Prediction of Meningioma Grade Using Hematological Parameters.

OBJECTIVE: Predicting the aggressiveness of meningiomas may influence the surgical strategy timing. Because of the paucity of robust markers, the systemic immune-inflammation (SII) index is a novel biomarker to be an independent predictor of poor prognosis in various cancers including gliomas. We aimed to investigate the value of SII as well as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) indices in predicting prognosis. METHODS: Records including demographic, clinical, and laboratory data of patients operated on due to intracranial meningioma in 2017-2023 were retrospectively reviewed. RESULTS: A total of 234 patients were included in this study. All of SII index, NLR, and PLR values at presentation were significantly higher in grade ≥2 meningiomas. A positive correlation was observed between SII index and Ki67 index (r=0.313; P<0.001); between NLR and Ki67 index (r=0.330; P<0.001); and between PLR and Ki67 index (r=0.223; P<0.01). SII index (optimal cutoff level >618), NLR (optimal cutoff level >3.53), and PLR (optimal cutoff level >121.2) showed significant predictive values. CONCLUSIONS: This is the first study to assess the prognostic value of the SII index in patients with intracranial meningiomas. Increased SII index, NLR and PLR were correlated with higher grade and higher Ki-67 index. They also harbor the potential to screen patients that may need more aggressive treatments or more frequent follow-up examinations.

Does the Extent of Rod Bending and Actual Lumbar Lordosis Mismatch Affect Quality of Life?

BACKGROUND: To evaluate any mismatch between rod bending and actual lordosis during posterior lumbar instrumentation and its effects on the quality of life (QOL) of patients. METHODS: Patient records for posterior lumbar fusion in 2018-2023 were retrospectively reviewed. The radiologic parameters consisted of pelvic incidence, sacral slope, L1S1 lumbar lordosis, lumbosacral angle, the distance between the posterior wall of the vertebra and the rod, lordosis of the rod. The postoperative QOL of patients was assessed using Oswestry Disability Index. The patients were grouped postoperative into Group-1 (minimal/moderate disability) and Group-2 (severe disability/crippled/bed bound). RESULTS: Total of 133 patients were included; 99 women, 34 men. The difference was significant for patients with diabetes to be presented in the more disabled Group-2. The distance between the posterior vertebral wall and the rod was found to be short in Group-2. Preoperative and postoperative sagittal lumbar Cobb angles were significantly higher in Group-2. The changing degree of pain was found to score high in Group-2. The postoperative visual analog scale was high in Group-2. The difference between the preoperative and postoperative lumbar sagittal Cobb and rod Cobb-angles was found to be high in Group-2. CONCLUSIONS: The results of our study confirm the importance of considering the preoperative actual lumbar lordosis during bending and maintaining it as much as possible. To our knowledge, this is the first study that evaluated the effect of rod bending on quality of life (QOL) and supports that this might be affected in case of any mismatches.

Significance of O6-methyl guanine methyltransferase promoter methylation in high grade glioma patients: optimal cutoff point, CpG locus, and genetic assay.

PURPOSE: To evaluate O6-methyl guanine methyltransferase (MGMT) promoter methylation status in high grade glioma patients and to identify the best cutoff point as well as the most predictive CpG loci for patients survival. METHOD: Consecutive high grade glioma patients treated with surgical gross total resection followed by concomitant radiochemotherapy and adjuvant chemotherapy were included in this retrospective observational study. Methylation status of MGMT promoter CpG island of resected tumor tissue were evaluated using next generation sequencing assay. The outcomes were grouped as CpG 70-78, CpG 79-83, CpG 84-87, CpG 70-87, and whole promoter. Quantitative analyses were dichotomized as methylated or unmethylated based on the cutoff points set to %10, and methylation was further graded as <%10 unmethylated, %10-30 low-methylated, and %30-100 high-methylated. RESULTS: Total of 95 patients with the mean age of 51.50 ± 12.36 years were included in the study. Overall survival (OS) and progression free survival (PFS) were 14.53 ± 1.92 (95% CI 10.77-18.30) and 10.90 ± 2.05 (95% CI 6.89-14.92) months, respectively. MGMT promoter was methylated in 38.2% of cases and high-methylated in 10.5% of cases. Methylation status of MGMT promoter was recognized as a very powerful predictor of OS and PFS. In particular, high-methylation of CpG 79-83 and CpG 84-87 islands at promoter region were strongly associated with better survival outcomes (p < 0.05). CONCLUSION: Our outcomes support the prognostic value of MGMT promoter methylation in patients with high grade glioma. Sequencing of whole promoter CpG islands demonstrated that methylation of particular CpG sites might predict clinical outcomes more precisely.

