Effectiveness and Safety of Epilepsy Surgery for Pediatric Patients with Intractable Epilepsy: A Clinical Retrospective Study from a Single-Center Experience.

INTRODUCTION: Pediatric epilepsy surgery is an effective treatment modality for patients with drug-resistant epilepsy (DRE). Early pediatric surgery yields favorable results for DRE in terms of seizure control and neurophysiological outcome. In this study, pediatric patients were categorized based on their age (above 3 years old and below 3 years old) to demonstrate the effectiveness and safety of surgical procedures. METHODS: In this retrospective, single-center study, 60 pediatric patients who underwent epilepsy surgery at Istanbul Faculty of Medicine between 2002 and 2018 were evaluated. Overall morbidity and mortality rates, as well as seizure outcomes of the patients, were assessed and compared based on two age groups: those aged 3 years old or younger and those older than 3 years old. The effectiveness of invasive monitoring was also evaluated in relation to pathological results. The postoperative seizure outcome rates were evaluated using Engel's classification, with an average follow-up period of 8.7 years. RESULTS: Out of the total number of patients, 47 (78.4%) underwent resective surgery, while 13 (21.6%) had palliative surgery. Ten patients (16.6%) had invasive monitoring. Among all patients, 34 were classified as Engel I and II (56.6%), while 26 were classified as Engel III and IV (43.4%) postoperatively. 47% of patients who were under 3 years old, 60.4% of patients who were over 3 years old, and 50% of patients who underwent invasive monitoring had a favorable seizure outcome (Engel I-II). Postoperative morbidity and mortality rates were 35% (n = 21) and 1.6% (n = 1), respectively. CONCLUSION: Pediatric epilepsy surgery is an important treatment modality for preserving cognitive abilities and providing effective treatment for pediatric DRE. In our study, we claim that both invasive monitoring and epilepsy surgery lead to favorable seizure outcomes for all age groups. Further clinical studies should be conducted to provide more reliable data on the safety and effectiveness of the surgery, particularly in patients under the age of three.

Focal cortical dysplasia pathology: diagnostic difficulty, classification, and utility for pathogenesis.

OBJECTIVE: In the histopathological examination of treatment-resistant epilepsy, focal cortical dysplasia (FCD) is the most common diagnosis in the pediatric group. FCD is classified histopathologically according to the International League Against Epilepsy (ILAE) classification. In the last decade since the ILAE classification has been released, molecular genetic studies have revealed mTOR pathway-related mutations as a major etiology. The objective of this study was to determine the incidence of FCD in treatment-resistant epilepsy patients, explore histomorphological and immunohistochemical features, examine clinicopathological correlation, demonstrate mTOR pathway activation using a pS6 antibody immunohistochemically, and try to introduce a candidate for possible targeted therapies. METHODS: Paraffin blocks and slides of tissue from patients with treatment-resistant epilepsy were reexamined retrospectively. Histopathological subtypes of FCD were determined according to the ILAE classification. NeuN and neurofilament H (NF-H) staining were performed, and additionally a pS6 antibody was used to demonstrate mTOR pathway activation. RESULTS: In 32 cases diagnosed with FCD, or 17.5% of 183 surgical epilepsy materials, there were no significant differences in the statistical analysis of clinical variables between the ILAE FCD subtypes. Recommended antibody NeuN revealed microcolumnar alignment in the FCD type Ia and IIIa groups and the loss of lamination in the type Ib group. Another recommended antibody, NF-H, was not found to be useful in discriminating between normal and dysmorphic neurons. pS6 expression, showing mTOR pathway activation, was observed in dysmorphic neurons and balloon cells in all FCD type II cases. CONCLUSIONS: Significant pS6 expression in FCD type II represents the genomic nature of the disease noted in the literature. Nevertheless, the known MTOR gene and mTOR pathway-related mutations remain behind proportionally to explain the mTOR pathway activation in all FCD type II cases. Clinicopathologically and genetically integrated classification and usage of mTOR pathway inhibitors in treatment are expected as a recent evolution.

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

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

Stereotyped high-frequency oscillations discriminate seizure onset zones and critical functional cortex in focal epilepsy.

