Endoscopic clipping of a middle cerebral artery aneurysm in a middle fossa arachnoid cyst and review of the literature.

BACKGROUND: Arachnoid cysts are often associated with subdural hematoma following head trauma. The incidental finding of an aneurysma and a cyst is rare. We describe for the first time the treatment of such a case using endoscopic techniques. CASE REPORT: A 44-year-old man was admitted to our hospital with a mild headache and a hemifacial spasm attack at the right side of his face. The radiological examinations demonstrated bilateral slyvian fissure arachnoid cysts and an aneurysm with the dome projecting superolaterally, at the bifurcation of the right middle cerebral artery in the arachnoid cyst. The patient underwent a complete endoscopic surgical clipping of the aneurysm, and partial excision of the right cyst wall and bilateral fenestration to the basal cistern via a single burr-hole craniectomy at the right temporal region. The patient had an uneventful postoperative course without neurological impairment and complication. However, his complaints still persisted postoperatively. CONCLUSION: Endoscopic management of arachnoid cysts is an effective and less morbid treatment. This less invasive option might be safe for the clipping of aneurysms within an arachnoid cyst with no additional morbidity for the patient. With smaller operative exposures and yet better visualization offered, neuroendoscopy may reduce operative morbidity.

Endoscopic approaches to the orbit: a cadaveric study.

INTRODUCTION: The role of the endoscopic management of lesions located in the anterior cranial fossa and skull base continues to expand. MATERIALS AND METHODS: An endoscopic anatomic study was conducted on cadaver specimens. 10 orbits from 5 cadaveric heads fixed in formalin were examined after the vascular structures had been perfused with colored latex and silicone. Endoscopic dissections were performed using rigid endoscopes of 4 mm diameter, 18 cm length, and equipped with 0 degrees , and 30 degrees lenses, according to the different steps of the anatomic dissection protocol. RESULTS: We have identified and described three endoscopic approaches to the orbit: 1) an inferolateral endoscopic orbital approach (IL-EOA), 2) an endoscopic endonasal medial orbital approach (EEM-OA), and 3) a transcranial key hole endoscopic orbital approach (TCK-EOA). DISCUSSION: The IL-EOA provides excellent exposure of the temporal compartment of the orbit. In this approach special care should be taken to preserve the ciliary ganglion, the ciliary artery and the ciliary nerves. The EEM-OA offers direct access to the medial and inferomedial orbit, the medial part of the optic nerve and orbital apex through its anteromedial walls. The EEM-OA is simple, relatively quick and has superiority over microsurgical operations by excluding the potential complications of intracranial operations. The EEM-OA is minimally invasive and cosmetically acceptable. The TCK-EOA offers an exposure of the orbital roof and the superior part of the optic nerve as well as other intraorbital structures from above. The TCK-EOA is a potentially safe approach for tumors extending from the orbital wall to the anterior cranial fossa and the parasellar region.

Simultaneously occurring vestibular schwannoma and meningioma in the cerebellopontine angle: case report and literature review.

Simultaneously occurring multiple primary brain tumors of different histological types are rare, and the coexistence of schwannoma and meningioma in the same cerebellopontine angle (CPA) without neurofibromatosis is extremely rare. A 57-year-old female patient presented with headache, speech disturbance, left facial numbness and deafness in the left ear. Magnetic resonance imaging demonstrated two different tumors in the left CPA. These tumors were not in continuity. The tumors were totally removed through the left suboccipital approach. Histopathological examination revealed that the large tumor was a vestibular schwannoma and the smaller was a meningioma. Neurofibromatosis was not diagnosed in the patient. No recurrence was observed at the end of 9 years after the operation. The simultaneous occurrence of vestibular schwannoma and meningioma in the CPA appears coincidental. This association must be kept in mind if two different tumors are detected radiologically in the same CPA.

Head injuries due to landmines.

