Optimizing surgical approaches for anterior communicating artery aneurysms: Development and internal validation of a novel surgical scoring system.

BACKGROUND: The objective was to provide comprehensive preoperative information on both the aneurysm orientation and the side and method of surgical approach for optimal preoperative information and safe clipping using 3D imaging modalities. This was achieved by making an objective risk assessment on the surgical side/method and evaluating its effectiveness with internal validation. MATERIALS AND METHODS: Radiologic data of 61 ACoA aneurysm patients between 2012 and 2020 were retrospectively analyzed. A scoring system based on five criteria; ACoA aneurysm dome orientation, A1 symmetry/control, perforating artery control, A2 trace orientation, and A2 fork symmetry was developed. The system is designed to align with the most common surgical approaches in ACoA aneurysm surgery. The patients were categorized into three groups based on the scoring results to determine the most appropriate surgical method. Group I was recommended, Group II was less recommended, and Group III was least recommended. Internal validation was performed to assess the system's effectiveness. Outcomes and complication rates were statistically evaluated. RESULTS: When the scoring system was utilized, the mean score difference between the first group and the other groups was 2.71 and 4.62, respectively. There was a homogeneous distribution among the groups in terms of age, sex, WFNS, and Fisher scores. Complication occurred in three patients in Group I and nine patients each in Group II and Group III. The further the deviation from the first option, the higher the complication rate (p = 0.016), and a significant cause-effect relationship was identified (p = 0.021). The ROC curve established a cut-off value of 12.5 points for complications and outcomes. CONCLUSION: Our study introduces a new scoring system for ACoA aneurysms, enhancing the use of 3D CTA in daily practice and providing internal validation for the proposed approach. By evaluating objective criteria, this scoring system helps predict surgical risks, prevent complications, and supports personalized evaluation and selection of the surgical approach based on objective criteria.

Development of a comprehensive and clinically applicable novel projection classification system for anterior communicating artery aneurysms.

Various surgical and anatomical classifications have been proposed to date related to ACoA aneurysm projection. Nonetheless, a universally accepted classification system is yet to be established. This study is aimed at establishing a standardized classification system for ACoA aneurysms with utilization 3D technology and defining reference lines for their projections. The goal is to create a simple, understandable, surgically beneficial, and reliable classification system based on neurovascular structures in the region, including safe and hazardous zones. The radiologic data of 96 patients with ACoA aneurysm who were treated in our university hospital between 2012 and 2020 were retrospectively analyzed, and a planned classification scale was developed with the data obtained. The classification aimed to create 9 main projection groups in the sagittal plane: superior, inferior, anterior, and posterior in linear orientation, and anterosuperior, posterosuperior, anteroinferior, posteroinferior, and complex in quadrant orientation. The coronal and axial planes included medial, lateral, and midline classifications, resulting in a 3-dimensional classification system with 25 projections. Among the 96 patients, 32 had linear and 64 had quadrant projections. In the sagittal plane, the linear projection breakdown was as follows: superior (28%), inferior (6.25%), anterior (53%), and posterior (12.5%). For the quadrant projection, the distribution was as follows: anterosuperior (53%), posterosuperior (12.5%), anteroinferior (21.87%), posteroinferior (3.12%), and complex (9.37%). Overall, 35.4% aneurysms were anterosuperior, 17.7% anterior, 14.58% anteroinferior, 9.37% superior, 8.3% posterosuperior, 6.25% complex, 4.16% posterior, 2.08% posteroinferior, and 2.08% inferior projection. Our study proposes a projection classification that utilizes 3D technology for safe surgery based on neurovascular structures in the region and thus better reveals safe and hazardous zones, including three plans, three dimensions, and two orientations. The use of this classification system offers valuable guidance for daily practice in the treatment of ACoA aneurysms.

Effects of Expression of Matrix Metalloproteinases and Discoidin Domain Receptors in Ligamentum Flavum Fibrosis in Patients with Degenerative Lumbar Canal Stenosis.

