Surgical treatment of peripheral nerve injuries: Better outcomes with intraoperative NAP recordings.

BACKGROUND: Peripheral nerve injuries are usually not lethal but may cause serious neurological deficits if not treated properly. The aim of this study is to present our patients who underwent surgical treatment for peripheral nerve trauma in the past 10 years and to discuss their results in light of the literature. METHODS: The clinical and electrophysiological results of 182 patients who underwent surgical treatment in our department between 2010 and 2019 were retrospectively analyzed. All surgeries were performed using intraoperative nerve action potentials (NAP) recordings. Demographic characteristics, etiologies, surgical timing, and results of surgical treatment were recorded. RESULTS: A total of 199 surgical interventions were performed in 182 patients with peripheral nerve trauma within 10 years. 162 patients were male, 20 were female and the mean age was 29.34 years for males and 30.2 years for females. The sciatic nerve trauma was the most common in men and peroneal nerve injury women. The most common cause of trauma was gunshot wounds in menand blunt/sharp traumas in women. External and internal neurolysis was the most common surgical technique, followed by epineural anastomosis and sural nerve grafting. 155 of 182 patients showed partial neurological improvement within 3 months after surgery, while 27 had no change in their neurological condition. CONCLUSION: Men are more frequently exposed to peripheral nerve trauma than women. Severe partial nerve lesions mostly benefit from surgical treatment, and neurolysis has become the most preferred method of surgical treatment. Intraoperative NAP recordings provide better clinical outcomes. Neurological improvement may not always be in correlation with electrophysiological improvement.

Resection of intra- and paraventricular malignant brain tumors using fluorescein sodium-guided neuroendoscopic transtubular approach.

BACKGROUND: The requirement of brain retraction and difficulty in distinguishing the tumor demarcation are challenging in conventional approaches to intra- and paraventricular malignant tumors (IV-PVMTs). Tubular retractors can minimize the retraction injury, and fluorescein-guided (FG) surgery may promote the resection of tumors. Our aim is to evaluate the feasibility, safety, and effectiveness of fluorescein-guided endoscopic transtubular surgery for the resection of IV-PVMTs. METHODS: Twenty patients with IV-PVMTs underwent FG endoscopic transtubular tumor resection. Fluorescein sodium was administered before the dural opening. The intraoperative fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was assessed using postoperative magnetic resonance imaging. Karnofsky Performance Status (KPS) score was used to evaluate the general physical condition of patients. RESULTS: There were 9 glioblastomas, 4 anaplastic astrocytomas and 7 metastatic tumors. "Helpful" fluorescence staining was observed in 16(80%) of 20 patients. Gross total resection was achieved in 16(80%) cases, near-total in 3(15%) cases, and subtotal in 1 (5%) case. No intra- or postoperative complications related to the fluorescein sodium occurred. The median preoperative KPS score was 83, and the median KPS score 3-month after surgery was 88. CONCLUSION: FG endoscopic transtubular surgery is a feasible technique for the resection of IV-PVMTs. It may be a safe and effective option for patients with these tumors. Future prospective randomized studies with larger samples are needed to confirm these preliminary data.

Fluorescein Sodium-Guided Neuroendoscopic Resection of Deep-Seated Malignant Brain Tumors: Preliminary Results of 18 Patients.

BACKGROUND: Deep-seated intracranial lesions are challenging to resect completely and safely. Fluorescence-guided surgery (FGS) promotes the resection of malignant brain tumors (MBTs). Classically, FGS is performed using microscope equipped with a special filter. Fluorescence-guided neuroendoscopic resection of deep-seated brain tumors has not been reported yet. OBJECTIVE: To evaluate the feasibility, safety, and effectiveness of the fluorescence-guided neuroendoscopic surgery in deep-seated MBTs. METHODS: A total of 18 patients with high-grade glioma (HGG) and metastatic tumor (MT) underwent fluorescein sodium (FS)-guided neuroendoscopic surgery. Tumor removal was carried out using bimanual microsurgical techniques under endoscopic view. The degree of fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was determined using magnetic resonance imaging (MRI). Karnofsky Performance Status (KPS) score was used for evaluation of general physical performances of patients. RESULTS: A total of 11 patients had HGG, and 7 had MT. No technical difficulty was encountered regarding the use of endoscopic technique. "Helpful" fluorescence staining was observed in 16 patients and fluorescent tissue was completely removed. Postoperative MRI confirmed gross total resection (88.9%). In 2 patients, FS enhancement was not helpful enough for tumor demarcation and postoperative MRI revealed near total resection (11.1%). No complication, adverse events, or side effects were encountered regarding the use of FS. KPS score of patients was improved at 3-mo follow-up. CONCLUSION: FS-guided endoscopic resection is a feasible technique for deep-seated MBTs. It is safe, effective, and allows for a high rate of resection. Future prospective randomized studies are needed to confirm these preliminary data.