High-frequency oscillations in local field potentials recorded with intracranial EEG are putative biomarkers of seizure onset zones in epileptic brain. However, localized 80-500 Hz oscillations can also be recorded from normal and non-epileptic cerebral structures. When defined only by rate or frequency, physiological high-frequency oscillations are indistinguishable from pathological ones, which limit their application in epilepsy presurgical planning. We hypothesized that pathological high-frequency oscillations occur in a repetitive fashion with a similar waveform morphology that specifically indicates seizure onset zones. We investigated the waveform patterns of automatically detected high-frequency oscillations in 13 epilepsy patients and five control subjects, with an average of 73 subdural and intracerebral electrodes recorded per patient. The repetitive oscillatory waveforms were identified by using a pipeline of unsupervised machine learning techniques and were then correlated with independently clinician-defined seizure onset zones. Consistently in all patients, the stereotypical high-frequency oscillations with the highest degree of waveform similarity were localized within the seizure onset zones only, whereas the channels generating high-frequency oscillations embedded in random waveforms were found in the functional regions independent from the epileptogenic locations. The repetitive waveform pattern was more evident in fast ripples compared to ripples, suggesting a potential association between waveform repetition and the underlying pathological network. Our findings provided a new tool for the interpretation of pathological high-frequency oscillations that can be efficiently applied to distinguish seizure onset zones from functionally important sites, which is a critical step towards the translation of these signature events into valid clinical biomarkers.awx374media15721572971001.

Relation of gray-white matter ratio with long-term cognitive functions and quality of life in patients with mild to moderate aneurysmal subarachnoid hemorrhage: a prospective observational study.

BACKGROUND: In the present study, we hypothesized that a low gray matter-white matter ratio (GWR) is associated with poor cognitive function and low quality of life in patients with mild to moderate (WFNS ≤3) aneurysmal subarachnoid hemorrhage (aSAH). METHODS: All patients with aSAH who were admitted to the neurointensive care unit (Neuro ICU) and whose WFNS score was ≤ 3 were enrolled in the study. During the Neuro ICU follow-up period, the following variables were recorded: demographics, neurological status, comorbidities, time elapsed between onset of bleeding and Neuro ICU admission, treatment method, number of days with vasospasm symptoms (DVS) and vasopressor usage. One year after bleeding, all patients except those who could not answer the questionnaires appropriately were administered the MoCA and SF-36 tests, and brain magnetic resonance imaging and then volumetric brain analysis were performed. RESULTS: Eighty-two patients completed the study. One year after aSAH, cognitive dysfunction and low quality of life were observed in 59.8% and 25.6% of patients, respectively. Among the variables obtained during Neuro ICU follow-up, DVS was found to be a major risk factor for cognitive dysfunction (OR: 3.9, 95% CI: 1.9-7.8; p < 0.001), poor quality of life (OR: 2.8, 95% CI: 1.4-5.3, p = 0.002) and a lower GWR value (p < 0.001, correlation coefficient = -0.410, R2 = 0.234). One year after aSAH, higher GWR values were associated with higher MoCA (R2 = 0.506 for males, R2 = 0.413 for females) and SF-36 (R2 = 0.270 for males, R2 = 0.364 for females) scores in both genders. Also, GWR ≤ 1.35 in males and GWR ≤1.33 in females indicated MoCApoor patients with over 80% specificity and sensitivity. CONCLUSION: GWR has good correlation with the MoCA and SF-36 score, and a low GWR can indicate cognitive dysfunction. In this context, GWR can be used as an additional method to evaluate cognitive function and quality of life.

Fully endoscopic interlaminar and transforaminal lumbar discectomy: Analysis of 47 complications encountered in a series of 835 patients.