BACKGROUND: Landmine explosions cause most of the war injuries in the battlefield and pose a substantial public health risk. Although the lower limbs are usually affected, head injuries also occur. The aim of this study is to describe the types of head injuries caused by the explosion of landmines and the management of the victims. PATIENTS AND METHOD: Fifteen patients who sustained a head injury due to a landmine explosion were treated in the Department of Neurosurgery between 2000 and 2006. The average age of the patients was 22.5 (range between 20 and 33). The Glasgow Coma Scale (GCS) score ranged between 3 and 15 and was 8 or less in 4. Shrapnel, stone and earth were the wounding agents. Four patients underwent neurosurgical treatment and 11, apart from simple scalp closure, had conservative treatment. Ten patients had associated lesions in the other parts of the body including thorax, upper and lower limbs, and the abdomen. FINDINGS: Two patients died. At the time of admission, one had a GCS score of 3 and the other a score of 4. Infection was observed among 4 patients and a cerebrospinal fluid (CSF) fistula in 1 patient. CONCLUSION: Landmines occasionally cause head injuries. Surgical intervention is seldom required and survival is likely unless the patient is in deep coma. Multidisciplinary approaches are required in case there are associated lesions in the other parts of the body.

Glioblastoma multiforme of the lateral ventricle: report of nine cases.

Glioblastoma multiforme is the most common lethal primary central nervous system (CNS) tumour in adults and they are rarely seen as primary intraventricular tumours. We present nine cases with lateral ventricle glioblastoma multiforme treated in our department. Seven of the nine tumours were located at the body of the lateral ventricle, whereas the other tumours were arising from septum pellicidum. Five patients were operated through an anterior transcallosal approach and four patients were operated through frontal transcortical approach. Total tumour excision was achieved only in one patient. Median survival time was 18.8 months. Three patients were alive at the end of study, and received radiotherapy and chemotherapy. Our goal was the decompressive surgery for these tumours without harming eloquent structures. In our opinion, patient's life quality is critically important in the postoperative period for these mortal tumours with rapid progression.

Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour.

Dermoid and epidermoid cysts are congenital, slowly growing tumours that usually become symptomatic when patients reach the middle of their third decade. An otherwise healthy 20-year-old man presented with an epileptic attack. Imaging studies including computed tomography and magnetic resonance imaging revealed an intradural cystic lesion located in the anterior subfrontal region. Choices of traditional approaches for such a lesion are a bicoronal craniotomy or a transfacial procedure. Taking the advantage of the endoscope, the authors decided to remove the lesion via an endonasal route. After a fully endoscopic endonasal operation, gross total resection of the dermoid tumour was achieved. We have not observed cerebrospinal fluid leakage or any infectious complication after the operation. In this report the technique of operation and reconstruction method are described. The endoscopic endonasal approach offers a good option for lesions located in the anterior skull base. Carefully piecemeal resection of the tumour while preserving the underlying neural and vascular structures should be the main strategy of the operation. Reconstruction is very important after the surgery and a carefully planned pedicled graft technique may help in the prevention of cerebrospinal fluid leakage.

Medial microsurgical approach to the orbit: an anatomic study.

The authors have identified and described three medial approaches to the intraorbital portion of the optic nerve in cadavers. The structures exposed via the superior, inferior or central approaches were approached through the medial orbital wall. The superior approach in which the medial rectus muscle is retracted inferiorly exposes the superomedial aspect of the orbit. The inferior approach in which the medial rectus muscle is retracted superiorly, provided the inferomedial aspect of the optic nerve from the globe to the muscle cone. The central approach in which the ethmoidectomy was performed and the medial rectus muscle was disinserted and retracted, provided excellent exposure of the structures of the medial part of the orbit and the optic nerve. There were no structures blocking access to the two third anterior optic nerve and medial surface of the globe. The structures encountered in these approaches are demonstrated under magnification in cadavers, and the exposure of the optic nerve is discussed.

The microsurgical anatomy of the ciliary ganglion and its clinical importance in orbital traumas: an anatomic study.

The ciliary ganglion can easily be injured during surgery for the repair of orbital fractures and laterally situated intraorbital mass lesions. The aim of this study is to elucidate the microsurgical anatomy of the ciliary ganglion and to emphasize its clinical importance in orbital traumas and surgeries. The orbits of 10 adult cadavers were fixed with 10 % formalin and dissected under the microscope with special attention to the presence and location of the ciliary ganglion. The motor (parasympathetic), sympathetic, and sensory roots, and the short ciliary nerves were exposed. Its relationship with other intraorbital neural and vascular structures were investigated. Some anatomic landmarks were determined and the distances between these landmarks were measured. The ciliary ganglion is an intraorbital neural structure approximately 3 mm in size, situated near the orbital apex, posterolateral to the globe in loose areolar tissue between the optic nerve and lateral rectus muscle. The mean distance between the ganglion and the optic nerve was 2.9 mm (range: 2.70 - 3.10 mm) and the mean distance between the lateral rectus muscle and the ganglion was 10.4 mm (range: 9.20 - 11.20 mm). Six to 10 short ciliary nerves arise from the ganglion and run forward in a curving manner with the ciliary arteries above and below the optic nerve. The ciliary ganglion should be taken into the account especially during lateral approaches to the orbit and the patients should be warned before the surgery about possible mydriatic or tonic pupils as a complication.

Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea.

The current treatment method for cerebrospinal fluid (CSF) rhinorrhea is surgical repair of the fistula. The aim of this study was to analyse different surgical approaches used for the treatment of CSF rhinorrhea regarding several preoperative and postoperative variables to determine the optimal method in these patients. Patients' charts were retrospectively reviewed to get the required data. Twenty-six patients who underwent different types of surgical approach for the treatment of CSF rhinorrhea were included in the study. Patients who had extensive comminuted fractures of the anterior cranial base and additional brain injury besides CSF rhinorrhea, mostly as a result of gunshot injuries, underwent craniotomy (n = 14). Osteoplastic frontal sinusotomy was used in two patients with a dural defect located at the posterior wall of the frontal sinus. Uncomplicated CSF fistulas in ten patients, located at the anterior and posterior ethmoid roof and in the sphenoid sinus, were closed with an endonasal endoscopic approach. Postoperative success rate was higher (97 % for intracranial approach, 100 % for extracranial external and endonasal endoscopic approach) for all techniques. Anosmia was the most frequent permanent complication (n = 5), seen after craniotomy. In conclusion, endonasal endoscopic approach can be preferred for the closure of uncomplicated CSF fistula, located at the anterior or posterior ethmoid roof and in the sphenoid sinus, due to its minimal postoperative morbidity. Uncomplicated CSF fistula, located at the posterior wall of frontal sinuses can be repaired extradurally with osteoplastic frontal sinusotomy. Intracranial approaches should be reserved for more complicated CSF rhinorrhea which results from extensive comminuted fractures of the anterior cranial base and is accompanied with intracranial complications.

Idiopathic hypogonadotrophic hypogonadism associated with arachnoid cyst of the middle fossa and forebrain anomalies: presentation of an unusual case.

We report a 22-yr-old male patient with hypogonadotrophic hypogonadism (HH) associated with a giant middle fossa arachnoid cyst (AC) diagnosed by magnetic resonance imaging (MRI). He presented with pubertal and growth delay. He also had learning disabilities and anosmia. Laboratory investigation revealed pre-pubertal levels of testosterone and normal results of the combined test of anterior pituitary function, except for in GnRH acute and prolonged test. Cranial MRI showed an AC in left middle fossa with expansion to suprasellar cisterna and several abnormalities like left temporal lobe hypoplasia, left optic tract and bilateral olfactory bulb hypoplasia and left hypothalamic hypoplasia.

Craniocerebral gunshot wounds: results of less aggressive surgery and complications.

Four hundreds patients who suffered from cranial gunshot wounds injuries were analyzed. Surgical therapy, primary and secondary debridement, including repair of dural defects and removal of retained intracranial bone and metal fragments were applied. Central nervous system infections were mostly observed in cases with cerebrospinal fluid (CSF) fistulas. In 130 of 400 patients, bone and metal fragments were determined on control CT scans. Most of the deaths in this group of patients were attributed to the influence of brain injury and occurred within the first month after injury. Fragments retained after first debridement were followed periodically by CT scans. Surgery was not performed until the infection developed. Retained fragments did not increase the infection risk but high rates of infection did occur in cases with CSF fistulas. The presence of diffuse brain damage, brainstem injury, CNS infection, or ventricular injury was associated with a poor outcome. The prognostic importance of complications such as intracranial haemorrhage, epileptic seizures, hydrocephalus, was also investigated.

Lateral approach to the orbit: an anatomical study.