Sellar Defect Reconstruction with Vascularized Superior Turbinate Mucosal Flaps in Endonasal Endoscopic Transsellar Approach.

BACKGROUND: The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for most skull base defects in endonasal endoscopic approaches. The superior nasal turbinate (ST) has received little attention. We report our preliminary experience with the use of the ST mucosal flap in selected cases. METHODS: We performed a retrospective review of patients who underwent endonasal endoscopic approaches and identified 9 patients who were reconstructed with vascularized ST mucosal flaps as part of a double-layer or triple-layer reconstruction. When there was no intraoperative cerebrospinal fluid (CSF) leak, we used a double-layer technique. If there was an intraoperative CSF leak, regardless of the quality of leakage, we preferred a triple-layer repair technique. In patients with high-flow leaks, triple-layer repair was performed using only autologous tissue grafts and flaps. RESULTS: Intraoperative CSF leaks were noted in 7 of 9 patients. Among them, 4 patients had low-flow CSF leaks (grade 1 and 2) and 3 patients had high-flow CSF leaks (grade 3). All reconstructions had complete defect coverage with the ST flaps and NSFs were preserved. All the flaps were viable at 4 weeks without a CSF leak or complication at the reconstruction site. There was no contraction or partial loss of the flap. After a mean follow-up period of 9 months, none of the patients required a flap revision, developed a mucocele, infection, or other complication. CONCLUSIONS: An ST flap can be used for the vascularized reconstruction of sellar defects if it is bilaterally available. This option should not be overlooked and wasted.

The evaluation of the effects of steroid treatment on the tumor and peritumoral edema by DWI and MR spectroscopy in brain tumors.

OBJECTIVE: To investigate the effects of dexamethasone on brain tumor and peritumoral edema by different sequences of magnetic resonance imaging (MRI). MATERIALS AND METHODS: MRI was performed in 28 patients with brain tumor. Patients were divided into the 3 groups based on the histological diagnosis; Group I: high-grade glial tumor, Group II: low-grade glial tumor, and Group III: brain metastasis. The measurements of peritumoral edema volume and apparent diffusion coefficient (ADC) values were performed while the peak areas of cerebral metabolites were measured by spectroscopy in groups I and II. The changes in edema volumes, ADC values and cholin/creatine peak areas were compared. RESULTS: The volume of peritumoral edema was decreased in groups I and II, but increased in group III after dexamethasone treatment. These changes were not statistically significant for 3 groups. ADC value was decreased in group I and increased in groups II and III. Changes in ADC values were statistically significant. Cholin/creatine peak areas were decreased after dexamethasone in groups I and II, but these changes were also not significant. CONCLUSION: Dexamethasone has no significant effect on the volume of peritumoral edema in glial tumor and metastasis. Moreover, dexamethasone increases the fluid movements in low grade gliomas and metastases, decreases in high grade gliomas. However, more comprehensive clinical studies are needed to show the effects of dexamethasone on brain tumors and peritumoral edema.

Extended endoscopic endonasal approach to the ventral skull base lesions.