OBJECTIVE: To report perioperative complications in fully endoscopic lumbar discectomy (FELD). METHODS: From September 2010 to November 2016, 835 patients underwent FELD. In total, 865 disc levels were operated on. Of the 835 patients, the transforaminal (TF) approach was used in 174 patients, while 691 patients were operated on using the interlaminar (IL) approach. Surgical complications occurred in 47 patients, which were retrospectively analyzed. RESULTS: Neurological deficits occurred in six patients. In four of these six patients, deficits resolved spontaneously. In one patient, symptoms resolved after a laminectomy procedure. In only one case, the neurological deficit was permanent. Seven patients complained of dysesthesia, which resolved spontaneously with medical treatment in four patients. In the remaining two patients, dysesthesia symptoms improved after epidural and foraminal injections. Dural tears were encountered in 26 patients. Pudendal neuralgia occurred in three patients. Two cases showed wound infection. The other complications comprised one disc infection, one retroperitoneal hematoma and one wrong level surgery. CONCLUSION: The FELD procedure has a steep learning curve and it is a difficult procedure to master. Surgeons should be aware of complications that can occur with the FELD procedure, most of which resolve spontaneously.

Neuronal autoantibodies in mesial temporal lobe epilepsy with hippocampal sclerosis.

OBJECTIVE: Our aim was to investigate the prevalence of neuronal autoantibodies (NAbs) in a large consecutive series with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and to elucidate the clinical and laboratory clues for detection of NAbs in this prototype of frequent, drug-resistant epilepsy syndrome. METHODS: Consecutive patients diagnosed with MTLE fulfilling the MRI criteria for HS were enrolled. The sera of patients and various control groups (80 subjects) were tested for eight NAbs after ethical approval and signed consents. Brain tissues obtained from surgical specimens were also investigated by immunohistochemical analysis for the presence of inflammatory infiltrates. The features of seropositive versus seronegative groups were compared and binary logistic regression analysis was performed to explore the differentiating variables. RESULTS: We found antibodies against antigens, contactin-associated protein-like 2 in 11 patients, uncharacterised voltage-gated potassium channel (VGKC)-complex antigens in four patients, glycine receptor (GLY-R) in 5 patients, N-methyl-d-aspartate receptor in 4 patients and γ-aminobutyric acid receptor A in 1 patient of 111 patients with MTLE-HS and none of the control subjects. The history of status epilepticus, diagnosis of psychosis and positron emission tomography or single-photon emission CT findings in temporal plus extratemporal regions were found significantly more frequently in the seropositive group. Binary logistic regression analysis disclosed that status epilepticus, psychosis and cognitive dysfunction were statistically significant variables to differentiate between the VGKC-complex subgroup versus seronegative group. CONCLUSIONS: This first systematic screening study of various NAbs showed 22.5% seropositivity belonging mostly to VGKC-complex antibodies in a large consecutive series of patients with MTLE-HS. Our results indicated a VGKC-complex autoimmunity-related subgroup in the syndrome of MTLE-HS.

Metabolic changes and factors influencing base deficit in infants undergoing craniosynostosis surgery: a retrospective study.

BACKGROUND: Corrective craniosynostosis surgery is often associated with a large amount of blood loss and metabolic disturbances. In the present study, we investigated the severity, duration of metabolic disturbances, and causal risk factors in infants. METHODS: A retrospective analysis was performed of 36 infants who underwent craniosynostosis surgery. We analyzed the following: demographics, duration of surgery, intraoperative blood loss, RBC, FFP and fluids transfused, urine output, hemodynamic parameters, and electrolyte and base deficit (BD) values. The lowest intraoperative BD value and time required (period I: <6 h; period II: 6-12 h; period III: >12 h) for BD values to return to normal (-4 to +2) in the postoperative period were determined. In addition, we recorded the postoperative length of stay in the ICU and hospital, postoperative blood loss, and early complications. RESULTS: We detected that 88% of the patients had subnormal BD levels and 22% had metabolic acidosis. The lowest average BD measured during the operation was -8.4 ± 2.6 mmol/l. We carried out a multiple regression analysis, which revealed that lower BD values were associated with a longer duration of hypotension (p = 0.002, R(2) = 0.453) and greater intraoperative blood loss (p = 0.002, R(2) = 0.674). We examined the amount of intraoperative blood loss and found that that there were fewer blood product transfusions in period I patients and longer hypotensive episodes in period III patients. Also, a negative correlation was detected between the lowest intraoperative BD value with ICU duration (p = 0.004, r = -0.466) and hospital stay (p < 0.001, r = -0.764). CONCLUSION: Almost all patients developed intraoperative negative BD, which was prolonged in the postoperative period. The most important risk factors for developing negative BD are the amount of blood loss and duration of hypotension.

