The Effect of Halofuginone Use on Epidural Fibrosis After Spinal Surgery: An Animal Experiment.

AIM: To investigate the effectiveness of local halofuginone application for spinal epidural fibrosis (EF) after lumbar laminectomy in rats. MATERIAL AND METHODS: Forty rats were equally divided into four groups (Groups I-IV; 10 rats in each group), and lumbar laminectomy was performed under general anesthesia. After laminectomy, Group I received saline (NaCl 0.9%) locally (control), Group II received spongostan, Group III received 0.5 mL of halofuginone-impregnated spongostan, and Group IV received 0.5 mL of halofuginone. Spongostan was used to prolong the exposure period of halofuginone. All rats were sacrificed after four weeks and evaluated according to histopathological criteria. A p-value of < 0.05 was considered statistically significant. RESULTS: Fibrosis was significantly lower in Group IV than in Group I (p < 0.05). There was no significant difference in fibrosis between Group II/III and Group I. It was observed that spongostan increased fibrosis. CONCLUSION: Halofuginone helps prevent EF after spinal surgery. However, further clinical and experimental studies are needed to assess its safety in humans.

Full-Endoscopic Transforaminal Approach for Lumbar Discectomy.

With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and instruments, including a dilator, a beveled working sleeve, and an endoscope with a 20-degree angle and 177 mm length, equipped with a 9.3-diameter oval shaft and a 5.6 mm diameter working channel. Additionally, the procedure involves using a Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (5.4 mm), tip control radioablator applying a radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round. During the surgery, it is essential to identify significant landmarks, including the caudal pedicle, ascending facet, annulus fibrosis, posterior longitudinal ligament, and the exiting nerve root. The steps of the technique are relatively easy to follow, especially when utilizing the appropriate instruments and having a good understanding of the anatomy. Research studies have demonstrated comparable outcomes to open microdiscectomy techniques. ETALD presents itself as a safe option for lumbar discectomy, as it minimizes tissue disruption, results in low postoperative surgical site pain, and allows for early mobilization.

First case of Rhinocladiella mackenziei brain abscess in Turkey: Case report and review of the literature.

Rhinocladiella mackenziei is a highly neurotropic fungus, mainly reported from the Middle East. However, in recent years, there have been some cases from outside this region. We described an additional fatal case of R. mackenziei cerebral infection for the first time from Turkey and made a literature review of all previously reported cases. During 34 years (1988-2022), there have been 42 R. mackenziei brain abscess cases. Most patients have been reported from Saudi Arabia (n = 14, 33.3%). It is noteworthy that 40.5% of patients, including our case, were immunocompetent at initial diagnosis and mostly presented with a single lesion (n = 10, 23.8%). The most frequent comorbidities were solid organ transplant (n = 9, 21.4%), diabetes mellitus (n = 6, 14.3%), malignancy (n = 6, 14.3%) and prior surgery (n = 3, 7.1%). The most commonly used initial antifungal regimen were amphotericin B together with itraconazole (n = 9, 21.4%), combinations of lipid preparations of amphotericin B, voriconazole and/or posaconazole (n = 9, 21.4%) and amphotericin B alone (n = 8, 19%). Although both surgical procedures and antifungal medication in the majority of patients were performed, mortality rates remained high (90.4%). The area at risk of R. mackenziei cerebral abscess cases extends to other countries. Clinicians should be aware of this emerging disease and take a detailed travel history in patients with atypical and undocumented brain abscesses. Our case confirms the hypothesis that this fungus might spread more widely than previously predicted regions.

Pediatric Cerebral Cavernous Malformation: A Single-Centered Experience of 23 Cases.