Impact of Post-Master PhD Degree on Publication Productivity in Neurosurgery.

AIM: To evaluate the impact of the post-master PhD degree on publication productivity in neurosurgery. MATERIAL AND METHODS: An online national electronic survey was designed based on the recent literature and factors related to publication productivity. The survey was conducted to simply evaluate main bibliometrics of the participants consisting of neurosurgeons in different stages of their career. The survey was distributed via email to all Turkish Neurosurgical Society members. RESULTS: A total of 220 neurosurgeons participated and answered the survey. Neurosurgeons that had published their Master's dissertation were found to have significantly higher number of published articles, citations and Hirsch (h)-index during their career (p < 0.001). Neurosurgeons with a PhD degree who have been involved in such program were found to have significantly higher number of published articles and h-index (p < 0.01). A majority of neurosurgeons who were involved in a PhD program were found to work in university hospitals (41.5%) and research and training hospitals (26.8%). Clinical anatomy, neuroscience, and molecular/ genetic biology were the most common PhD programs. CONCLUSION: Standardization in measurability of scientific productivity is mandatory to maintain stability and move further in academic activity. PhD programs have a significant contribution to academic performance and scientific productivity. Surgical residents and young neurosurgeons should be encouraged to be involved in such PhD training programs to promote success in both neurosurgery and scientific arenas.

Posterior fossa epidermoid tumors: a single-center study and proposed classification system.

BACKGROUND: Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates. METHODS: The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients' data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical-radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes. RESULTS: The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological-anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup 'a' was correlated with higher resection rates (GTR and NTR), whereas the subgroup 'b' was correlated with STR. CONCLUSIONS: Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.

IL-33 induces ADAMTS5 expression and cell migration in glioblastoma multiforme.

Glioblastoma multiforme (GBM), characterized by a high rate of proliferation and migration capacity, is an incurable brain tumor in adults. Interleukin-33 (IL-33), a member of the IL-1 cytokine superfamily, and a disintegrin and metalloproteinase with thrombospondin motifs 5 (ADAMTS5), a family of zinc dependent metalloproteinases, are known to have essential roles in GBM migration and invasion. Previous studies have separately revealed elevated expressions of IL-33 and ADAMTS5 in GBM; however, the interaction between IL-33 and ADAMTS5 in GBM remains unclear. Here, using publically available GlioVis and GEPIA programs, we showed that mRNA expressions of IL-33 and ADAMTS5 are significantly high in GBM cells, and a positive correlation between IL-33 and ADAMTS5 was also determined in these cells. In parallel with the mRNA data of IL-33 and ADAMTS5, by Western blot analysis, protein levels were found to be elevated in GBM tissues and increased gradually with the disease progression. Primary GBM cells and low-grade glioma cells were then treated with IL-33 to examine its stimulating effect on ADAMTS5 expression. Exposure to IL-33 raised ADAMTS5 protein levels in a dose-dependent manner. Finally, the wound-healing method was performed to confirm the impact of IL-33 on migration in primary GBM cells. IL-33 promoted migration of primary GBM cells three times higher than untreated GBM cells. Thus, the current study suggests for the first time that IL-33 might have a role in playing a part in GBM progression through induction of ADAMTS5 expression and promotion of migration in GBM cells.