STUDY DESIGN: This is a retrospective cohort study. PURPOSE: This study aimed to clarify the role of crosstalk between discoidin domain receptors (DDRs) and matrix metalloproteinases (MMPs) in the ligamentum flavum (LF) fibrosis obtained from patients with degenerative lumbar canal stenosis (DLCS). OVERVIEW OF LITERATURE: The DDRs, DDR1 and DDR2, are cell surface receptors and have an essential role in collagen fiber accumulation in several fibrotic diseases. MMPs are one of the critical factors in extracellular matrix remodeling and elastic fiber degradation in LF tissues. However, the crosstalk between DDRs and MMPs and the role of this molecular signal in LF fibrosis remain unclear. METHODS: A total of 35 patients were divided into two groups in this study. Spinal surgery was performed in 23 of these patients with the diagnosis of DLCS. Twelve patients with lumbar disk herniation (LDH) were included in the control group. On axial T2-weighted magnetic resonance imaging, LF thickness was measured bilaterally at the level of the facet joint. Histology, quantitative real-time polymerase chain reaction (qRT-PCR), and Western blot analyses were performed on LF tissue samples. LF tissues were stained with hematoxylin and eosin. In addition, the grade of fibrosis was histologically assessed using Masson trichrome triple staining. DDR1 and DDR2 Western blot analyses were performed. DDR1, DDR2, MMP2, MMP3, MMP9, and MMP13 expression levels were measured using qRT-PCR analysis. RESULTS: The grade of fibrosis and LF thickness were significantly higher in the DLCS patients than in the LDH patients. DDR1 and DDR2 gene expression and protein levels in LF tissues are significantly greater in DLCS samples than in control samples, according to both qRT-PCR and Western blot analyses. In addition, we detected a significant expression of the MMP3, MMP9, and MMP13, which are known to have important roles in extracellular matrix remodeling in DLCS. Furthermore, we discovered a link between DDR protein levels and LF thickness, fibrosis, and MMP3/MMP9. CONCLUSIONS: Our results indicate that DDR1, DDR2, and MMP3 and MMP9 signals can be correlated with each other in LF tissues and be promoted LF fibrosis leading to spinal canal narrowing in patients with DLCS.

Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma.

INTRODUCTION: The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition. METHODS: We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018. RESULTS: The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH. CONCLUSIONS: CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.

The effects of the early and ultra-early intervention on the outcome in aneurysmatic subarachnoid hemorrhage.

BACKGROUND: The optimal timing of intervention for aneurysmatic subarachnoid hemorrhage is one of the historically controversial issues in neurosurgery. Although numerous studies investigated the subject, they had many limitations due to the nature of the disease. Early and ultra-early interventions have gained more and more supporters in recent decades. Nevertheless, the effects of the early and ultra-early intervention on the outcome of the disease are far from clarity. METHODS: A single-center retrospective cohort study was carried out at Trakya University Medical Faculty Training and Practice Hospital. The study includes data on all patients admitted with an aneurysmal subarachnoid hemorrhage between January 1, 2001, and December 31, 2005. Patients were divided into two groups according to their WFNS grade status: Good (I-III) or poor (IV-V) grades. Patients are also classified according to their Glasgow Outcome Scale score: Unfavorable (1-2) or favorable (3-5) outcomes. Data were analyzed statistically, and the effects of the early and ultra-early intervention on the outcome were assessed. RESULTS: A total of 580 patients were admitted in the study period. Among them, 494 were eligible for the study. The median age (interquartile range) was 55 (18) years. While 244 (49.4%) patients were women, 250 (50.6%) patients were men. Three hundred and fourteen (63.6%) patients were operated, and 25 patients (5.1%) were undergone endovascular treatment. The ultra-early intervention was achieved in 60 (12.1%) patients and 142 patients (28.7%, including the previous ultra-early intervention group) early intervention was achieved. A meaningful outcome difference was present between the poor-grade ultra-early treatment group and the rest (p=0.007). Analogously, a meaningful outcome difference was present between the poor-grade early treatment group and the rest (p<0.001). CONCLUSION: This study supports the growing trend toward early or ultra-early intervention in aneurysmatic subarachnoid hemorrhage. Our findings showed that both early and ultra-early interventions have positive effects on the outcome in poor-grade aneurysmatic subarachnoid hemorrhage patients. Future studies with more homogenized and larger samples should be realized to clarify the optimal timing of intervention for aneurysmatic subarachnoid hemorrhage.