AIM: To describe, and to evaluate the clinical and radiological characteristics of pediatric cavernous malformations (CMs) and the surgical approaches and their outcomes in a single center. MATERIAL AND METHODS: We retrospectively reviewed pediatric patients with CMs that were treated in our center between 2010 and 2020. Radiological, clinical, and demographic features, as well as treatment details were evaluated. RESULTS: Of 23 patients, 12 were male, and 11 were female. Two patients with multiple CMs had a family history. The most common symptoms were headaches (9/23, 39.1%) and seizures (9/23, 39.1%). Twenty patients had single lesions and three patients had multiple lesions. According to Zabramski classification, eight (34.7%) patients had type 1, 11 (47.8%) had type 2 and four (17.3%) had type 3 lesions. Thirteen patients had recurrent preoperative hemorrhages and nine had increased lesion size. Seven patients (30.4%) had coexisting deep venous anomalies in the CM vicinity. Twenty-one patients underwent microsurgical resection (5/23 simple lesionectomy, 16/23 lesionectomy + resection of the surrounding hemosiderin ring). All lesions were completely resected. No surgical mortalities or major complications occurred. CONCLUSION: Since pediatric CMs are more aggressive than adult CMs, they should not be underestimated. Microsurgical total resection should be the first treatment choice where possible. We concluded that early surgical treatment and resection of perilesional hemosiderin-stained tissue, when feasible, yield the most favorable results at long-term follow-up including seizure outcomes.

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment.

INTRODUCTION: Relatively constant surgical risks and rapid advances in endovascular treatment have caused a major shift toward endovascular management of posterior circulation aneurysms. This paper presents the results of a series of endovascularly treated posterior circulation aneurysms. METHODS: A total of 81 patients who underwent endovascular treatment of posterior circulation aneurysms performed by a single team between 2009 and 2019 were included. Demographic, clinical, radiologic, and management details were retrospectively obtained from hospital records. RESULTS: Among the included patients, 50 (61.7%) and 31 (38.3%) were female and male, respectively. Subarachnoid hemorrhage was observed in 30 patients (37%). Moreover, 40 (49.3%) aneurysms were treated with stent-assisted coiling, 1 (1.2%) aneurysm was treated with parent artery occlusion, 2 (2.4%) aneurysms were coiled using balloon assistance, 24 (29.6%) aneurysms were coiled primarily, 1 (1.2%) patient had an unsuccessful treatment attempt, and 13 (16.0%) aneurysms were treated with flow-diverter stents or stent monotherapy. During the last follow-up, 57 (83.8%) aneurysms were completely occluded, whereas 6 (8.8%) and 2 (2.9%) aneurysms did and did not have a residual neck, respectively. Flow diversion was used to treat 13 patients, among whom 8 had total occlusion or stable residue. A total of 7 deaths (8.6%) were encountered in this series. CONCLUSION: Endovascular treatment should be considered as the primary treatment modality for posterior circulation aneurysms. Despite the high morbidity and mortality rates, promising results can be achieved with correct patient selection. Flow diversion can be a feasible alternative for complex aneurysms that are difficult to treat.

Human-derived hair follicle stem cells and hydrogen sulfide on focal cerebral ischemia model: A comparative evaluation of radiologic, neurobehavioral and immunohistochemical results.

The present study investigated the effects of intracerebral human-derived hair follicle stem cells (HFBSCs), whether alone or in combination with hydrogen sulfide (H2S) in a rat model of focal cerebral ischemia. The rats were randomly assigned into 4 groups (n = 10): Control (phosphate buffered saline (PBS)), Group A (at 24 h post-middle cerebral artery occlusion(MCAo), stereotaxic intracerebral, 1,0 × 106, total 10 µL HFBSCs), Group B (3-14 d post-MCAo, intraperitoneal (i.p.), 25 µM/kg/day H2S), Group AB (HFBSCs + H2S). Cranial magnetic resonance images were recorded on postoperative 1st and 28th days. Three dimensional analysis was performed to calculate the infarct volumes. Rotarod and cylinder tests were performed after MCAo and finally all rats were euthanized by cardiac perfusion at 28 days after MCAo for immunohistochemical analysis. The reduction in infarct volumes of rats receiving HFBSC was significant. The cranial infarct volume on the postoperative 28th day was significantly higher in the group in which H2S was administered alone compared to the HFBSC alone group. All animals showed steadily improved spontaneous locomotor activity from day 7 post-MCAo on rotarod test, from day 1 on cylinder test, but showed no significant differences at all times. In all groups, the grading scores of CD34, CD5, CD11b and GFAP immunohistochemical markers did not differ significantly. In conclusion, intracerebral HFBSC treatment after 24 h of ischemic stroke may be an effective way to reduce the cranial infarct volume, whereas H2S treatment alone or in combination with HFBSC may not be sufficient for ischemic brain injury.