OBJECTIVE: With the use of multiple endoscopic endonasal surgical corridors, extended endoscopic endonasal approaches (EEEAs) are now being used to treat a wide range of ventral skull base lesions. Our aim was to present our experience with EEEAs to the ventral skull base lesions. PATIENTS AND METHODS: The study group consisted of 106 patients (57 men and 49 women) who underwent surgery for skull base lesions using EEEAs from 2010 to 2017. The EEEA was most commonly used for giant pituitary macroadenomas, sinonasal malignancies, cerebrospinal fluid (CSF) leaks, meningiomas, craniopharyngiomas, and fibro-osseous lesions. Four different approaches were used including transtuberculum-transplanum, transethmoidal-transcribriform, transclival, and transmaxillary-transpterygoidal. RESULTS: The overall gross total resection (GTR) rate for these diverse pathologies was 75.0% in 88 patients (excluding the operations performed for non-neoplastic pathologies). GTR was achieved in 100%, 77.8%, 75%, 75%, 72.2%, 62.5%, 60% of fibro-osseous lesions, giant/large pitutary adenomas, meningiomas, esthesioneuroblastomas, sinonasal malignancies, craniopharyngiomas, and chordomas, respectively. The overall rate of improvement in visual fields was 86%. The overall rate of CSF leak was 8.4%. Other surgical complications included intracerebral hematoma and tension pneumocephalus. The mortality rate was 0.9%. CONCLUSION: EEEA is a safe, well-tolerated and effective surgical treatment modality in the management of ventral skull base lesions. It should be performed with close interdisciplinary collaboration. Appropriate case selection is mandatory. However, despite improved reconstruction techniques, postoperative CSF leakage still remains a challenge.

Comparison of Electrophysiological Outcomes of Tethered Cord Syndrome and Spinal Intradural Tumors: A Retrospective Clinical Study.

AIM: Electrophysiological evaluation of the outcomes of spinal procedures is important for neurosurgeons. Somatosensorial evoked potentials (SSEPs) are used for electrophysiological evaluation of tethered cord syndrome (TCS) and spinal intradural tumors (SIT). The aim of this study was to document the electrophysiological outcomes of surgery for TCS and SIT and to compare the results based on the preoperative diagnosis. MATERIAL AND METHODS: The data of 30 patients, who were operated for TCS and SIT between 2011 and 2013, were reviewed retrospectively. Surgical release of the spinal cord was performed for TCS and tumor removal was performed for SIT. Median and tibial nerve SSEPs at the left and right sides were measured at preoperative, early and late postoperative periods and compared statistically based on the diagnosis and the time of electrophysiological assessment. RESULTS: The diagnosis was TCS in 12 (40%) patients and SIT in 18 (60%) patients. There was a significant difference between preoperative, and early and late postoperative SSEPs values. Tibial nerve latencies were prolonged in the early postoperative, but shortened in the late postoperative period. In contrast, median nerve latencies were shortened in the early postoperative, but prolonged in the late postoperative period. There was no significant difference between the TCS and SIT groups based on the surgical intervention. CONCLUSION: Tibial nerve latency may be prolonged in the early postoperative period of TCS and SIT patients. However, electrophysiological changes were not predictive for these patients. Further studies with more patients are needed for other spinal lesions.

Endoscopic Removal of Suprasellar Colloid Cyst with Interpeduncular and Prepontine Cisterns Extension.

BACKGROUND: Colloid cysts (CCs) are rarely found in the sellar-suprasellar region. Differential diagnosis of CCs is more challenging in this region because many other cystic lesions may locate or invade sellar or suprasellar structures. We present a large and unusual case of sellar-suprasellar CC with extension into the suprasellar, interpeduncular, and prepontine cisterns. This is the first case of sellar-suprasellar CC treated with an endoscopic transsphenoidal approach. CASE DESCRIPTION: A 33-year-old woman presented with a 1-year history of recurrent headaches. Her headaches had been unresponsive to medical treatment for the last 2 weeks. She had normal neurologic and ophthalmologic examinations. Neuroradiologic studies showed a large cystic sellar lesion with extension into the suprasellar, interpeduncular, and prepontine cisterns. The lesion did not show any enhancement, not even in the cyst wall. Her hormonal status was also normal. The cystic lesion was totally resected via a purely endoscopic endonasal approach. There were no complications, and the patient was recovered completely with improvement of her headache. Pathology was consistent with a CC. At 6-month follow-up, magnetic resonance imaging did not show any evidence of the residual or recurrent lesion. CONCLUSIONS: Although rarely found in this location, CC should be considered in the differential diagnosis in patients who present with a sellar-suprasellar cystic lesion. Additionally, sellar-suprasellar CC would be a good candidate for the endoscopic endonasal approach.