Effect of L-Arginine Therapy on Vasospasm: Experimental Study in Rats.

OBJECTIVE: Cerebral vasospasm occurring after subarachnoid hemorrhage is a serious cause of morbidity. Cerebral vasospasm-related studies aim to prevent complications after subarachnoid hemorrhage. Nitric oxide affects brain blood flow and local vascular hemodynamics. L-arginine is used in the synthesis of nitric oxide, and hence we have investigated the efficacy of L-arginine treatment by using femoral artery vasospasm model. METHODS: Twenty-four male Sprague-Dawley rats have been divided into 3 groups as vasospasm, vasospasm + L-arginine, and control. In this study, we have preferred the "Rat Femoral Artery Vasospasm Model" described by Okada et al. Rats in the vasospasm + L-arginine group were given 300 mg/kg L-arginine for 7 days. At the end of the study, all samples of rat femoral arteries have been dissected and examined microscopically for histopathologic analysis. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney U tests, and P < 0.05 value was considered statistically significant. RESULTS: L-arginine treatment reduced the morphometric changes such as irregularity of the elastic lamina, disruption of the endothelial cells, vacuolization, and hemorrhages that are caused by vasospasm. When the wall thickness and lumen diameter measurements were evaluated statistically, significant improvement was observed in the vasospasm + L-arginine group compared with the vasospasm group (P < 0.01). CONCLUSIONS: In our study, the use of L-arginine, as a nitric oxide substrate, improved the experimental vasospasm in rats. Therefore we think that L-arginine therapy can be used in the prevention and treatment of cerebral vasospasm after subarachnoid hemorrhage.

Symptomatic Bilateral Xanthogranuloma of the Choroid Plexus.

Xanthogranulomas (XGRs) of the choroid plexus are rare, asymptomatic, and benign lesions usually found incidentally. Here, we present a case of a 47-year-old male with bilateral XGR of the choroid plexus with periventricular edema and discuss our case in relation to a review of existing literature pertaining to the radiology of XGRs. To the best of our knowledge, this is the first reported case of bilateral trigonal XGR causing brain edema without ventricular dilatation. Despite the fact that they can cause hydrocephalus, XGRs are silent and benign lesions. Although the etiopathology of XGRs remains poorly understood, enhanced imaging analyses may provide additional information regarding edema and focal white matter signal changes.

The Histological Effects of Ozone Therapy on Sciatic Nerve Crush Injury in Rats.

OBJECTIVE: Peripheral nerve injury is a common, important problem that lacks a definitive, effective treatment. It can cause neurologic deficits ranging from paresthesia to paralysis. This study evaluated the effect of ozone therapy on sciatic nerve crush injury in rats. MATERIALS AND METHODS: Twenty-four male rats were divided into control sham surgery, sciatic nerve injury, and sciatic nerve injury with ozone groups (each n = 8). The sciatic nerve injury was inflicted via De Koning's crush-force method. The sciatic nerve injury group received medical air and the sciatic nerve injury ozone group received 0.7 mg/kg ozone. Sciatic nerve samples were obtained 4 weeks after injury. Vascular congestion, vacuolization, edema formation, S100 expression, and the thicknesses of the perineurium and endoneurium and diameter of the injured sciatic nerves were evaluated. RESULTS: The diameter of the sciatic nerve and thicknesses of the perineurium and epineurium were significantly greater in the sciatic nerve injury group (P < 0.05) and significantly less in the sciatic nerve injury with ozone group (P < 0.001). High S100 immunoreactivity was seen in the sciatic nerve injury group compared with the other 2 groups (P < 0.05). The distributions of vascular congestion and vacuolization were significantly less in the sciatic nerve injury with ozone group (P < 0.05). CONCLUSIONS: Ozone therapy improved sciatic nerve injury recovery without causing an increase in fibrotic tissue. Ozone reduced fibrosis, vascular congestion, vacuolization, and edema in rodents. Ozone treatment might be used to assist in sciatic nerve injury.