A Comparison of Subgaleal Active Drainage and Subdural Passive Drainage and an Analysis of Factors Affecting Chronic Subdural Hematoma Outcomes.

AIM: To analyze and to compare the factors that influence the recurrence of chronic subdural hematoma (CSDH) among patients treated with subdural non-suction-assisted passive drainage, subgaleal suction-assisted active drainage, and without drainage. MATERIAL AND METHODS: We retrospectively evaluated 87 surgical patients with a diagnosis of CSDH treated between 2007 and 2018 using patient records from the neurosurgery archive of our faculty. The patients were divided into three groups: drainfree group (group A), subdural passive drainage group (group B), and subgaleal active drainage group (group C). Recurrence was defined as an increase in hematoma volume on imaging and persistence of the patient?s symptoms. RESULTS: Patients with double-membrane CSDH exhibited higher recurrence rates (p=0.043) and those with low-density CSDH exhibited lower recurrence rates (p=0.015) compared to the other patients. No relationship was found between the number of burr holes made and CSDH recurrence (p=0.177). Group C showed the lowest recurrence rate (13.3%), but the differences between groups were not statistically significant. CONCLUSION: Hematoma density, membrane type, postoperative Glasgow Outcome Scale scores, and postoperative drainage time were found to be statistically significant predictors of recurrence. Burr-hole craniotomy with subgaleal active drainage is a safe and effective method for preventing CSDH recurrence and carries a reduced risk of parenchymal injury.

Analysis of the Prognosis of High-Grade gliomas in the View of New Immunohistochemistry Markers and 2016 WHO Classification.

AIM: To evaluate isocitrate dehydrogenase (IDH) mutation status and Ki67 percentages of tumors that were treated in our institution to determine whether these markers affected the initial diagnosis and survival rates. MATERIAL AND METHODS: High-grade glioma patients, who were operated in our department between 2013 and 2018, were enrolled in the study and retrospectively reviewed. New immunohistochemistry staining studies were conducted and survival analyses were performed. RESULTS: Of 135 patients and 136 tumors, 117 were glioblastoma multiforme (GBM), 8 were grade III-IV glioma, 4 were anaplastic astrocytoma and 7 were anaplastic oligodendroglioma. One patient had two different lesions, which were GBM and anaplastic astrocytoma respectively. Mean age was 55 (7-85) years, and 88 (65%) were male and 47 (35%) were female. The most common complaint was motor deficit (56%). Fourteen patients underwent reoperation due to recurrent disease. Tumors were most commonly found in the frontal lobe (53, 39%). Magnetic resonance imaging (MRI) features showed that existence of necrosis is strongly related to GBM (p < 0.01). Approximately 126 patients were found to be IDH-wildtype, which changed 6 patients? diagnosis to GBM, IDH wildtype from grade III-IV glioma. Five patients, who were diagnosed with anaplastic astrocytoma and anaplastic oligodendroglioma initially were found to be IDH wildtype. IDH mutation status, extend of resection, and age were found to affect survival. CONCLUSION: IDH mutation status is important in classifying high-grade gliomas, as well as its effects on prognosis. This mutation is related to several radiological features of tumors. Extent of resection and patient age are also profoundly affect survival. Detailing the diagnosis with molecular features will help physicians to shape targeted adjuvant therapies, which would better outcomes.

An Early Warning System Using Machine Learning for the Detection of Intracranial Hematomas in the Emergency Trauma Setting.