Fully Endoscopic Resection of Intra-Axial Brain Lesions Using Neuronavigated Pediatric Anoscope.

AIM: To present a new simple disposable tubular retractor which provides fully endoscopic resections of the intraaxial brain lesions. MATERIAL AND METHODS: A total of 13 patients underwent surgical resection of an intraaxial brain lesion larger than 3 cm with a fully endoscopic approach using the navigation-guided pediatric anoscope. The anoscope was adapted to serve as a tubular retractor. All lesions were resected under endoscopic visualization and navigation guidance. There were 7 men and 6 women with a mean age of 49.6 years (range, 19-76 years). Lesion location was as follows: frontal (n=4), parietal (n=1), frontoparietal (n=2), temporal (n=2), and intraventricular (n=4). RESULTS: With the use of this technique, preoperative goals of surgery were met in all patients. Gross total resection of the lesions was achieved in 7 of 13 patients (53.8%), near-total resection in 3 patients (23.1%) and subtotal resection in 3 (23.1%) patients. The histological diagnosis included 2 metastases, 5 (38.5%) glioblastomas, 3 meningiomas, 2 low grade gliomas and one oligodendroglioma. There were no complications related to the surgical procedure. Duration of surgery ranged from 60 to 110 minutes, with an average 90 minutes. The average postoperative hospital stay was 2.7 days. CONCLUSION: Endoscopic resection of deep-seated brain lesions with the neuronavigated tubular retractor is a safe and an effective technique and may be a feasible alternative to conventional microsurgical or endoscope-assisted methods in selected patients. The modified transparent plastic pediatric anoscope can be used as a tubular retractor and it is easy to apply, simple, lightweight, inexpensive and effective.

The Use of Neuronavigation and Intraoperative Imaging in Spinal Stabilization Surgery.

AIM: Misplacement of pedicle screw is the serious complication of spinal surgeries. Intraoperative imaging techniques and navigation systems are currently in use for the prevention of this complication. The aim of this study was to document the results of our experience with the navigation and intraoperative imaging technique and to share our experience with our colleagues. MATERIAL AND METHODS: Between 2011 and 2014, one hundred and two patients underwent instrumented spinal surgery while using intraoperative computed tomography (iCT) and a navigation system. All patients had a CT scan performed no more than three days postoperatively to confirm adequate placement of the screws. The accuracy of pedicle screw placement was assessed by postoperative CT scan. Pedicle violations were graded according to an established classification system. RESULTS: In the 36-month period, a total of 610 screws in 102 patients were evaluated. Stabilization surgery was performed in the lumbosacral region in 51 (50%) patients, lumbar region in 35 (34.31%) patients, cervical region in 5 (4.9%) patients, thoracolumbar region in 7 (6.86%) patients and thoracic region in 4 (3.92%) patients. Of the 610 screws, 396 (64.91%) were placed in lumbar, 66 (10.81%) in thoracic, 106 (17.37%) in sacral and 42 (6.8%) in cervical vertebrae. Of the 610 screws, 599 screws (98.18%) were placed without a breach. Grade 1 breaches occurred in 8 screws (1.31%), Grade 2 breaches occurred in 2 screws (0.32%), and Grade 3 breaches in 1 screw (0.16%). No dural defect or neurological deficit occurred after the surgeries. CONCLUSION: The use of an iCT scan associated with a navigation system increases the accuracy of pedicle screw placement. This system protects the surgical team from fluoroscopic radiation exposure and the patient from the complications of screw misplacement and repeated surgeries.

Evaluation and Management of Lumbosacral Myelomeningoceles in Children.

