Pituitary apoplexy: An emergent and potential life-threatening complication of pituitary adenomas.

BACKGROUND: Pituitary apoplexy is an emergent and potential life-threatening complication of pituitary adenomas if not managed properly. The aim of our study is to present our series of pituitary adenomas and to focus on the clinical, radiological, and surgical characteristics of this rare complication. METHODS: In this study, a total of 143 patients with pituitary adenoma underwent surgical treatment between 2016 and 2018. All patients were operated using endoscopic endonasal transsphenoidal (EET) technique. The data of pituitary apoplexy cases were recorded. Resection rates, hormonal results, and visual outcomes of patients with pituitary apoplexy were evaluated. RESULTS: Of the 143 patients, 8 (5.59%) were presented with the symptoms and radiological findings of pituitary apoplexy. The mean age was 26.75 years, and 4 (50%) of them were male and 4 were female. Pre-operative mean Knosp grading score was 2.1 All of eight patients underwent emergent surgical intervention and total resection was achieved in 75% of patients with apoplexy. Hormone levels were significantly decreased after surgery (p<0.05), except prolactin (p>0.05). Cerebrospinal fluid leakage occurred in one pa-tient. None of the patient with pituitary apoplexy died in our series. CONCLUSION: Pituitary apoplexy is an important complication of pituitary adenomas. Early diagnosis and surgical intervention provide excellent ophthalmological and hormonal outcomes. Emergent EET approach is crucial for patients with ophthalmological findings and macroadenomas.

Radial nerve injuries and outcomes: Our surgical experience.

BACKGROUND: The aim of this study was to retrospectively evaluate patients who underwent surgery in our department for radial nerve lesions in terms of surgical outcomes. METHODS: Thirty-eight patients were admitted to our department with radial nerve lesion. Twenty-seven of the patients had entrapment neuropathy and 11 had radial nerve injury secondary to other traumas. Various factors such as surgical results, time to surgical intervention, injury mechanism, and reconstruction technique were analyzed. RESULTS: In all of 27 patients who were operated for radial nerve entrapment neuropathy, a complete improvement in wrist dorsal flexion was detected at postoperative 3rd month. Seven of the 11 patients who were operated for radial nerve lesion had different degrees of improvement in wrist dorsal flexion at the postoperative 3rd month. Two of the seven patients underwent anastomosis using a sural nerve graft. The recovery rate in our series was 89%. Three of the 4 patients who did not recover after the radial nerve injury were the patients who were operated within the 1st month after the trauma. CONCLUSION: Better functional results were obtained in the postoperative period in patients who were operated after the 1st month, underwent internal neurolysis and used a short nerve graft for anastomosis in the radial nerve lesions. In patients with entrapment neuropathy, the earliest surgery revealed satisfactory results in the postoperative period.

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.

Surgical Management of Giant Intracranial Meningiomas.

OBJECTIVE: Giant intracranial meningiomas are a challenge for neurosurgeons because of their size and location in the cranium. Difficult tumor dissection and encasement of important neurovascular structures make them a horrible nightmare. The aims of this study are to present our giant intracranial meningioma series and to compare our experience using advanced surgical technology with the current literature. MATERIALS AND METHODS: The data of patients with the diagnosis of giant intracranial meningioma between 2014 and 2020 who underwent surgical treatment were retrospectively reviewed. The demographic, radiological, and surgical characteristics of patients were documented. The size and location of tumors as well as surgical technique were analyzed in detail. RESULTS: A total of 61 patients with intracranial meningioma underwent surgical treatment over a 7-year period, and 10 (16.4%) tumors were larger than 5 cm in diameter, which were classified as giant meningioma. Seven patients were male and 3 were female, with a mean age of 64.9 years. Four tumors were located at the skull base. Histological diagnosis was meningioma World Health Organization grade I in 7 patients and grade II in 3 patients. Simpson grade 1 resection was achieved in 6 patients and grade 2 resection in 4 patients. No mortality was observed. CONCLUSION: Careful surgical planning should be made for giant intracranial meningiomas. Their location, adjacent neurovascular structures, and vascular supply affect the resection level of these giant tumors. Simpson grade 1 resection is seldom possible for skull base meningiomas.

Chemoresistance in Malignant Intracranial Tumors: Longer Survival with Negative MDR1 Expression.