AIM: To present an early warning system (EWS) that employs a supervised machine learning algorithm for the rapid detection of extra-axial hematomas (EAHs) in an emergency trauma setting. MATERIAL AND METHODS: A total of 150 sets of cranial computed tomography (CT) scans were used in this study with a total of 11,025 images. Of the CTs, 75 were labeled as EAH, the remaining 75 were normal. A random forest algorithm was utilized for the detection of EAHs. The CTs were randomized into two groups: 100 samples for training of the algorithm (split evenly between EAH and normal cases), and 50 samples for testing. In the training phase, the algorithm scanned every CT slice separately for image features such as entropy, moment, and variance. If the algorithm determined an EAH on two or more images in a CT set, then the workflow produced an alert in the form of an email. RESULTS: Data from 50 patients (25 EAH and 25 controls) were used for testing the EWS. For all CTs with an EAH, an alert was produced, with a 0% false-negative rate. For 16% of the cases, the practitioner received an email from the EWS that the patient might have an EAH despite having a normal CT scan. Positive and negative predictive values were 86% and 100%, respectively. CONCLUSION: An EWS based on a machine learning algorithm is an efficient and inexpensive way of facilitating the work of emergency practitioners such as emergency physicians, neuroradiologists, and neurosurgeons.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality.

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

Versatile Use of Intraoperative Ultrasound Guidance for Brain Puncture.

BACKGROUND: Intraoperative ultrasound (iUS) is an effective guidance and imaging system commonly used in neuro-oncological surgery. Despite the versatility of iUS, its utility for single burr hole puncture guidance remains fairly underappreciated. OBJECTIVE: To highlight the simplicity, versatility, and effectiveness of iUS guidance in brain puncture by presenting the current case series and technical note collection. METHODS: We present 4 novel uses of iUS guidance for single burr hole brain puncture: cannulation of normal-sized ventricles, endoscopic third ventriculostomy (ETV) guidance, evacuation of interhemispheric empyema, and stereotactic biopsy assistance. RESULTS: All techniques were performed successfully in a total of 16 patients. Normal-sized ventricles were cannulated in 7 patients, among whom 5 underwent Ommaya reservoir placement and 2 underwent ventriculoperitoneal shunt placement for idiopathic intracranial hypertension. No more than 1 attempt was needed for cannulation. All ventricular tip positions were optimal as shown by postoperative imaging. iUS guidance was used in 5 ETV procedures. The working cannula was successfully introduced to the lateral ventricle, providing the optimal trajectory to the third ventricular floor in these cases. Interhemispheric subdural empyema was aspirated with iUS guidance in 1 patient. Volume reduction was clearly visible, allowing near-total evacuation of the empyema. iUS guidance was used for assistive purposes during stereotactic biopsy in 3 patients. No major perioperative complications were observed throughout this series. CONCLUSION: iUS is an effective and versatile guidance system that allows for real-time imaging and can be easily and safely employed for various brain puncture procedures.

Effects of different molecular subtypes and tumor biology on the prognosis of medulloblastoma.

PURPOSE: Medulloblastoma is one of the most common malignant brain tumors in the pediatric population. Recent studies identified four distinct medulloblastoma subgroups with different molecular alterations and pathways, and natural courses and outcomes. To evaluate the results of surgical and medical treatments of patients with medulloblastoma and compare them among the medulloblastoma subgroups. METHODS: The clinical and radiological features, medical and surgical management and treatment outcomes and their correlation with molecular subgroups of 58 patients treated for medulloblastoma in the last 20 years were evaluated. RESULTS: Fifty-eight patients, of whom 35 were male and 23 were female, were evaluated. The median age was 6 years (range, 1-19 years). The most common symptoms were nausea and vomiting (60%). Forty-three percent of the patients had headache and 40% had ataxia. Previous pathology reports revealed that 43 (74%), eight (14%), five (8%), and two (3%) had classic, desmoplastic, desmoplastic/nodular, and anaplastic morphologies, respectively. After the subgroup analyses, five patients (12%) were attributed to the wingless subgroup (WNT) group; 14 (32.5%), to the sonic hedgehog subgroup (SHH) group; and 24 (56%), to the non-WNT non-SHH group. On the basis of immunohistochemical analysis results, 15 patients could not be attributed to any subgroups. The clinical risk groups (average vs high-risk) and age at diagnosis (≥ 3 years vs < 3 years of age) were significant for 5-year event free survival (86% vs 43%, p:0.011 and 59% vs 36%, p:0.039). There was no significant difference in survival or event free survival according to molecular subtypes in this cohort. CONCLUSION: In corporation of molecular features to the clinicopathologic classification leads to risk-adapted treatment. Although the molecular subgroups did not affect outcome significantly in this study, more studies with larger numbers of patients are needed to understand the tumor pathophysiology of medulloblastoma and design the future medical practice.