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. METHODS: After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked by performing the Valsalva maneuver at the end of the surgery. RESULTS: No CSF leakages were observed after surgery. CONCLUSIONS: Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might be effective in cases with untraumatized arachnoid membrane.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

OBJECTIVE: In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. METHODS: Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. RESULTS: Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure. CONCLUSIONS: Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.

Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern.

BACKGROUND: Approaching ambient cistern lesions is still a challenge because of deep location and related white matter tracts (WMTs) and neural structures. OBJECTIVE: To investigate the white matter anatomy in the course of 3 types of transtemporal-transchoroidal fissure approaches (TTcFA) to ambient cistern by using fiber dissection technique with translumination and magnetic resonance imaging fiber tractography. METHODS: Eight formalin-fixed cerebral hemispheres were dissected on surgical corridor from the temporal cortex to the ambient cistern by using Klingler's method. The trans-middle temporal gyrus, trans-inferior temporal sulcus (TITS), and trans-inferior temporal gyrus (TITG) approaches were evaluated. WMTs that were identified during dissection were then reconstructed on the Human Connectome Project 1021 individual template for validation. RESULTS: The trans-middle gyrus approach interrupted the U fibers, arcuate fasciculus (AF), the ventral segment of inferior frontoocipital fasciculus (IFOF), the temporal extensions of the anterior commissure (AC) posterior crura, the tapetum (Tp) fibers, and the anterior loop of the optic radiation (OR). The TITS approach interrupted U fibers, inferior longitudinal fasciculus (ILF), IFOF, and OR. The TITG approach interrupted the U fibers, ILF, and OR. The middle longitudinal fasciculus, ILF, and uncinate fasciculus (UF) were not interrupted in the trans-middle gyrus approach and the AF, UF, AC, and Tp fibers were not interrupted in the TITS/gyrus approaches. CONCLUSION: Surgical planning of the ambient cistern lesions requires detailed knowledge about WMTs. Fiber dissection and tractography techniques improve the orientation during surgery and may help decrease surgical complications.

Anterior Subcutaneous Transposition With Expanded Polytetrafluoroethylene (ASTEP) for Cubital Tunnel Syndrome: Technical Note.

BACKGROUND: Ulnar nerve entrapment neuropathy at the elbow is the most common upper-extremity entrapment neuropathy after carpal tunnel syndrome. Surgical treatment can be complicated by perineural scarring and fibrosis, which may lead to recurrent symptoms. Expanded polytetrafluoroethylene (ePTFE) is a synthetic polymer with antiadhesive properties. OBJECTIVE: To introduce the operative technique and outcomes of anterior subcutaneous transposition with ePTFE (ASTEP) in primary and recurrent cubital tunnel neuropathy. METHODS: We studied 14 adult patients (11 men, 3 women; mean age, 45 yr) with cubital tunnel neuropathy (10 primary, 4 revision) who underwent surgery with the ASTEP technique between January 2008 and May 2018. Pain, numbness in the fourth/fifth fingers, and weakness of the intrinsic hand muscles were the most common presenting symptoms. Surgical outcomes were assessed using the modified McGowan and Wilson-Krout criteria. RESULTS: The average (± standard deviation) preoperative symptom duration was 12.1 ± 5.2 mo (McGowan Grade 1, n = 5; Grade 2, n = 6; Grade 3, n = 3). No intraoperative or postoperative complications were observed with the ASTEP technique. Postoperative follow-up ranged from 9 mo to 7 yr (mean, 4.3 yr). All 14 patients experienced improvement in or complete resolution of their symptoms after this unique intervention. CONCLUSION: Our novel technique of anterior transposition of the ulnar nerve with ePTFE was safe and highly effective in treating primary and recurrent ulnar nerve entrapment neuropathy at the elbow and represents an alternative to the current techniques.

Microsurgical Management of Ventral Intradural-Extramedullary Cervical Meningiomas: Technical Considerations and Outcomes.