Neuronavigation-assisted percutaneous balloon compression for the treatment of trigeminal neuralgia: The technique and short-term clinical results.

BACKGROUND: Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia. However, this technique has a steep learning curve and significant complications were reported that were related to foramen ovale puncturing. The aim of this study was to evaluate the clinical results of a small patient group who underwent neuronavigation-assisted PBC. METHODS: An intraoperative computed tomography (CT) device (CereTom, Neurologica, Danvers, MA/USA) was used to obtain CT scans with 2-mm slice thicknesses. The data were transferred to a neuronavigation system planning station (BrainLab, Feldkirchen, Germany). A soft touch registration system was used for image registration. With the image guidance, a trajectory was defined and the foramen ovale was cannulated using neuronavigation and Hartel's landmarks. RESULTS: Sixteen procedures were performed on 13 patients (4 female and 9 male) without complications. The total length of the procedure was not more than 57 min in all instances. CONCLUSIONS: We believe that image-guided neuronavigation is useful for neurosurgeons who are at the beginning of their PBC learning curve. It may also be an alternative for particular patients with significant anatomic variations that result in an unsuccessful foramen ovale puncture.

Full-Endoscopic Surgery for Hypothalamic Hamartoma Resection.

Hypothalamic hamartomas (HH) are rare developmental anomalies of the inferior hypothalamus that often cause refractory epilepsy, including gelastic seizures. Surgical resection is an effective method to treat drug-resistant epilepsy and endocrinopathy in a suitable patient group. Open surgery, endoscopic surgery, ablative procedures, and stereotactic radiosurgery can be utilized. In this study, we aimed to describe the full-endoscopic approach for HH resection. The technique involves the use of an intraoperative ultrasonography (USG) system, a 30° rigid endoscope system that has an outside diameter of 2.7 mm with two working channels, a stylet that has an outer diameter of 3.8 mm, a monopolar coagulation electrode, a fiberoptic light guide, and the endovision system. Microforceps and monopolar electrocautery are the two main surgical instruments for HH removal. The protocol is easy to apply after a particular learning curve has been passed and shorter than open surgical approaches. It leads to less blood loss. Full-endoscopic surgery for HH is a minimally invasive technique that can be applied safely and effectively with good seizure and endocrinological outcomes. It provides low surgical site pain and early mobilization.

A Morphometric Study of Cadavers for the Anterior Approach to the Lower Lumbar Spine.

AIM: To explore the relationship between the retroperitoneal vasculature and anterior surface of the lower spine, and to establish values for aiding in prediction of the pertinence of anterior approach at the L4-L5 and L5-S1 intervertebral discs. MATERIAL AND METHODS: The study included 13 fresh human cadavers. After exploration of the abdominal cavity and removal of the visceral organs, the vasculature, and anterior spinal surface were revealed beneath the lower extension of the perirenal fascia. Morphometric measurements of the great vessels and the intervertebral discs were obtained. All measurements were analyzed and presented as mean and standard deviation. Differences in the values between sexes were assessed. RESULTS: The anterior height of the L4-L5 and L5-S1 intervertebral disc was 6.8 ± 0.81 mm and 6.7 ± 0.99 mm, respectively. The widths of the aorta, inferior vena cava, right and left common iliac arteries, and right, and left common iliac veins were 16.4 ± 3.58, 20.6 ± 3.36, 11.5 ± 2.32, 11.5 ± 2.43, 14.7 ± 3.13, and 15.5 ± 3.27 mm, respectively. The mean aortic bifurcation angle was 45.5°. The aortic bifurcation was located above the lower endplate of the L4 vertebrae in 53.8% of the cadavers. The area of the interarterial and interiliac trigones was 14.6 ± 5.33 cm < sup > 2 < /sup > and 7.1 ± 4.35 cm2, respectively. No statistically significant differences were noted between the sexes. CONCLUSION: An elaborate radiological examination of the vasculature should be performed prior to surgery to avoid unwanted vascular complications during the anterior approach. Knowing the area of the interarterial and interiliac triangles and the aortic bifurcation location could be aid in assessing the safe working zone.

