Is prophylactic anti-convulsive treatment necessary in subdural hematomas?

BACKGROUND: Subdural hematoma (SDH) is usually an emergent clinical condition in neurosurgery. The relationship between the SDH and epilepsy is not well established. Therefore, the use of anti-convulsive treatment in patients with SDH is controversial. The aim of this study is to analyze the presence of seizures in patients who underwent surgery for SDH. METHODS: Patients who were operated on for SDH in our department between 2016 and 2021 were reviewed retrospectively. Demographic features, Glasgow Coma Scale (GCS) score at admission, type of SDH, location, etiology, type of surgical intervention, presence of seizures, and re-operation were evaluated. RESULTS: There were 175 patients with SDH. There is a statistically significant difference between the frequency of seizures and the type of SDH. More seizures were observed in acute SDH than in the others. There is also a statistically significant difference between the GCS score and the frequency of seizures. Patients with a GCS score <12 at admission had more frequent seizures than patients with a score of 12 or higher. No statistically significant difference was found between factors such as etiology, re-operation, hematoma location, and the development of seizures. CONCLUSION: Anti-convulsive treatment may be recommended in patients with acute SDH and a low GCS score at admission. Further studies with larger series should be performed to determine the most appropriate anti-convulsive agent for patients with SDH.

Risk Factors and Surgical Treatment Options for Intracranial Infections.

AIM: To present our experience on intracranial infections, and to determine the possible locations as well as the risk factors for surgical treatment. MATERIAL AND METHODS: Over 13 years, 103 patients with intracranial infection underwent surgical evacuation. Seventy-one (68.9%) patients were men, and the mean age was 38.57 years. For intracranial infections, direct and indirect microbiological identification methods were used. The clinical and radiological data of patients were retrospectively analyzed and compared statistically based on the type of infection, location, history of previous surgery, comorbid diseases, and demographic features of the patients. RESULTS: Forty-six (44.7%) patients had intraparenchymal abscess, 25 (24.3%) had subdural empyema, and 32 (31.0%) had epidural empyema. Emergent surgical evacuation was performed in 60 (58.25%) patients. Microbiological agents were not isolated in 26 (25%) patients, while multiple microorganisms were isolated in 17 (16.5%) patients. Intraparenchymal abscesses are more common in the frontal lobe and cerebellum, while subdural empyemas are located more frequently in the frontoparietal region. There was no significant difference between intracranial infection and age, gender, history of surgery, and preoperative antibiotic use. However, a statistically significant relationship between intracranial infection, history of previous surgery, and the patient?s comorbid disease was found. Specifically, intraparenchymal abscesses were more frequently detected in immunocompromised patients, and subdural empyemas were common in patients with previous tumor surgery. CONCLUSION: Brain abscesses commonly develop in the frontal lobe and cerebellum. Patients who underwent previous cranial surgery and patients with comorbid diseases are more prone to intracranial infections. Large abscesses with significant edema are best candidates for emergent surgical evacuation.

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.

Endoscopic endonasal approach to the cavernous sinus Epstein-Barr virus-positive B cell non-Hodgkin lymphoma in a child: case report.

Cavernous sinus (CS) lymphoma without paranasal sinuses involvement is extremely rare in pediatric population and remains a diagnostic challenge due to its similarity to other tumors located in this area. An 8-year-old boy presented with a 6-day history of gradually developing ptosis in the right eyelid. After admission, his symptoms progressed within 24 h to include right-sided ophthalmoplegia consisting of oculomotor and abducens nerve palsies. Endoscopic endonasal approach (EEA) was performed urgently to decompress the CS and to obtain a diagnosis. The postoperative course was uneventful, and there was no complication related to the surgical approach. No immunodeficiency was identified. The histopathological diagnosis was an Epstein-Barr virus (EBV)-positive high-grade mature B cell non-Hodgkin lymphoma. He was initiated chemotherapy according to COG ANHL01P1 protocol. Two months after surgery, the third and sixth nerve palsies had resolved completely. Currently, he is well and has no clinical or radiological recurrence. This is the first pediatric case with EBV-positive CS lymphoma that underwent EEA for the diagnosis and decompression. In the pediatric population, EEA enables minimally invasive access to the CS and can play an alternative role in the management of CS lesions, either through biopsy or debulking.

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.

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.

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.

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.