OBJECTIVE: Cervical meningiomas are uncommon intradural-extramedullary tumors that have a tendency to be situated anterior to the spinal cord. The optimal surgical corridor to reach purely ventral cervical meningiomas has not been established. This article presents a series of patients with ventral cervical meningiomas treated via 1 of 2 microneurosurgical approaches: the anterior approach with corpectomy and fusion or the posterolateral approach. METHODS: Eight patients who underwent surgical resection of solitary, histopathologically confirmed, intradural-extramedullary cervical meningiomas of purely ventral location were retrospectively examined. Preoperative and postoperative Nurick scores quantified the degree of ambulatory function. Patients were followed for an average of 2.1 years after surgery. Postoperative imaging was performed to determine the extent of resection and to assess for tumor recurrence. RESULTS: Two patients with lower cervical meningiomas underwent resection via an anterior approach with single-level corpectomy and fusion. Six patients were treated via a posterolateral approach including ipsilateral hemilaminectomy and partial facetectomy without fusion. No intraoperative or postoperative complications were observed. Gross total resection was achieved in 8 of 8 patients, although 1 patient exhibited tumor recurrence. Improvement in ambulatory function was observed in all patients. CONCLUSIONS: Purely ventral cervical meningiomas are uncommon and pose unique technical challenges for neurosurgeons. We document favorable outcomes from 2 cases of lower cervical meningioma treated via an anterior approach and 6 cases of upper cervical tumors treated via a posterolateral approach. This series demonstrates operative considerations for effectively managing ventral cervical meningiomas.

Supraorbital Keyhole Approach: Lessons Learned from 106 Operative Cases.

OBJECTIVE: The supraorbital keyhole approach through an eyebrow incision has been a potentially less invasive approach as an alternative to the standard pterional craniotomy. We aimed to review procedures for anterior and middle cranial fossa lesions and identify lessons learned from addressing various pathologies through this approach. METHODS: We retrospectively reviewed 106 consecutive patients who underwent this approach. We documented patients' age, sex, pathology, clinical results, extent of tumor resection, complications, use of endoscope, and cosmetic results. RESULTS: Our series addressed a variety of pathologies. Male patients accounted for 55% of the cohort and mean age was 51.7 (2-79) years. Notably, 52% of patients underwent resection of extra-axial masses. Gross total resection was achieved in 74.4% of intra-axial lesions according to postoperative imaging. Two (1.9%) patients developed transient ptosis. One (0.9%) patient developed an allergic reaction to titanium. No cerebrospinal fluid fistula or rhinorrhea occurred. Three patients developed temporary diabetes insipidus after resection of parasellar lesions (2 craniopharyngiomas and 1 pituitary adenoma). In 14 patients with olfactory groove meningiomas, 6 (42.8%) suffered from absence or diminished olfaction postoperatively, and 2 (14.2%) developed postoperative anosmia. Five (38.5%) patients underwent a subsequent resection of recurrent glial tumors. Four weeks postoperatively, 95% of patients demonstrated acceptable cosmetic results. Cosmetic results for 6 (5%) patients were unavailable. CONCLUSIONS: The supraorbital keyhole approach may be safely used for various lesions within the anterior and middle cranial fossa. The effectiveness and limitations of this approach and possible complications are discussed. This is a valuable approach for selected patients.

Surgical Management of Spinal Arachnoid Cysts in Adults.

BACKGROUND: Spinal arachnoid cysts (SACs) are uncommon lesions in the spinal canal. They are usually asymptomatic, but can occasionally cause mass effect leading to neurologic symptoms. They can be congenital or secondary to a variety of causes. They can produce a variety of neurologic symptoms including pain, weakness, sensory changes, incontinence, and more. Surgical intervention may be necessary when SACs cause symptomatic mass effect. METHODS: Thirteen consecutive patients who underwent surgical intervention for an SAC were retrospectively reviewed. The data included presenting symptoms, imaging findings, neurologic status, and follow-up. RESULTS: Of the 13 patients, the majority of cases were located in the thoracic spine (54%) and all but one case were located dorsally or dorsolaterally. Furthermore, 38% were located extradurally and 54% were located intradurally. Pain (80%) was the most common presenting symptom. Most patients had improvement or complete resolution of their symptoms after intervention. Extradural SACs and their capsules were completely resected, whereas intradural SACs underwent fenestration. No complications occurred in this series. CONCLUSIONS: SACs are usually asymptomatic, but rarely cause mass effect and neurologic deficits requiring surgical intervention. Surgical intervention is tailored to the position of the cysts' dorsal or ventral locations. Pain and weakness are the most likely symptoms to improve, whereas sensory symptoms are least likely to improve.