Effects of Ozone on Spinal Cord Recovery via the Wnt/ Β-Catenin Pathway Following Spinal Cord Injury in Rats.

AIM: At the cellular level, spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the spinal cord but may also contribute to its repair. Besides intracellular antioxydant increase after exactly estimated oxidative stress; oxygen formation and transport is also advanced by ozone. The Wnt family of proteins contributes to the development of the nervous system, influencing cell proliferation. In the present study we evaluated the effect of ozone on spinal cord injury in rats. MATERIAL AND METHODS: Twenty-one male Sprague-Dawley rats were used. The rats were randomly allocated into three groups (control, trauma and trauma+ozone). SCI was inflicted using Allen"s spinal cord trauma method. The study was performed to determine the effects of ozone therapy on rats with SCI in terms of locomotor strength clinically and neuronal injury, white matter cavitation, edema, number of blood vessels, and expression of ß-catenin immunohistochemically. RESULTS: Comparison of the locomotor strength scores revealed a significant improvement on day 7 in trauma+ozone group. The groups were compared with regard to edema, neuronal injury, and white matter cavitation. Average ß-catenin levels were significantly different between the control group (68.11 ± 0.43), trauma+ozone group (37.96 ± 2.16), and trauma group (25.46 ± 1.07) (F = 1677.74, df = 2, p < 0.0005). CONCLUSION: The results of this study indicated that ozone therapy accelerates the healing process, increases vascularity, and reduces neuronal damage in rodents, suggesting that ozone therapy may be an adjuvant treatment in patients with SCI.

Vascular Variations Associated with Intracranial Aneurysms.

AIM: To investigate the vascular variations in patients with intracranial aneurysm in circle of Willis. MATERIAL AND METHODS: We used the data on 128 consecutive intracranial aneurysm cases. Cerebral angiography images were analyzed retrospectively. Arteries were grouped as anterior cerebral arterial system (ACS), posterior cerebral arterial system (PCS) and middle cerebral arterial system (MCS) for grouping vascular variations. Lateralization, being single/multiple, gender; and also any connection with accompanying aneurysms" number, localization, dimension, whether bleeding/incidental aneurysm has been inspected. RESULTS: Variations were demonstrated in 57.8% of the cases. The most common variation was A1 variation (34.4%). The rate of variations was 36.7%, 24.2% and 10.2% respectively in ACS, PCS and MCS. MCS variations were significantly higher in males. Anterior communicating artery (ACoA) aneurysm observance rates were significantly higher and posterior communicating artery (PCoA) aneurysm and middle cerebral artery (MCA) aneurysm observance rates were significantly lower when compared to "no ACS variation detected" cases. In "PCS variation detected" cases, PCoA aneurysm observance rates and coexistence of multiple variations were significantly higher. CONCLUSION: The rate of vascular variations in patients with aneurysms was 57.8%. Arterial hypoplasia and aplasia were the most common variations. ACS was the most common region that variations were located in; they were mostly detected on the right side. Coexistence of ACoA aneurysm was higher than PCoA and MCA aneurysms. In the PCS variations group, PCoA aneurysms were the most common aneurysms that accompanying the variation and multiple variations were more common than in the other two groups. The variations in MCS were most common in males.

The Effect of Ozone Therapy on Experimental Vasospasm in the Rat Femoral Artery.

