enough to cause symptoms of compression are also encountered, though rarely. When they are really large, tuberculomas may result in increased intracranial compression, neurologic deficits, or epileptic attacks. Giant tuberculomas may be confused with brain tumors on cranial magnetic resonance imaging. Cranial magnetic resonance imaging and histopathology examinations are used for diagnosis. Although magnetic resonance imaging is useful for diagnosing tuberculoma, histopathology examination is the gold standard for a final diagnosis. This paper presents a case involving a 66-year-old patient who complained of headache, imbalance and dizziness, and underwent an operation in the neurosurgery clinic with a pre-diagnosis of brain tumor, and was then diagnosed with intracranial giant tuberculoma.

Anterior transpedicular screw fixation of cervical spine: Is it safe? Morphological feasibility, technical properties, and accuracy of manual insertion.

OBJECT Due to lack of construct stability of the current anterior cervical approaches, supplemental posterior cervical approaches are frequently employed. The use of an anterior-only approach with anterior transpedicular screws (ATPSs) has been proposed as a means of providing 3-column fixation. This study was designed to investigate the feasibility of anterior transpedicular screw (ATPS) fixation of cervical spine, to obtain the morphological measurements for technical prerequisites, and to evaluate the accuracy of the ATPS using fluoroscopy. METHODS The study included both radiological and anatomical investigations. The radiological investigations were based on data from cervical spine CT scans performed in 65 patients. Technical prerequisites of ATPS were calculated using OsiriX for Mac OS. In the anatomical part of the study, 30 pedicles (C3-7) from 6 formalin-preserved cadavers were manually instrumented. Measurements obtained included pedicle width (PW), pedicle height (PH), pedicle transverse angle (PTA), distance of the entry point from the midline (DEPM), and distance of the entry point from the superior endplate (DEPSEP). The authors also analyzed screw position in the manually instrumented vertebrae. RESULTS The mean PW and PH values showed a tendency to increase from C-3 to C-7 in both males and females. The means were significantly larger for both PW and PH in males than in females at all levels (p = 0.001). The overall mean PTA value was significantly lower at C-7 (p < 0.0001). The mean value for the distance of entry point from the midline (DEPM) represented a point at the contralateral side of the pedicle for every level except C-7. The mean DEPSEP values showed significant differences between all levels (p < 0.0001). Seven of the 30 screws were identified as breaching the pedicle (23.3%); these screw malplacements were seen at C-3 (3 screws), C-4 (2 screws), and C-5 (2 screws). CONCLUSIONS The morphological measurements of this study demonstrated that ATPS fixation is feasible in selected cases. They indicate that ATPS insertion using a fluoroscopy-assisted pedicle axis view is safe at the C-6 and C-7 levels, but the results at the other levels did not prove the safety of this technique.

Simultaneous transsphenoidal and transventricular endoscopic approaches for giant pituitary adenoma with hydrocephalus.

The surgical management of giant pituitary adenomas is challenging. Although most pituitary adenomas, even those with suprasellar extension, can be resected using the transsphenoidal surgery alone, the transcranial approach is still needed for approximately 1% to 4% of these tumors. The transcranial approach is usually used in large adenomas with hourglass configuration and adenomas with firm consistency impeding the adjunctive measures, which are used for delivering the suprasellar part of the tumor into the sellar area and thereby obscure the tumor resection by transsphenoidal route. In this report, we describe the successful use of transventricular endoscope as an adjunctive measure to remove giant pituitary adenoma from transsphenoidal route and discuss the limitations of this new technique. We concluded that this technique would be used safely in selected cases. Case selection and surgical strategies should be based on preoperative magnetic resonance imaging findings, ventricular size, and the availability of experienced surgeons.

Resolution of papilledema after endoscopic third ventriculostomy versus cerebrospinal fluid shunting in hydrocephalus: a comparative study.

