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.

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.

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.

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.

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.

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.

Spontaneous fusion several years after undiagnosed cervical distractive flexion injury: a report of 3 cases.

We report three cases of spontaneously fused distractive flexion injury (DFI) in the cervical spine detected several years after the trauma. This is the first report in the literature that describes such late presentation of healed DFI. Although injuries are considered highly unstable requiring fusion surgery, all three healed spontaneously without intervention or immobilization. Despite significant misalignment, stability was confirmed with flexion-extension radiographs. All the three patients had no neurologic deficits. The possibility of healed old DFI should be kept in mind for patients who present with neck pain and a history of high-energy trauma.

A series of post-traumatic midline epidural hematoma and review of the literature.

BACKGROUND: Supratentorial midline epidural hematoma is rare but challenging in diagnosis and management. Indication for surgery can arise even following hospital admission. Being familiar to the presentation and watching out for direct and indirect signs on axial computed tomography (CT) such as suture diastasis or fracture traversing midline are essential to plan multi-planar CT enabling exact diagnosis including form and mass effect of hematoma. METHODS: Nine patients with midline epidural hematoma including two pediatric patients underwent surgery between 2013 and 2018. Pre-operative and post-operative patient status, radiological features, and surgical technique were analyzed. RESULTS: Four patients had deteriorating consciousness levels and two patients had paraparesis. All had fractures traversing midline and epidural hematomas with significant mass effect. They were operated through separated craniotomies around the midline and midline bone strip was used for dural tenting and as support for natural closure of bone flaps. No post-operative complications were developed. All patients were discharged with Glasgow Outcome Score of 5. CONCLUSION: Because of the rarity of the lesion and small number of patients, definitive conclusions may be misleading but we think that, in experienced hands, midline epidural hematomas can safely be operated on and, preservation of midline bone strip pro-vides easier bleeding control.

Analysis of the Prognosis of High-Grade gliomas in the View of New Immunohistochemistry Markers and 2016 WHO Classification.

AIM: To evaluate isocitrate dehydrogenase (IDH) mutation status and Ki67 percentages of tumors that were treated in our institution to determine whether these markers affected the initial diagnosis and survival rates. MATERIAL AND METHODS: High-grade glioma patients, who were operated in our department between 2013 and 2018, were enrolled in the study and retrospectively reviewed. New immunohistochemistry staining studies were conducted and survival analyses were performed. RESULTS: Of 135 patients and 136 tumors, 117 were glioblastoma multiforme (GBM), 8 were grade III-IV glioma, 4 were anaplastic astrocytoma and 7 were anaplastic oligodendroglioma. One patient had two different lesions, which were GBM and anaplastic astrocytoma respectively. Mean age was 55 (7-85) years, and 88 (65%) were male and 47 (35%) were female. The most common complaint was motor deficit (56%). Fourteen patients underwent reoperation due to recurrent disease. Tumors were most commonly found in the frontal lobe (53, 39%). Magnetic resonance imaging (MRI) features showed that existence of necrosis is strongly related to GBM (p < 0.01). Approximately 126 patients were found to be IDH-wildtype, which changed 6 patients? diagnosis to GBM, IDH wildtype from grade III-IV glioma. Five patients, who were diagnosed with anaplastic astrocytoma and anaplastic oligodendroglioma initially were found to be IDH wildtype. IDH mutation status, extend of resection, and age were found to affect survival. CONCLUSION: IDH mutation status is important in classifying high-grade gliomas, as well as its effects on prognosis. This mutation is related to several radiological features of tumors. Extent of resection and patient age are also profoundly affect survival. Detailing the diagnosis with molecular features will help physicians to shape targeted adjuvant therapies, which would better outcomes.

Versatile Use of Intraoperative Ultrasound Guidance for Brain Puncture.

BACKGROUND: Intraoperative ultrasound (iUS) is an effective guidance and imaging system commonly used in neuro-oncological surgery. Despite the versatility of iUS, its utility for single burr hole puncture guidance remains fairly underappreciated. OBJECTIVE: To highlight the simplicity, versatility, and effectiveness of iUS guidance in brain puncture by presenting the current case series and technical note collection. METHODS: We present 4 novel uses of iUS guidance for single burr hole brain puncture: cannulation of normal-sized ventricles, endoscopic third ventriculostomy (ETV) guidance, evacuation of interhemispheric empyema, and stereotactic biopsy assistance. RESULTS: All techniques were performed successfully in a total of 16 patients. Normal-sized ventricles were cannulated in 7 patients, among whom 5 underwent Ommaya reservoir placement and 2 underwent ventriculoperitoneal shunt placement for idiopathic intracranial hypertension. No more than 1 attempt was needed for cannulation. All ventricular tip positions were optimal as shown by postoperative imaging. iUS guidance was used in 5 ETV procedures. The working cannula was successfully introduced to the lateral ventricle, providing the optimal trajectory to the third ventricular floor in these cases. Interhemispheric subdural empyema was aspirated with iUS guidance in 1 patient. Volume reduction was clearly visible, allowing near-total evacuation of the empyema. iUS guidance was used for assistive purposes during stereotactic biopsy in 3 patients. No major perioperative complications were observed throughout this series. CONCLUSION: iUS is an effective and versatile guidance system that allows for real-time imaging and can be easily and safely employed for various brain puncture procedures.