AIM: To analyze the Glutathione S-transferase (GST)-P, GST-M, cytochrome p450 (CYP)1-A1, CYP1-B1, and multidrug resistance (MDR)-1 expressions in malignant intracranial tumor (ICT)s, and to elicit their role on patient survival. MATERIAL AND METHODS: GST-P, GST-M, CYP1-A1, CYP1-B1, and MDR-1 expressions were analyzed using immunostaining in 149 samples from 141 patients with preoperative ICT diagnosis. The case characteristics were reviewed, and the enzyme expressions were equated based on the age, gender, and tumor type. Then, 77 of 141 patients with malignant ICT and complete medical records postoperative were also investigated in detail for the relationship between the diagnosis, enzyme expression, and overall survival. RESULTS: The average age was 49.44 years, with 83 (58.45%) male patients. Among the 77 malignant ICTs, 38 (49.3%) and 29 were glial tumors and metastases, respectively, with a 13.35-month overall survival. Patients with metastatic tumor have approximately threefold higher GSTP level than those with glial tumors. MDR-1 expression was approximately twofold higher in > 60-year-old patients. No statistically significant association was found between patients? smoking behaviors, alcohol consumption, and overall survival. Only MDR-1 expression was correlated with overall survival. Better overall survival was observed in patients with a negative MDR-1 expression than those with a positive one. CONCLUSION: MDR-1 is an important indicator of survival in malignant intracranial tumor patients. Longer survival is associated with negative MDR-1 expression.

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.

Direct Stimulation of Neural Placode and Nerve Roots in Open Myelomeningocele: The Efficacy of Neural Tube Reconstruction.

INTRODUCTION: Intraoperative electrophysiological studies are increasingly used in spinal surgery. However, its use in myelomeningocele (MMC) surgery is still not widespread. The aim of this study was to present our experience in neural placode (NP) and nerve root stimulations in newborns with open MMC. METHODS: Eight newborns underwent surgical treatment for thoracolumbar and lumbosacral MMCs. Intraoperative neuromonitoring including free-running electromyography and stimulation of NP, nerve roots, and spinal cord were performed in all cases. Stimulation sites and intensities and distal response's amplitudes and latencies were recorded. RESULTS: Five patients had thoracolumbar and 3 patients had lumbosacral MMC. Two patients had no movements at the lower extremities while the other had some movements. No response on the lower extremities was obtained in only 1 patient. Responses from the nerve root stimulations were more robust and significant than the placode stimulations. CONCLUSIONS: It is clear that the NP and nerve roots originating from the placode are mostly functional and should be preserved during the surgery. Intraoperative neuromonitoring and direct stimulation should be performed during the MMC repair in order to obtain a better neurological outcome.

Older patients with intraventricular hemorrhage are prone to infection after external ventricular drainage.

BACKGROUND: External ventricular drainage (EVD) is a life-saving and emergent procedure in neurosurgery. However, infection is the main problem in patients with EVD. The present study aims to analyze the infection rate of patients with EVD and to investigate the factors that contribute to infection and mortality rates. METHODS: The data of patients who underwent emergent EVD procedure between 2018 and 2019 were retrospectively analyzed in this study. The demographic features of the patients were recorded. The correlation between age, gender, indication and duration of EVD, and the infection and mortality rate were investigated. RESULTS: In this study, 47 patients underwent emergent EVD in two years. Thirty (63.83%) patients were male, and 17 were female with a mean age of 28.02 years. The mean duration of drainage was 6.2 days. Fifty-eight cerebrospinal fluid (CSF) samples were analyzed during the drainage period and CSF culture was positive in 14 (24.14%) samples. The most common microorganism was Staphylococcus epidermidis. The infection rate was high in older and male patients with duration longer than six days. Nine (19.15%) patients died during the treatment period and six of them had IVH. CONCLUSION: The duration of EVD should be shorter in patients older than 65 years with the diagnosis of intraventricular hemorrhage, which is mostly related to dea.

Prognostic factors in craniocerebral gunshot wounds: Analysis of 30 patients from the neurosurgical viewpoint.