OBJECT: In this study the authors compare the efficacy of endoscopic third ventriculostomy (ETV) versus CSF shunting for resolution of papilledema in hydrocephalus. METHODS: This comparative case series study recruited 12 patients (24 eyes) with hydrocephalus who underwent either an ETV (Group 1, 6 patients [12 eyes]) or CSF shunt treatment (Group 2, 6 patients [12 eyes]). A complete ophthalmological examination including retinal nerve fiber layer (RNFL) evaluation by optical coherence tomography was provided for all patients before surgery and in the 1st week, 1st month, and 3rd month postoperatively. The 2 groups were compared for quantitative changes in RNFL thickness and, thereby, resolution of papilledema. Statistical evaluation was performed using the Mann-Whitney U-test with the aid of SPSS version 16.0. RESULTS: The mean preoperative RNFL thickness was 259.7 ± 35.8 µm in Group 1 and 244.5 ± 53.4 µm in Group 2 (p = 0.798). The mean decrease in RNFL thickness was 101.3 ± 38.8 µm, 141.2 ± 34.6 µm, and 162.0 ± 35.9 µm in Group 1 versus 97.0 ± 44.6 µm, 143 ± 45.6 µm, and 130.0 ± 59.8 µm in Group 2 for the postoperative 1st week, 1st month, and 3rd month, respectively. There was no significant difference between the two groups with respect to decrease in RNFL thickness during the 1st week, 1st month, and 3rd month (p = 0.563, p = 0.753, and p = 0.528, respectively). CONCLUSIONS: This is the first study to quantitatively evaluate papilledema in assessing the success of ETV and CSF shunting. The authors' results indicated that ETV is as effective as CSF shunting with respect to decreasing intracranial pressure and resolution of papilledema.

Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients.

BACKGROUND CONTEXT: We retrospectively analyzed a total of 1,218 pedicle screws for accuracy, with postoperative computed tomography (CT), in 198 patients who were operated on between March 2004 and September 2012. PURPOSE: To determine the incidence of screw misplacement in patients who received a transpedicular screw fixation, with intraoperative fluoroscopy in the lateral and lateral with anteroposterior (AP) positions. The results are compared between the two groups. STUDY DESIGN: Retrospective comparative study of accuracy of pedicle screw placement in thoracic and lumbar spine. PATIENT SAMPLE: The sample consists of 198 consecutive patients who underwent transpedicular screw fixation. OUTCOME MEASURES: Accuracy of screw placement was evaluated by postoperative CT scan. Misplacement was defined in cases where more than 25% of the screw size was residing outside the pedicle. METHODS: The indications for hardware placement, radiologic studies, patient demographics, and reoperation rates were recorded. Five hundred twenty-eight screws (Group A, n=81) were inserted into the vertebral body with the assistance of lateral fluoroscopy only, whereas 690 screws (Group B, n=117) were inserted with the assistance of lateral fluoroscopy, and the final positions of the screws were checked with AP fluoroscopy. RESULTS: A total of 1,218 screws were analyzed, with 962 screws placed at the lumbosacral region and 256 screws at the thoracic region. According to the postoperative CT scan, 27 screws (2.2%) were identified as breaching the pedicle. Nineteen of them (3.6%) were in Group A, whereas 8 (1.16%) were in Group B. The rate of pedicle breaches was significantly different between Group A and B (p=.0052). In Group A, the lateral violation of the pedicle was seen in 10 screws (1.9%), whereas medial violation was seen in 9 screws (1.7%). In Group B, the lateral violation of the pedicle was seen in six screws (0.87%), whereas medial violation was seen in two screws (0.29%). The medial and lateral penetration of screws were significantly different between Groups A and B (p<.05). A pedicle breach occurred in 21 patients, and 15 of them underwent a revision surgery to correct the misplaced screw. Of these patients, 11 (13.6%) were in Group A, and 4 (3.4%) were in Group B (p=.0335). CONCLUSIONS: In this study, we evaluated and clarified the diagnostic value of intraoperative fluoroscopy in both the lateral and AP imaging that have not yet been evaluated in any comparative study. We concluded that the intraoperative use of fluoroscopy, especially in the AP position, significantly decreases the risk of screw misplacement and the results are comparable with other advanced techniques.

Symptomatic pneumorrhachis.

Pneumorrhachis (PR) is the presence of air within the spinal canal, whether localized in the epidural or in the subarachnoid space. Evidence of intraspinal air, especially in the subarachnoid space, had been thought to be merely a radiological artifact of serious underlying pathology until it was proven that PRs can be related to neurologic symptoms ranging from radicular pain to serious neurologic deficits. The etiologies, pathomechanisms, and natural courses show differences from case to case, with the result that no consistent treatment strategies exist in the literature. Although the conservative treatment modalities seem to be more appropriate in nonsymptomatic cases, treatment strategies in symptomatic cases remain the subject of discussion. In this study, we present two symptomatic cases of PR arising from different causes and review the literature, focusing especially on the symptomatic cases and strategies for treating them.