A single-center experience of transsphenoidal endoscopic surgery for acromegaly in 73 patients: results and predictive factors for remission.

BACKGROUND: Transsphenoidal endoscopic surgery is the first-line treatment for growth hormone-secreting adenomas. OBJECTIVE: To analyse the results of the transsphenoidal endoscopic approach for acromegaly and to determine the predictive factors of remission. METHODS: A single-centre retrospective review was performed in patients who underwent endoscopic transsphenoidal surgery for acromegaly between January 2009 and January 2019. Demographic features, clinical presentation, histopathology records, complications and pre- and postoperative radiologic and endocrinological assessments were evaluated. The factors that influenced the remission rates were investigated. RESULTS: A total of 73 patients underwent surgery via the transsphenoidal endoscopic approach. Cavernous sinus invasion was detected in 32 patients (43.8%); and macroadenoma, in 57 (78%). The pathology specimens of the 27 patients (36.9%) showed dual-staining adenomas with prolactin. A total of 51 patients (69.8%) attained biochemical remission 1 year after surgery. A second operation was performed in 10 patients (13.6%) with residual tumours without biochemical remission in the first year. Six (60%) of the patients attained remission at the last follow-up. Transient diabetes insipidus was observed in 18 patients (24.6%); and rhinorrhoea, which was resolved with conservative treatment, in 4 (5.4%). None of the patients developed panhypopituitarism. The presence of cavernous sinus invasion and preoperative IGF-1, immediate postoperative GH and third-month IGF-1 levels were predictive of remission. CONCLUSION: Transsphenoidal endoscopic surgery is a safe and effective treatment for acromegaly. Reoperation should be considered in patients with residual tumours without remission.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival.

BACKGROUND: In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival. METHODS: Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated. RESULTS: Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006). CONCLUSIONS: Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

Gray-to-white matter ratio predicts long-term recovery potential of patients with aneurysmal subarachnoid hemorrhage.

Predicting recovery potential of patients with aneurysmal subarachnoid hemorrhage (aSAH) is challenging. We investigated whether the gray-to-white matter ratio (GWR) predicts recovery of cognitive function (CF) and quality of life (QOL) of these patients. We analyzed data of 69 patients with aSAH. Patients' demographics, comorbidities, and neurological status were recorded. One year after aSAH, Montreal Cognitive Assessment (MoCA) and Short Form-36 (SF-36) tests were administered to the patients, and brain volumes of patients were examined using MRI. Three years after aSAH, MoCA and SF-36 tests were conducted again. Differences between the test scores 1 and 3 years after aSAH were evaluated (ΔMoCA and ΔSF-36). Patients with ΔMoCA ≥ 4 points and those with ΔSF-36 ≥ 8 points were referred to as good MoCA and SF-36 recovery, respectively. ΔMoCA correlated with GWR in male and female patients (females: p < 0.001, R2 = 0.581; males: p < 0.001, R2 = 0.481). In female patients, GWR > 1.34 predicted good MoCA recovery with 82.3% sensitivity and 80% specificity, and in male patients, GWR > 1.36 predicted good MoCA recovery with 80% sensitivity and 95% specificity. ΔSF-36 correlated with GWR in male and female patients (females: p < 0.001, R2 = 0.479; males: p < 0.001, R2 = 0.627). In female patients, GWR > 1.35 predicted good SF-36 recovery with 74% sensitivity and 84% specificity, and in male patients, GWR > 1.38 predicted good SF-36 recovery with 72% sensitivity and 92% specificity. GWR is a good predictor of the recovery of CF and QOL in patients with aSAH and, thus, can help physicians to better organize rehabilitation of patients.

Transpulmonary thermodilution monitoring-guided hemodynamic management improves cognitive function in patients with aneurysmal subarachnoid hemorrhage: a prospective cohort comparison.