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

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

Factors influencing blood loss and postoperative morbidity in children undergoing craniosynostosis surgery: a retrospective study.

BACKGROUND: Craniosynostosis is a condition resulting from the premature fusion of cranial sutures. Corrective surgery is often associated with a large amount of blood loss, with transfusion of red blood cells (RBC) and fresh frozen plasma (FFP). The aims of this study were to determine the variables associated with increased blood loss and postoperative complications. METHODS: A retrospective analysis was performed of 42 pediatric patients who underwent craniosynostosis surgery. We analyzed the following: demographic parameters, duration of surgery, intraoperative blood loss, RBC, FFP and fluid transfusion, urine output, and hemodynamic parameters. In addition, we recorded the postoperative length of stay in the intensive care unit and hospital, postoperative blood loss and early complications. RESULTS: The mean age, weight and surgical duration were 9.2 ± 3.2 months, 9.3 ± 2.0 kg and 255.8 ± 46.7 min, respectively. Intraoperative blood loss was 61.2 ± 15.3 ml/kg and RBC, FFP and fluid transfusion were 27.3 ± 7.1 ml/kg, 16.5 ± 4.7 ml/kg and 21.7 ± 4.6 ml/kg/h, respectively. Greater intraoperative blood loss was associated with longer surgical duration (p = 0.001, correlation coefficient = 0.495, R2 = 0.245) and lower patient weight (p < 0.001, correlation coefficient = -0.557, R2 = 0.311). Longer hospital stay was associated with greater intraoperative blood loss (p < 0.001, correlation coefficient = 0.754, R2 = 0.568) and greater intraoperative RBC transfusion (p < 0.001, correlation coefficient = 0.795, R2 = 0.632). CONCLUSION: Severe blood loss occurred in all children who underwent craniosynostotic corrections. Furthermore, the duration of surgery, patient weight and certain surgical procedures correlated with greater blood loss. Careful hemodynamic monitoring and evaluation of a patient's hematocrit value and volume status together may be helpful in maintaining the balance between insufficient and excessive blood product transfusion.

Effects of combined and individual use of N-methyl-D aspartate receptor antagonist magnesium sulphate and caspase-9 inhibitor z-LEDH-fmk in experimental spinal cord injury.

BACKGROUND: We investigated the individual and combined effects of magnesium sulphate, which is an N-Methyl-D aspartate receptor antagonist (NMDA), and z-LEHD-FMK, which is a caspase 9 inhibitor, on the genesis of secondary injury in a rat spinal cord injury model. We aimed to minimize the effects of secondary injury in spinal cord trauma by choosing these two agents which served to block the two major mechanisms of cell loss, apoptosis and necrosis. METHODS: The drugs were given to the subjects according to their groups, either in singular or combined fashion. For motor examination, the subjects were kept under close clinical evaluation for five days. Histopathological examination and the emerging spinal cord samples were prepared with haematoxylene-eosin and Tunel techniques. RESULTS: A statistically significant difference in favor of the treatment groups has been found between the treatment and control groups in terms of histological data. However, there was no difference in the evaluation of motor examination between trauma and treatment groups. CONCLUSION: We have found no difference between the individual and combined uses of MgSO4 and z-LEHD-FMK in the prevention of secondary injury; however, there were better histological results in the treatment groups compared to trauma and control groups which gives us hope for future investigations.

Corrigendum: Full-endoscopic removal of third ventricular colloid cysts: technique, results, and limitations.

[This corrects the article DOI: 10.3389/FSURG.2023.1174144.].

Full-endoscopic removal of third ventricular colloid cysts: technique, results, and limitations.