OBJECTIVE: Myelomeningoceles are the common form of open neural tube defects that are usually associated with neurological deficits. Many techniques of repair and methods of prevention have been proposed with respect to the size of defect and the neurological condition of patient. The aim of this study was to report our experience on the management of lumbosacral myelomeningoceles in children. MATERIALS AND METHODS: We retrospectively analysed the data of 36 paediatric cases of surgically lumbosacral myelomeningocele treated in our department between 1998 and 2013. Twenty (56%) patients were female and sixteen were male, with a mean age of 4 months (ranged between 0 and 24 months). All patients had neurological deficits in the preoperative period. Computed tomography was performed in 33 (92%) patients and magnetic resonance imaging in 15 (42%) patients in the preoperative period. Repair of the myelomeningocele and closure of the skin defect were performed in all patients. The mean follow-up period was 36 months. RESULTS: Thirty (83%) patients were operated for hydrocephalus and 10 (28%) patients were re-operated for tethered cord syndrome during the follow-up period. Neurological worsening was not observed in any patient while cerebrospinal fluid fistula was detected in 2 patients. CONCLUSION: Surgical treatment using appropriate microsurgical techniques is crucial for lumbosacral myelomeningoceles in children. Early surgical intervention with close follow-up will improve the neurological condition of the patients.

Pain perception differences between patients and physicians: a pain severity study in patients with low back pain.

AIM: Perception, definition and tolerance of pain vary individually because of its subjective character. This study aimed to determine the perception differences between patients with mechanical low back pain (MLBP) and their physicians regarding the assessments of the patients' pain severity. MATERIAL AND METHODS: 181 patients with MLBP and 2 physicians took part in the study. Before the initial examination, the patients filled out a questionnaire consisting of demographic data, pain characteristics, Modified Oswestry Disability Questionnaire (MODQ) and Visual Analog Scale (VAS). The patients' forms were concealed from the physicians. Then physicians examined their patients and rated their pain severity using a different VAS form. RESULTS: The mean age of the patients was 36.2 ± 12.3 years. 64.6% (n:117) were female, 71.9% (n:13) were highly educated and 57.1% (n:103) were obese. Physicians always rated the patients' pain severity significantly lower than the patients rated their own pain regardless of all demographic data (p < 0.001). Correlation between the VAS scores of patients and physicians were detected as 0.41 (p < 0.001) and the power of the study was calculated as 91.5%. The mean MODQ score of the patients was calculated as 54.4 ± 21.1. Reliability of the questions in MODQ was calculated as alpha:0.87. A moderate correlation between VAS ratings and MODQ was observed (r:0.52, p < 0.001). CONCLUSION: As a main factor directly affecting many outcomes, good communication between patient and physician, is essential to assess the patients' pain more accurately.

Computer-based surgical planning and custom-made titanium implants for cranial fibrous dysplasia.

BACKGROUND: The procedure of reconstruction after the removal of cranial fibrous dysplasia (FD) must be precise to achieve good functional and aesthetic results. Intraoperative modeling of implants is difficult and may cause cosmetic disturbances. OBJECTIVE: To present our experience with the treatment of cranial FD using preoperative computer-based surgical planning of tumor removal with reconstruction of the cranium with custom-made titanium implants. METHODS: Four patients underwent surgical treatment for cranial FD over a 2-year period. All patients were male with a mean age of 25.25 years and had monostotic-type FD. Computed tomography (CT) with 0.5-mm slices was obtained preoperatively. Computer-based planning of the tumor removal was performed, and a template was created by the computer to determine the margins of tumor removal. After this procedure, the preoperative computer-based construction of the titanium implant was performed. The patients underwent surgical treatment, and the tumor was removed with the use of this template. Then, the titanium implant was inserted onto the bone defect and fixed with mini-screws. Patients were followed up by periodic CT scans. RESULTS: The histological diagnosis of all patients was FD. No intraoperative or postoperative complications have occurred. Postoperative CT scans showed complete tumor removal and confirmed appropriate cosmetic reconstruction. The mean follow-up period was 15.25 months. CONCLUSION: Computer-based surgical planning associated with the production of custom-made titanium implants is a highly promising method for the treatment of cranial FD. Better radiological and cosmetic outcomes could be obtained by this technique with interdisciplinary work with medical designers.

Surgical strategies for the removal of sphenoorbital meningiomas.