BACKGROUND: The effects of goal-directed hemodynamic management using transpulmonary thermodilution (TPT) monitor on the cognitive function of patients with aneurysmal subarachnoid hemorrhage (aSAH) remain unclear. The present study aimed to determine whether hemodynamic management with TPT monitor provides better cognitive function compared with standard hemodynamic management. METHODS: Patients with aSAH who were admitted to the intensive care unit in 2016 were assigned to cohort 1, and those admitted in 2017 were assigned to cohort 2. In cohort 1, hemodynamic and fluid management was performed in accordance with the traditional pressure-based hemodynamic parameters and clinical examination, whereas in cohort 2, it was performed in accordance with the TPT monitor-measured flow-based parameters. The incidence of delayed cerebral ischemia (DCI) and pulmonary edema (PE) was determined. The functional outcome of patients was assessed using the modified Rankin scale (mRS) score and Montreal cognitive assessment (MoCA) test at 1 year following aSAH. RESULTS: Cohort 1 included 45 patients and cohort 2 included 39 patients who completed the trial. The incidence of DCI (38% versus 26%) and PE (11% versus 3%) was comparable between the cohorts (p > 0.05). The mRS score was similar between the cohorts (p = 0.11). However, the MoCA score was 20.2 (19.2-21.4) and 23.5 (22.2-24.8) in cohort 1 and cohort 2, respectively (p < 0.001). Accordingly, the occurrence of poor MoCA score (38% versus 18%) was significantly lower in cohort 2 (p = 0.045). CONCLUSIONS: TPT monitor-based hemodynamic management provides better cognitive outcome than standard hemodynamic management in patients with aSAH.

Comparison of ability of pulse pressure variation to predict fluid responsiveness in prone and supine position: an observational study.

We aimed to compare the ability of pulse pressure variation (PPV) to predict fluid responsiveness in prone and supine positions and investigate effect of body mass index (BMI), intraabdominal pressure (IAP) and static respiratory compliance (CS) on PPV. A total of 88 patients undergoing neurosurgery were included. After standardized anesthesia induction, patients' PPV, stroke volume index (SVI), CS and IAP values were recorded in supine (T1) and prone (T2) positions and after fluid loading (T3). Also, PPV change percentage (PPVΔ%) between T2 and T1 times was calculated. Patients whose SVI increased more than 15% after the fluid loading were defined as volume responders. In 10 patients, PPVΔ% was ≤ - 20%. All of these patients had CST2 < 31 ml/cmH2O, seven had BMI > 30 kg/m2, and two had IAPT2 > 15 mmHg. In 16 patients, PPVΔ% was ≥ 20%. In these patients, 10 had CST2 < 31 ml/cmH2O, 10 had BMI > 30 kg/m2, and 12 had IAPT2 > 15 mmHg. Thirty-nine patients were volume responder. When all patients were examined for predicting fluid responsiveness, area under curves (AUC) of PPVT2 (0.790, 95%CI 0.690-0.870) was significantly lower than AUC of PPVT1 (0.937, 95%CI 0.878-0.997) with ROC analysis (p = 0.002). When patients whose CST2 was < 31 ml/cmH2O and whose BMI was > 30 kg/m2 were excluded from analysis separately, AUC of PPVT2 became similar to PPVT1. PPV in the prone can predict fluid responsiveness as good as PPV in the supine, only if BMI is < 30 kg/m2 and CS value at prone is > 31 ml/cmH2O.

Neurosurgical treatment of nonconvulsive status epilepticus due to focal cortical dysplasia.

We present a rare case of focal cortical dysplasia (FCD) and nonconvulsive status epilepticus (NCSE) treated successfully with early surgical intervention. Our case is a 9-year-old boy whose seizures, characterized by short episodes of loss of consciousness, appeared at the age of 7, and he showed progressive cognitive decline in the following years. NCSE was diagnosed, and his MRI revealed FCD in the left frontal region which was the same side as his EEG abnormality. Following lesionectomy, his NCSE disappeared and cognitive functions improved. Histopathologic analysis of the resected tissue revealed type-IIB FCD. This case illustrates the importance of early surgery to help restore cognitive functions by eliminating the clinical and electrophysiological features of NCSE.