The authors have identified and described three lateral approaches to the intraorbital portion of the optic nerve in cadavers. The structures exposed via the superior, inferior or central approaches were directed through the lateral orbital wall. The superior approach in which the lateral rectus muscle is retracted inferiorly exposes the superolateral aspect of the orbit. The inferior approach in which the lateral rectus muscle is retracted superiorly, provided the inferolateral aspect of the optic nerve from the globe to the muscle cone. The central approach in which the lateral rectus muscle was disinserted and retracted provided excellent exposure of the structures of the lateral part of the orbit and the optic nerve. There were no structures blocking access to the ciliary ganglion and two third anterior optic nerve and lateral surface of the globe. The structures encountered in these approaches are demonstrated under magnification in cadavers, and the exposure of the optic nerve is discussed.

Inferolateral microsurgical approach to the orbit: an anatomical study.

Using detailed cadaveric dissection this study has demonstrated the increase in exposure by using the inferolateral microsurgical approach for neurosurgical and ophthalmological access. The approach to surgical exploration of this region is divided into three steps. The neural, muscular and vascular structures of each step are discussed. We think that, with an intimate understanding of the anatomy of the orbit, many large intraorbital lesions located in the muscle cone and the inferior nasal compartment of the orbit can be safely removed through inferolateral orbitotomy.

Microsurgical anatomy of the orbital part of oculomotor nerve.

The microsurgical anatomy of the oculomotor nerve through its intraorbital course and branching was studied in 30 specimens obtained from 15 cadaver heads fixed in formalin. The superior and inferior divisions of the oculomotor nerve were shown and neural and vascular relationships of each division were examined, then some measurements were performed. In this part of the oculomotor nerve, some critical key points to the various orbital approaches were determined and microanatomic relationships of the orbital contents were revised.

Orbital foreign bodies after penetrating gunshot wounds: retrospective analysis of 22 cases and clinical review.

We conducted a retrospective analysis of 22 patients having orbital penetrating gunshot wounds treated over a 4-years period. The neurological status and the site of injury for each patient are evaluated in this study. We propose a practical protocol in the management of these orbital foreign bodies. Surgical treatment was performed in 4 patients (had functional deficit) with medial orbitotomy in 2, lateral orbitotomy in 1, and superior orbitotomy in 1. 3 of them are improved, in one case the blindness has been continued. 18 patients were treated conservatively and all of them are improved. All patients were followed-up for 2 years with cranial X-rays and CT scans. Neurological sequelae were regressed which existed before the surgery. In conservatively treated cases, infection, migration and functional deficit were not seen. In conclusion, orbital penetrating gunshot wounds must be evaluated precisely by the surgeon and this evaluation sets the guidelines for management. The operation should be reserved for the patients in whom the necrotic soft tissues or orbital damages restrict ocular movements.

Subdural and intraventricular traumatic tension pneumocephalus: case report.

Simple pneumocephalus most frequently arises as a complication of a head injury in which a compound basal skull fracture with tearing of the meninges allows entry of air into the cranial cavity. It can also follow a neurosurgical operation. Tension traumatic pneumocephalus with intraventricular extension is an extremely rare, potentially lethal condition that requires prompt diagnosis and treatment. We report the case of subdural and intraventricular accidental tension pneumocephalus occurring in a 26-year-old man as a result of skull fracture. This case is combined with rhinorrhea and meningitis that suggest some difficulties to treat. The operative procedure associated with medical treatment was performed and a good result was obtained.

The human tail associated with intraspinal lipoma: case report.

A case of a tail in a 9-month-old baby is reported. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the spinal canal. A few medical-historical aspects are discussed. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation and microsurgery.

Orbital manifestation of multiple myeloma: case report.

Orbital involvement is a rare manifestation of multiple myeloma. Therefore, the correct diagnosis and appropriate management are usually difficult and generally require biopsy. We report a 60-year-old woman having multiple myeloma with orbital involvement. Right orbitozygomatic craniotomy was carried out and the mass lesion was removed. After the histological examination, the diagnosis of multiple myeloma was confirmed. The clinical course and the treatment modalities of this entity are discussed in view of the literature.

Multiple sclerosis with mass effect: case report.

Multiple sclerosis (MS) may rarely present as a cerebral mass with the clinical features and computed tomography (CT) scan appearance of a cerebral tumor. We report a case of MS with large cranial involvement showing a mass effect. We carried out a complete examination, including contrast enhancement, with neuroimaging studies. The operative procedure associated with medical treatment was performed and we obtained a good result.