Structure of corona radiata and tapetum fibers in ventricular surgery.

In this study the three-dimensional anatomy of the corona radiata and tapetum via the fiber dissection and diffusion tensor imaging of the brain for ventricular surgery was demonstrated. Ten formalin-fixed cerebral hemispheres were dissected for corona radiata and tapetum via Klingler's fiber dissection method under an operating microscope. The corona radiata and tapetum were dissected through lateral and medial surfaces of the cerebral hemisphere, respectively. All surgical routes for ventricular lesions were evaluated for white matter fibers during and after dissections. Corona radiata and tapetum fibers were demonstrated by dissecting hemispheres through lateral and medial aspects of the brain. The internal capsule contains all fibers that extend from thalamus to cortex and cortex to thalamus, brainstem, and spinal cord. These fan-shaped fibers extending from cortex to internal capsule were named the corona radiata. The corona radiata is not a specific pathway, and it is composed of several different fiber pathways. The tapetum contains splenium and body fibers of the corpus callosum. Tapetum is located immediately medial to the ependymal line of the ventricular wall and forms a fiber layer in the medial optical radiation on the coronal and axial sections. Surgical planning for ventricular lesions requires detailed information regarding white matter fibers that can be obtained by the fiber dissection and diffusion tensor imaging of the brain to decrease surgical complications.

Is a Unilateral Surgical Approach Effective in Patients with Bilateral Leg Pain with Unilateral Lumbar Disc Herniation? A Prospective Nonrandomized Clinical and Surgical Study.

OBJECTIVE: To examine the surgical results of unilateral lumbar discectomy in patients with bilateral leg pain and discuss short- and long-term outcomes within the limits of lumbar decompression. METHODS: We analyzed 60 patients with unilateral disc herniation who underwent unilateral lumbar discectomy and hemipartial laminectomy between 2014 and 2017. Group 1 (30 patients) had bilateral leg pain and unilateral lumbar disc herniation. Pain lateralization was determined radiologically. Group 2 (30 patients) had unilateral leg pain and unilateral lumbar disc herniation. Pain scores were preoperatively evaluated with visual analog scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. In both groups, surgery was performed on the ipsilateral side of the herniated disc. Scores were repeated on postoperative day 1 and 1, 3, 6, 12, and 24 months later. VAS score differences for pain lateralization and disc levels were compared in group 1. ODI score differences were compared between both groups. Results were statistically analyzed. RESULTS: VAS score differences were statistically significant at all follow-up time points in patients with ipsilateral and contralateral pain. VAS score differences between L4-L5 and L5-S1 level discopathies were statistically insignificant for all time points in both groups. All postoperative ODI score decreases for all time points were statistically significant (P < 0.001) for both groups, whereas the differences between groups 1 and 2 were statistically insignificant. CONCLUSIONS: Conventional lumbar disc surgery alone is sufficient for the ipsilateral side of radiologically demonstrated disc herniation in patients with bilateral leg pain.

Pure Robotic Surgery for Odontoid Tumor: First Case.

BACKGROUND: Transoral robotic surgery has been used successfully to assist many surgical procedures. Here, we report its first use as pure robotic surgery, applied to excise an odontoid metastatic mass. CASE DESCRIPTION: A 48-year-old woman was hospitalized due to a lesion consistent with metastasis that extended to the pharyngeal constrictor muscles and that had completely destroyed the odontoid bone. Occipitocervical fixation was performed initially, and transoral surgery took place 5 days later. The da Vinci Surgical System Robot was used to resect the tumor. The patient was discharged with a very good general condition. CONCLUSIONS: This article presents the first pure robotic surgery for odontoid. The increasing number of robot-assisted cases will demonstrate the necessity of this evolution in neurosurgery and should accelerate the process.