AIM: Oxidation products following subarachnoid hemorrhage (SAH) are among the causative substances of cerebral vasospasm and poor outcome. Ozone (O3) is a gas that contains three atoms of oxygen with a cyclic structure. It has been suggested that application of low-dose ozone has an antioxidant effect and provides resistance to oxidative stress. We investigated the effect of oxygen-ozone therapy on rat femoral artery vasospasm. MATERIAL AND METHODS: Twenty-four male Sprague-Dawley rats were randomly separated into vasospasm, vasospasm + ozone and control groups. The femoral artery vasospasm model was used. Rats in the vasospasm + ozone group were given 4 mL of ozone (20 µ/mL) daily for 7 days. Femoral arteries were examined by light microscopy for histological changes and morphometric analysis. Kruskal Wallis test and Mann Whitney U tests were used for the statistical analysis. The values of p < 0.01 and p < 0.05 were recognized as statistically significant. RESULTS: Ozone treatment reduced the morphometric changes as irregularity of the elastic lamina, disruption of the endothelial cells, vacuolization and hemorrhages that caused by vasospasm. The measurements of the wall thickness (p=0.003; p < 0.01) and lumen diameter (p=0.001; p < 0.01) showed statistically significant difference (p < 0.01) between the vasospasm and vasospasm+ozone groups. CONCLUSION: Ozone therapy may be useful in the treatment of post-hemorrhagic vasospasm.

Prognostic Factors in Patients who Underwent Aneurysmal Clipping due to Spontaneous Subarachnoid Hemorrhage.

AIM: Despite technical and medical advances, aneurysmal subarachnoid hemorrhages (SAH) continue to be a challenging pathology, associated with high rates of morbidity and mortality. In this regard, a definition is required of the various prognostic indicators of an SAH. The aim of the present retrospective study is to examine the various prognostic factors of the clinical outcomes of the patients who underwent a neurosurgical clipping of aneurysms due to aneurysmal SAH. MATERIAL AND METHODS: The data of 104 patients that had suffered an aneurysmal SAH were analyzed. The baseline demographic, clinical and radiological data were all analyzed. The prognostic study was derived from an analysis of these variables. Relationship between prognostic factors and outcome was evaluated by univariate and logistic multivariate regression analysis. RESULTS: This study has identified unfavorable outcomes on the Glasgow Outcome Scale at discharge after the surgical treatment of aneurysmal SAH associated with increased age, poor World Federation of Neurosurgical Societies (WFNS) grade on admission, higher Fisher's grade on admission computed tomography scan, larger aneurysm, and clinical vasospasm. In a multivariate logistic regression analysis, age, high WFNS grade, positive clinical vasospasm and size of aneurysm were found to be independent risk factors for mortality. The presence of hydrocephalus, number of aneurysms, positive risk factors, and the presence of Doppler vasospasm did not reach statistical significance. CONCLUSION: The most important prognostic factors in patients undergoing surgery due to aneurysmal subarachnoid hemorrhage were WFNS grade, age, size of aneurysm and clinical vasospasm.

Effects of hemostatic polysaccharide agent on epidural fibrosis formation after lumbar laminectomy in rats.

BACKGROUND CONTEXT: Epidural fibrosis is a common adverse outcome of spinal surgery that can compress the dural sac and nerve root. Local hemostatic agents have many indications in numerous types of spinal surgery. As these agents may behave as foreign bodies, inducing inflammation and delaying regeneration, they could enhance the risk of epidural fibrosis. PURPOSE: We evaluated the effects of hemostatic polysaccharide on epidural fibrosis development in laminectomized rats. STUDY DESIGN: This is a randomized controlled trial. OUTCOME MEASURES: One month after surgery, tissues were histopathologically examined. Spinal tissue surrounding the laminectomy site was cut with a microtome and stained with hematoxylin and eosin and Masson trichrome. Slides were evaluated by a pathologist in a blinded fashion. The extent of epidural fibrosis, fibroblast cell density, cartilage, and bone regeneration was evaluated. METHODS: Rats were randomly assigned to receive sham surgery, laminectomy, or laminectomy with hemostatic polysaccharide (seven rats per group). Sham surgery that consisted of a skin incision was performed without laminectomy. Laminectomy was performed at the L1 and L2 vertebrae. In the experimental group, the polysaccharide hemostatic material, HaemoCer was placed in the laminectomy area. RESULTS: The proportion of rats with epidural fibrosis in laminectomized mice (both with and without hemostatic material) was higher than in sham-operated rats (p<.01). There was no difference in fibrosis between the two groups of laminectomized rats (p>.05). CONCLUSIONS: Our study indicates that hemostatic polysaccharide does not enhance epidural fibrosis following laminectomy in rodents, suggesting that absorbable polysaccharides may be appropriate for use in hemostasis during spinal surgery.