AIM: Surgical removal of sphenoorbital meningiomas is challenging for neurosurgeons. The aim of study is to share our experience on sphenoorbital meningiomas and to provide a picture of the current state of the art in surgical treatment of these tumors. MATERIAL AND METHODS: The data of 13 cases of sphenoorbital meningioma who were operated between 2006 and 2013 was reviewed retrospectively. Intraorbital extension was present in 10 cases while sphenoid bone invasion was detected in 9 cases. All patients underwent surgical treatment after the radiological evaluation with magnetic resonance imaging and computed tomography. The degree of resection and the clinical outcome of all patients were analyzed. RESULTS: Extended pterional approach with a large frontotemporal craniotomy was performed in all cases. Simpson's grade I and II excision was achieved in 4 (31%) cases while subtotal excision (Simpson's grade III or higher) was performed in 9 cases. The main reason for subtotal excision was the cavernous sinus invasion. Optic canal decompression was performed in patients with intraorbital invasion. CONCLUSION: Although total removal is the main objective of surgery, the sphenoorbital meningiomas are difficult to resect especially with cavernous sinus invasion. But in the meantime, it is not recommended to take any excessive risks to achieve a greater degree of resection for a benign tumor. Endoscopic approach is an option for inferomedial orbital parts of these tumors.

The use of neuronavigation and intraoperative imaging systems in the surgical treatment of orbital tumors.

AIM: We aimed to show the effects of neuronavigation and intraoperative imaging systems on the surgical outcomes of orbital tumors. MATERIAL AND METHODS: Seventeen patients who underwent surgical treatment for orbital tumors by transcranial and transnasal approaches between 2008 and 2013 were analyzed retrospectively. Twelve of them were male and 5 were female. The mean age was 41.6 years. Neuronavigation systems were used in all cases. Four patients were operated using intraoperative imaging systems. RESULTS: The transcranial approach was used in 9 (53%) patients, endoscopic medial orbital approach in 4 (23.5%), endoscopic inferolateral approach in 1 (6%), cranioorbitozygomatic approach in 1, lateral approach in 1, and the combined (medial endoscopic and lateral) approach in 1 patients. Total resection was achieved in 5 patients, gross total excision in 2, subtotal in 9 and partial in 1 patients. CONCLUSION: Modern technology has made a significant contribution to the treatment of orbital tumors. Although technological equipments facilitate the excision of tumors, the level of resection is mainly determined by the nature of tumor and adhesion to the adjacent neurovascular structures. It should not be forgotten that advanced technology never replaces a good anatomical knowledge and surgical experience, but has a complementary role.

Dr. Rollas: a humble and persistent man.

Dr. Zinnur Rollas is the founder of the Department of Neurosurgery at the Gulhane Military Medical Academy (GMMA). He was educated in the United States and returned to Turkey in order to practice neurosurgery. He is also the first surgeon who performed pediatric neurosurgical procedures at GMMA. Dr. Rollas operated on many pediatric cases of meningocele, myelomeningocele, encephalocele, hydrocephalus and trauma. He not only performed the surgeries but also took the pictures and recorded the data of the patients. Unfortunately, he did not publish any of these cases. In this paper, we tried to document his experience on pediatric neurosurgery, and to summarize the evolution of pediatric neurosurgery at GMMA.

Morphological structure and variations of lumbar plexus in human fetuses.

The objective of this study is to study the anatomy of lumbar plexus on human fetuses and to establish its morphometric characteristics and differences compared with adults. Twenty lumbar plexus of 10 human fetal cadavers in different gestational ages and genders were dissected. Lumbar spinal nerves, ganglions, and peripheral nerves were exposed. Normal anatomical structure and variations of lumbar plexus were investigated and morphometric analyses were performed. The diameters of lumbar spinal nerves increased from L1 to L4. The thickest nerve forming the plexus was femoral nerve, the thinnest was ilioinguinal nerve, the longest nerve through posterior abdominal wall was iliohypogastric nerve, and the shortest nerve was femoral nerve. Each plexus had a single furcal nerve and this arose from L4 nerve in all fetuses. No prefix or postfix plexus variation was observed. In two plexuses, L1 nerve was in the form of a single branch. Also, in two plexuses, genitofemoral nerve arose only from L2 nerve. Accessory obturator nerve was observed in four plexuses. According to these findings, the morphological pattern of the lumbar plexus in the fetus was found to be very similar to the lumbar plexus in adults.