Introduction: Colloid cysts (CCs) are rare benign lesions that usually arise from the roof of the third ventricle. They may present with obstructive hydrocephalus and cause sudden death. Treatment options include ventriculoperitoneal shunting, cyst aspiration, and cyst resection microscopically or endoscopically. This study aims to report and discuss the full-endoscopic technique for removing colloid cysts. Materials and methods: A 25°-angled neuroendoscope with an internal working channel diameter of 3.1 mm and a length of 122 mm is used. The authors described the technique of resecting a colloid cyst by a full-endoscopic procedure and evaluated the surgical, clinical, and radiological results. Results: Twenty-one consecutive patients underwent an operation with a transfrontal full-endoscopic approach. The swiveling technique (grasping the cyst wall and rotational movements) was used for CC resection. Of these patients, 11 were female, and ten were male (mean age, 41 years). The most frequent initial symptom was a headache. The mean cyst diameter was 13.9 mm. Thirteen patients had hydrocephalus at admission, and one needed shunting after cyst resection. Seventeen patients (81%) underwent total resection; 3 (14%), subtotal resection; and 1 (5%), partial resection. There was no mortality; one patient had permanent hemiplegia, and one had meningitis. The mean follow-up period was 14 months. Conclusion: Even though microscopic resection of cysts has been widely used as a gold standard, successful endoscopic removal has been described recently with lower complication rates. Applying angled endoscopy with different techniques is essential for total resection. Our study is the first case series to show the outcomes of the swiveling technique with low recurrence and complication rates.

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

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

Full-Endoscopic Technique for Posterior Fossa Decompression in Chiari Malformation.

BACKGROUND AND IMPORTANCE: Full-endoscopic techniques are well-described for spinal procedures. Although endoscopic-assisted techniques are reported for posterior fossa decompression (PFD) in Chiari malformation (CM), a full-endoscopic technique is yet to be reported in these patients. The aim of this study was to present and describe a full-endoscopic technique for PFD in patients with CM. CLINICAL PRESENTATION: Two patients diagnosed with CM were operated on by the full-endoscopic PFD technique. The patients consented to the procedure and to the publication of their image. An endoscope with an oval shaft cross-section with a diameter of 9.3 mm, a working length of 177 mm, a viewing angle of 20°, and a working channel of 5.6 diameters were used. Operative videos were recorded. The surgical steps were easily applied after the clear anatomic landmarks, such as the C1 posterior tubercle and the rectus capitis posterior minor muscles. The patients were followed up for 6 months. Both patients were symptom-free with a significant decrease in Visual Analog Scale score and a good functional outcome assessed by Chicago Chiari Outcome Scale after surgery without any complications. CONCLUSION: All the steps of the full-endoscopic technique for PFD described by the authors in their previous human cadaveric study were also feasible on patients with CM.

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

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

Surgical management of interhemispheric subdural empyemas: Review of the literature and report of 12 cases.

BACKGROUND: Subdural empyemas (SDEs) are rare intracranial infections mostly secondary to sinusitis. Incidence of SDEs is 5-25%. Interhemispheric SDEs are even rarer, which makes their diagnosis and treatment difficult. Aggressive surgical interventions and wide-spectrum antibiotics are needed for treatment. In this retrospective clinical study, we intended to evaluate the results of surgical management supported by antibiotics in patients with interhemispheric SDE. METHODS: Clinical and radiological features, medical and surgical management and outcomes of 12 patients treated for interhemi-spheric SDE have been evaluated. RESULTS: 12 patients were treated for interhemispheric SDE between 2005 and 2019. Ten (84%) were male, two (16%) were female. Mean age was 19 (7-38). Most common complaint was headache (100%). Five patients were diagnosed with frontal sinusitis prior SDE. Initially, three patients (27%) underwent burr hole aspiration and ten patients (83%) underwent craniotomy. In one patient both were done in the same session. Six patients were reoperated (50%). Weekly magnetic resonance imaging and blood tests were used for follow-up. All patients received antibiotics for at least 6 weeks. There was no mortality. Mean follow-up period was 10 months. CONCLUSION: Interhemispheric SDEs are rare, challenging intracranial infections that have been related to high morbidity and mor-tality rates in the past. Both antibiotics and surgical interventions play role in treatment. Careful choice of surgical approach and repeated surgeries if necessary, accompanied by appropriate antibiotic regimen, leads to good prognosis reducing morbidity and mortality.