Foramen Magnum Decompression and Duraplasty is Superior to Only Foramen Magnum Decompression in Chiari Malformation Type 1 Associated with Syringomyelia in Adults.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To compare surgical results of foramen magnum decompression with and without duraplasty in Chiari malformation type 1 (CM-1) associated syringomyelia (SM). OVERVIEW OF LITERATURE: The optimal surgical treatment of CM-1 associated with SM is unclear. METHODS: Twenty-five cases of CM-1 with SM were included. There were 12 patients (48%) in the non-duraplasty group and 13 patients (52%) in the duraplasty group. The rate of improvement, state of postoperative SM size, amount of tonsillar herniation, preoperative symptom duration, complications and reoperation rates were analysed. RESULTS: The rate of clinical improvement was significantly higher with duraplasty (84.6%) than without (33.3%, p <0.05). The rate of postoperative syrinx regression was significantly higher in the duraplasty group (84.6%) than in the non-duraplasty group (33.3%, p <0.05). One case in the duraplasty group needed a reoperation compared with five cases in the non-duraplasty group (p =0.059). CONCLUSIONS: Duraplasty is superior to non-duraplasty in CM-1 associated with SM despite a slightly higher complication rate.

Effects of the popular food additive sodium benzoate on neural tube development in the chicken embryo.

AIM: Many more additives have been introduced with the development of processed foods. Neural tube defects are congenital malformations of the central nervous system. More than 300 000 children are born with neural tube defects every year and surviving children remain disabled for life. Sodium benzoate is used intensively in our daily lives. We therefore aimed to evaluate the effects of sodium benzoate on neural tube defects in chicken embryos. MATERIAL AND METHODS: Fertile, specific pathogen-free eggs were used. The study was conducted on five groups. After 30 hours of incubation, the eggs were opened under 4x optical magnification. The embryonic disc was identified and sodium benzoate solution was injected. Eggs were closed with sterile adhesive strips and incubation was continued till the end of the 72nd hour. All eggs were then reopened and embryos were dissected from embryonic membranes and evaluated histopathologically. RESULTS: We found that the development of all embryos was consistent with the stage. We detected neural tube obstruction in one embryo. Neural tube defects were not detected in any embryos. CONCLUSION: This study showed that sodium benzoate as one of the widely used food preservatives has no effect to neural tube defect development in chicken embryos even at high doses.

Fourth Ventriculostomy in Occlusion of the Foramen of Magendie Associated with Chiari Malformation and Syringomyelia.

We present four cases of hydrocephalus caused by occlusion of foramen of Magendie associated with Chiari Type I malformation and syringomyelia. The aim of this study is to evaluate the results of surgical treatment via fourth ventriculostomy with catheter from the fourth ventricle to the upper cervical subarachnoid space. Obstructive tetraventricular hydrocephalus due to occlusion of the foramina of Luschka and Magendie can be treated with cerebrospinal fluid shunting, opening the membranes with suboccipital craniotomy, placement of a catheter, endoscopic third ventriculostomy, and endoscopic fourth ventriculostomy. Our aim was to solve all the pathologies such as Chiari malformation, hydrocephalus, and syringomyelia in one approach. Thus, the treatment consisted of posterior fossa decompression and exploration. All the patients were treated with suboccipital craniectomy and C1 laminectomy with excision of the membrane obstructing the foramen of Magendie. Fourth ventriculostomy with cathetering from fourth ventricle to upper cervical subarachnoid space was performed. The postoperative period was uneventful in all the patients. Neurological status of all the patients improved. Tetraventricular hydrocephalus and syrinx were reduced in the control cranial magnetic resonance imaging. Complications such as infection and catheter migration were not observed during the follow-up period. Treatment with fourth ventriculostomy using a catheter from fourth ventricle to upper cervical subarachnoid space could be a treatment of choice in cases with hydrocephalus caused by occlusion of the foramina of Magendie, with associated Chiari Type I malformation and syringomyelia.