The use of a simple self-retaining retractor in the endoscopic endonasal transsphenoidal approach to the pituitary macroadenomas: technical note.

BACKGROUND: During tumor removal in the endoscopic endonasal approach to pituitary adenomas with a significant suprasellar extension, the early descent of diaphragma sellae obscuring the visualization of the surgical field is a surgical challenge. OBJECTIVE: To describe a simple diaphragma retraction technique to eliminate this problem. METHODS: A transparent flexible material (a strip of polypropylene) was used as a self-retaining retractor to elevate the redundant diaphragma and to maintain the diaphragma elevation. This technique was performed in 3 patients who had pituitary adenoma with suprasellar extension. The degree of tumor removal was determined by a combination of surgeon's intraoperative impression and the postoperative magnetic resonance imaging obtained 3 months later. RESULTS: The technique was performed very easily and no complication was observed owing to this technique and self-retaining retractor. Total tumor removal was achieved in 2 patients with this technique and subtotal removal in 1 patient. CONCLUSION: This technique was effective and practicable to elevate the diaphragma sellae during the tumor removal phase of transsphenoidal surgery. This simple self-retaining retractor may support the neurosurgeon's skill by providing control of the entire surgical field and adequate working space. It may also eliminate the risks of blind curettage during surgery.

The effects of splenectomy on lipid peroxidation and neuronal loss in experimental spinal cord ischemia/reperfusion injury.

AIM: The aim of this study is to investigate the effects of prior splenectomy on oxidative stress and neuronal loss following spinal cord ischemia and reperfusion injury. MATERIAL AND METHODS: Twenty-one Sprague Dawley rats were randomly divided into three groups as sham laparatomy (n=7), spinal cord ischemia/reperfusion (SCIR) injury (n=7) and splenectomy+spinal cord ischemia/reperfusion (SSCIR) injury (n=7). In the latter group, splenectomy was performed 3 days before the SCIR injury. The activity of lipid peroxidation in the spinal cord was assessed by malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) activities. The difference between the 3 groups was compared using Kruskal-Wallis test. The histological differences were assessed by counting the viable neurons. RESULTS: SCIR injury resulted in a decrease of tissue lipid peroxidation activities. There was statistically significance between the three groups (p < 0.05), but there was not any significance between the SCIR and SSCIR injury groups (p > 0.05). The number of viable neurons was higher in SSCIR group when comparing with SCIR group (p < 0.05). CONCLUSION: SCIR injury affects lipid peroxidation in rats. Prior splenectomy does not attenuate lipid peroxidation, but prevents neuronal loss after SCIR injury.

Comparison of intrathecal flunarizine and nimodipine treatments in cerebral vasospasm after experimental subarachnoid hemorrhage in rabbits.

BACKGROUND: the aim of this study was to assess and to compare the ability of intrathecal flunarizine and nimodipine to prevent vasospasm in a rabbit model of subarachnoid hemorrhage (SAH). METHOD: forty male New Zealand white rabbits were allocated into 5 groups randomly. The treatment groups were as follows: (1) control (no SAH [n = 8]), (2) SAH only (n = 8), (3) SAH plus vehicle (n = 8), (4) SAH plus nimodipine (n = 8), and (5) SAH plus flunarizine (n = 8). Before sacrifice, all animals underwent femoral artery catheterization procedure by open surgery under anesthesia and angiography performed for each animal. FINDINGS: there was a statistically significant difference between the mean basilar artery cross-sectional areas and the mean arterial wall thickness measurements of the control and SAH-only groups (p < 0.05). Basilar artery vessel diameter and luminal section areas in group 4 were significantly higher than in group 2 (p < 0.05). Basilar artery vessel diameter and basilar artery luminal section areas in group 5 were significantly higher than in group 2 (p < 0.05).Basilar artery vessel diameter and basilar artery luminal section areas in group 5 were significantly higher than in group 4 (p < 0.05). CONCLUSIONS: these findings demonstrate that flunarizine has marked vasodilatatory effect in an experimental model of SAH in rabbits.