Subcutaneous Schwannoma in the Head Region.

Schwannoma is a benign neural tumor derived from Schwann cells surrounding the nerves. It occurs primarily in subcutaneous tissues and muscles with a tendency for distal extremities, head, and neck area. Treatment of schwannoma is surgical excision. Lipomas are the most common soft-tissue lesions. A case is presented to increase awareness on differential diagnosis of head and neck subcutaneous masses.

Surgical Management of Supratentorial Intracerebral Hemorrhages: Endoscopic Versus Open Surgery.

OBJECTIVE: Intracerebral hemorrhage continues to be a major global problem. No standard treatment or surgical procedure has been identified for intracerebral hemorrhages. High morbidity and mortality rates caused by conventional approaches and the disease itself have necessitated more-invasive treatment methods. The endoscopic approach is a more minimally invasive method than craniotomy, which is another alternative surgical treatment. METHODS: We compared intracerebral hematoma drainage in 2 groups of 17 patients each, treated with minimally invasive endoscopic method versus craniotomy. All the patients were treated for supratentorial spontaneous hemorrhage between December 2013 and February 2017 at the Neurosurgery Clinic of Ankara University Faculty of Medicine. RESULTS: We retrospectively evaluated 34 patients surgically treated between December 2013 and February 2017. All patients underwent surgery within the first 24 hours. Patients in the early surgery group had better surgical outcomes. In the neuroendoscopic group, Glasgow Coma Scale increased from 6 to 11 at 1 week postoperatively compared with 5 to 9 in the craniotomy group. CONCLUSIONS: Minimally invasive endoscopic hematoma evacuation may be a good alternative surgical method for treating supratentorial spontaneous cerebral hematomas.

Preoperative Exposure of Sigmoid Sinus Trajectory in Posterolateral Cranial Base Approaches Using a New Landmark Through a Neurosurgical Perspective.

The location of burr holes in posterolateral cranial base approaches should be appropriate to provide an adequate operative field, and surgical freedom is crucial for bone window opening. The aim of this study was to search for more convenient and easily detectable landmarks in comparison with current landmarks in posterolateral cranial base surgery. Twenty 3-dimensional reconstructed head and neck computed tomography angiography images (group 1) and 20 cadaver heads (group 2) were evaluated. An imaginary line connecting the angle of the mandible and the mastoid tip was extended upward. A second line passing through the lateral edge of the zygomatic arch was also extended posteriorly. The authors examined if the first line met with the sigmoid sinus throughout its course and determined the location of the intersection point of these 2 lines relative to the sigmoid-transverse sinus junction. The intersection point did not correspond to the sinus region in 3 images from group 1 and 4 specimens from group 2. The matching of the mandibula-mastoid line trajectory with the sigmoid sinus course was unacceptable in 4 images and 5 cadavers. For venous anatomy preservation and anatomic skull base fossa orientation during posterolateral cranial base approaches, upward extension of the mandibula-mastoid line can be a proper landmark for surgical planning in this region. The authors' proposed superficial anatomical line and intersection point over the skull could be used as a reliable indicator for the external projection of the sigmoid sinus and an appropriate initial burr-hole location.

Pneumorrhachis.

The presence of air in spinal canal is called as "pneumorrhachis." Nontraumatic, noniatrogenic spontaneous spinal air is an uncommon case. Peripheral alveoli burst due to the increased pressure in alveoli in the case of trauma, asthma, pneumothorax, or pneumomediastinum. Air pass to the mediastinum and then to retropharyngeal space and reaches to epidural space. In this paper, a 44-year-old female patient who has a spontaneous pneumorrhachis in the epidural space in the spinal canal L5-S1 lumbar level has been presented.