BACKGROUND: Craniocerebral gunshot wounds (CGW) are the most lethal injuries of the cranium. CGW is mostly secondary to military conflicts but may also be seen in civilian life. These injuries also have severe consequences, such as epilepsy, hydrocephalus, infection and late-term cognitive dysfunctions. The present study aims to present our series of CGW and to discuss the prognostic factors and consequences of these injuries. METHODS: The data of patients who were treated in our department for CGW between 2011 and 2019 were retrospectively reviewed in this study. The injury type, wounding site, surgical management and outcomes were analyzed. Radiological evaluation was also performed. RESULTS: Thirty patients were treated with the diagnosis of CGW. All of the patients were male and the mean age was 27.9 years. The frontal lobe was affected in 12 (40%) patients, while temporal lobe in eight, occipital lobe in six, parietal lobe in three, and posterior fossa in one patients. Twenty-three patients underwent surgical treatment, seven patients were treated conservatively. Thirteen (43.3%) patients died despite the treatment. CONCLUSION: Mortality in CGW is high. Ventricular injuries, bihemispheric or midline injuries, perforating injuries, brain stem injuries and low GCS score at admission are prognostic factors for CGW. Appropriate management is mandatory to obtain a better clinical outcome.

Pediatric head traumas: A different perspective.

BACKGROUND: We aim to present our series on pediatric head traumas and discuss our results with the current literature. METHODS: The data of children who underwent treatment for head trauma in our department between 2010 and 2019 were retrospectively reviewed. Their clinical condition at admission, radiological findings, treatment methods and outcomes were analyzed. RESULTS: Ninety children underwent treatment for head trauma, 60 of them were male and 30 were female. The mean age was 6.6 years. Linear skull fracture was seen 55 patients, while epidural hematoma in 15 patients. Twenty patients underwent surgical treatment, while 70 patients underwent conservative treatment. No patient died in our series, three patients underwent rehabilitation due to neurological deficits after discharge. CONCLUSION: Children were more prone to head trauma, but their mortality was less than the adults. Conservative treatment should be the first goal, but surgical management should be reserved for children with significant hematoma and declining neurological conditions.

The efficacy of continuous lumbar drainage in post-traumatic cerebrospinal fluid fistulas.

BACKGROUND: This study aims to investigate the clinical outcomes of patients who underwent closed continuous lumbar drainage (CLD) for post-traumatic cerebrospinal fluid (CSF) fistula and to compare with those of non-traumatic patients. METHODS: The data of patients who were treated in the department of neurosurgery between January 2018 and December 2019 and underwent CLD were analyzed. The diagnosis, demographic characteristics, CSF results and clinical outcomes of these patients were evaluated. The outcomes of the patients with dura defect and CSF fistula due to trauma were compared with patients who underwent CLD for other diagnoses. RESULTS: In this study, 45 patients underwent CLD for 51 times. The mean age was 38.84 years, and 27 (60%) of the patients were male. Seven (15.55%) patients underwent CLD due to post-traumatic CSF fistula and 38 patients after tumor or malformation surgery. While five patients developed CSF fistula due to dura defect after gunshot injury, two patients developed CSF fistula secondary to motor vehicle accident. Staphylococcus Epidermidis was isolated in one patient among post-traumatic CSF fistula patients while Serratia Marcescens was isolated in patients with CSF fistula secondary to posterior fossa tumor surgery. While none of the seven patients died during the follow-up period in post-traumatic group, one of the 38 patients with CLD secondary to tumor surgery was lost due to sepsis in the follow-up period. CONCLUSION: CLD in post-traumatic CSF fistulas is a safe and effective treatment method. Especially in patients with gunshot wounds, CLD should be performed before revision surgery in the treatment of CSF fistula. Studies with different parameters are needed in larger trauma populations.

Extended endonasal endoscopic approach for anterior midline skull base lesions.

AIM: In recent years, extended endoscopic endonasal approach (EEEA) has been used as an alternative to transcranial approaches in the treatment of anterior midline skull base lesions. We retrospectively reviewed our cases operated using this technique and compared the results with current literature. METHOD: The data of 24 patients who were operated using EEEA in our department between 2010-2018 were retrospectively analyzed. The lesions were located in the midline between the posterior wall of the frontal sinus and tuberculum sella. Tumor locations, histopathological diagnoses, surgical techniques, outcomes and complications were documented. RESULTS: Eleven patients were female and 13 were male. Their ages ranged between 18-75 years (mean 40.5 years). Considering their locations; 12 were in the anterior fossa (50 %), 7 were in the tuberculum sella (29.1 %), and 5 were in both anatomic sites (20.8 %). Histopathologically, our series consisted of 15 meningiomas, 6 osteomas, 2 dermoid tumors and 1 metastatic carcinoma. We achieved gross total resection in 75 % of our patients. Ten patients presented with visual complaints and 7 of them improved postoperatively. Postoperative cerebrospinal fluid leakage (CSF) was observed in 3 patients and one of them developed meningitis and subsequently died of sepsis. CONCLUSION: Although the number of cases is low, EEEA seems like a safe, effective and well-tolerated treatment modality for anterior midline skull base lesions. But strict preventive measures should be taken for a possible CSF leak.