Obstructive hydrocephalus due to vertebrobasilar dolichoectasia: diagnostic and therapeutic considerations.

BACKGROUND: Obstructive hydrocephalus caused by vertebrobasilar dolichoectasia is an extremely rare entity. Cerebrospinal fluid pathway obstruction may be localized at the level of either the foramina of Monro or the cerebral aqueduct. Radiological imaging can sometimes be misleading in establishing the precise location of the obstruction, which is crucial in determining the optimal surgical strategy. We report such a case with diagnostic challenges and also present a review of previously reported cases with a special focus on diagnostic and therapeutic controversies. CASE DESCRIPTION: We present a patient with an obstructive hydrocephalus associated with a dolichoectatic basilar artery extending to the level of the foramina of Monro. Although computed tomography angiography findings indicate bilateral occlusion of the foramina of Monro by the posterior cerebral arteries, mild but suspicious dilatation of the third ventricle raised concerns about the precise location of the obstruction. Endoscopic exploration of the right foramen of Monro was performed not only to clarify questionable radiological findings but also to be prepared to make a septostomy prior to monoventriculoperitoneal shunting if exploration would confirm occlusion of the foramina of Monro. However, the right foramen of Monro was documented to be patent during surgery and the cerebral aqueduct was considered to be the location of obstruction. The procedure was accomplished with monoventriculoperitoneal shunting, which achieved a full recovery immediately after the operation. CONCLUSIONS: Our current experience and the literature review highlight the usefulness of neuroendoscopy as a diagnostic and therapeutic solution, particularly in cases considered to have obstructive hydrocephalus caused by compression of the foramina of Monro by dolichoectatic basilar artery.

A primary orbital hydatid cyst.

Echinococcosis, caused by the tapeworm Echinococcus granulosus, is an endemic zoonosis in which humans act as accidental intermediate hosts. Orbital hydatid cysts comprise 1% to 2% of all hydatid lesions. We describe a 10-year-old boy with an orbital hydatid cyst. The orbital cyst was removed totally by frontal craniotomy and orbitotomy. It should be noted that unilateral painless proptosis in patients from countries endemic for echinococcosis could be caused by an orbital hydatid cyst.

Arachnoid granulations: a rare cause of lytic occipital bone lesion.

Arachnoid granulation is often found incidentally in the dural sinuses and skull. It may also enlarge the dural sinus or inner table of the skull. We report a 46-year-old woman who presented with occipital headaches and arachnoid granulations in both transverse sinuses and torcular herophili. Neurological examination was normal. Fundoscopic examination, visual fields and acuity were normal. The headache resolved with medical treatment. No intervention for these lesions was planned. The patient was followed up with magnetic resonance imaging studies.

Spinal dysraphisms of the cervicothoracic region in childhood.

PURPOSE: Spinal dysraphisms are the most common congenital anomalies of the CNS. Spinal dysraphism (SD) of cervical and upper thoracic region are rare, demonstrating distinct clinical and structural configurations compared to lumbar counterparts. METHODS: In Haydarpasa Numune Hospital, a total of 7 cases (3 male and 4 female) ranging between 20 days to 9 years of age with cervicothoracic SD were operated on between 2002 and 2008. The sacs were located in the cervical and thoracic region in 4 and 3 of the cases, respectively. The associated anomalies were diagnosed in 3 cases, including SCM type 2, Chiari type 2, hyrocephalus and hydromyelia. All cases underwent surgical treatment that involves excision of the sac and intradural exploration providing untethering of the spinal cord. Postoperative follow up of these patients was uneventful and neither neurological deficits nor complications were observed. CONCLUSION: Cervicothoracic SD has more favorable outcome in respect to neurological, orthopaedic and urologic problems compared to lumbar counterparts. In order to prevent forthcoming neurological deterioration, surgical treatment consisting of intradural exploration of the lesion, untethering of the spinal cord and excision of potential adhesions should be performed in the early period.