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.

Expression of Sigma-Class Glutathione-S-Transferase in Fetal and Pediatric Filum Terminale Samples: A Comparative Study.

Background and objectives: The pathophysiology of tethered cord syndrome (TCS) in children is not well elucidated. An inelastic filum terminale (FT) is the main factor underlying the stretching of the spinal cord in TCS. Our study aimed to investigate the expression of glutathione-S-transferase (GST) in children and fetal FT samples in order to understand the relationship between this enzyme expression and the development of TCS. Materials and Methods: FT samples were obtained from ten children with TCS (Group 1) and histological and immunohistochemical examinations were performed. For comparison, FT samples from fifteen normal human fetuses (Group 2) were also analyzed using the same techniques. Statistical comparison was made using a Chi-square test. Results: Positive GST-sigma expression was detected in eight (80%) of 10 samples in Group 1. The positive GST-sigma expression was less frequent in nine (60%) of 15 samples from Group 2. No statistically significant difference was detected between the two groups (p = 0.197). Conclusions: Decreased FT elasticity in TCS may be associated with increased GST expression in FT. More prospective studies are needed to clarify the mechanism of the GST-TCS relationship in children.

Intracavitary amphotericin B in the treatment of intracranial aspergillosis.

Intracranial aspergillosis is a rare infectious disease of the central nervous system with high mortality rates. Our aim is to present 3 cases of intracranial aspergillosis who were surgically treated with intracavitary amphotericin B administration. First case was a 21-year-old male patient. Allogeneic stem cell transplantation treatment was performed because of aplastic anemia and vocal cord paralysis developed 10 days after treatment. Multiple aspergillosis abscesses were observed in the cranial magnetic resonance imaging (MRI). Cerebral lesions were excised and 0.3 cc of amphotericin B was applied locally. Second case was a 18-year-old male patient treated for acute lymphocytic leukemia. MRI was performed on the development of consciousness change during treatment and right frontal abscess was detected. The abscess was excised and amphotericin B was applied locally. Third case was a 45-year-old woman with mastectomy. She had chemotherapy after surgery and had blood stem cell transplantation because of pancytopenia. Two months after treatments, MRI was performed on the development of ataxia and a cerebellar abscess was detected. The abscess was surgically excised and local amphotericin B was applied. The first case deceased 2 weeks after surgery and the second case died 2.5 years later due to multi-organ failure. The third case is stil alive and neurologically stable after 14 years of surgical treatment. In intracranial aspergillosis, intracavitary amphotericin B therapy may be used as an adjunct after the surgical excision of abscess. This procedure may contributes to the regression of abscess or prevention of the recurrence. But comparative clinical studies are needed for more accurate conclusions.

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.

Is spontaneous spinal epidural hematoma in elderly patients an emergency surgical case?

Spontaneous spinal epidural hematoma (SSEH) is a rare condition requiring urgent diagnosis and treatment. Patients with SSEH typically present with acute onset of severe back pain and rapidly develop signs of compression of the spinal cord. The authors present a case with spontaneous resolution of SSEH which is extremely rare. We discuss a man who presented to our clinic with mild paraparesis at the seventh day of his symptoms. He had a history of poorly controlled hypertension and hypercholestrolemia requiring an antihyperlipidemic agent and anticoagulation. His upper level of hypoesthesia was at the third thoracic segment. Cervicothoracic SSEH was diagnosed by magnetic resonance imaging. Since there was a gradual recovery of the neurological deficits beginning 12 hours after the onset of symptoms, surgery was obviated and strict bed rest, serial neurological examinations, and pain controls with opiates were instituted. The neurological deficits showed complete recovery on the 25th day of the clinical course. SSEH is rare and immediate surgical decompression is suggested. Rapid neurological deterioration followed by early and progressive neurological recovery, confirmed by radiological resolution of the lesion, may indicate nonoperative treatment.