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.

When to Assess: Cognitive Impact of Ventriculoperitoneal Shunt Operation in Elderly Adults with Normal Pressure Hydrocephalus.

OBJECTIVE: Normal pressure hydrocephalus (NPH) has clinical manifestations with different cognitive difficulties. Despite the intense interest, the change in cognitive functions after ventriculoperitoneal shunt (VPS) treatment varies widely. The aims of this study were to monitor the effect of NPH on cognition in elderly and the progress of cognitive abilities after VPS surgery. METHODS: Patients diagnosed with idiopathic NPH (iNPH) who had ventriculomegaly with narrow callosal angle and/or periventricular signal changes not attributable to ischemic changes were included in study. All patients (n = 30) underwent comprehensive neuropsychological assessment and received programmable VPS. After VPS placement, 2 consecutive examinations were performed at approximately 6-month intervals. RESULTS: At the baseline evaluation, patients with iNPH displayed poorer performance in executive functions (EFs) compared with the matched control group (n = 30). Among those patients, significant improvement was observed in semantic fluency (M = 13.94; standard deviation, 4.95) and clock drawing (M = 3.67; standard deviation, 1.57) at the second follow-up evaluation (P = 0.015 and P = 0.024, respectively). The other prominent finding was in memory process: patients with iNPH showed improvement in delayed recall (P = 0.011), recognition (P = 0.033), and learning scores (P = 0.041) at the second follow-up compared with evaluation before VPS placement. CONCLUSIONS: iNPH seems to have a detrimental effect predominantly on EFs. As EFs become corrupted, decline occurs in learning and recall processes of memory. VPS provides an improvement of cognitive deterioration; however, efficacy of this treatment on cognitive abilities is shows in a longer period compared with other iNPH symptoms.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival.

BACKGROUND: In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival. METHODS: Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated. RESULTS: Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006). CONCLUSIONS: Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

How I do it: ultrasound-guided placement of ommaya reservoir in a patient with small ventricles and cavum septum pellucidum.

BACKGROUND: Intraventricular chemotherapy via Ommaya reservoir is an important part of the treatment in patients with malignant central nervous system tumors. In these patients, catheter placement can be challenging due to the normal-sized ventricles. METHOD: Intraoperative ultrasound guidance was used for Ommaya reservoir placement in a 56-year-old patient with multiple intracranial and leptomeningeal metastases who had cavum septum pellucidum et vergae malformation. The catheter was successfully placed into the frontal horn of the lateral ventricle outside the cavum. CONCLUSION: Intraoperative ultrasound is a suitable image guidance system in patients with slit-like or normal-sized ventricles. It can also be used in patients with ventricular malformations.

Comprehensive Anatomic and Morphometric Analyses of Triangular Working Zone for Transforaminal Endoscopic Approach in Lumbar Spine: A Fresh Cadaveric Study.

OBJECTIVE: The aim of this study is to provide essential information for endoscopic transforaminal approach by performing morphometric analysis of the triangular working zone (TWZ) in fresh cadavers. METHODS: Fifteen fresh human cadavers (9 women and 6 men) with no history of spinal surgery were used in this study. Anatomic dissection of 150 foraminal levels were performed. Significant surgical landmarks constructing TWZ were measured bilaterally from L1-2 to L5-S1 on 15 fresh cadavers. The relationship between traversing roots and intervertebral discs was defined. RESULTS: Base, height, and hypotenuse measurements of TWZ were longer as the level lowered. Mean base height and hypotenuse of TWZ were 12.15 mm, 11.29 mm, and 16.69 mm (L1-2); 17.94 mm, 17.18 mm, and 28.03 mm (L5-S1), respectively. TWZ was triangular shaped at the upper lumbar levels (L1-2, L2-3, and L3-4), and trapezoid at the lower lumbar levels (L4-5 and L5-S1). Going down the levels, the exiting root angle was narrower, the mean exiting angle of the L5 root being 28.23°. All L2 and L3 traversing roots and nearly all L4 traversing roots (86.7%) originated from below the disc level. Forty percent of L5 traversing roots originated above the disc level, and 53.3% originated at the disc level. Most S1 traversing roots originated at the proximal margin of the disc level (80%). CONCLUSIONS: Our study reveals a detailed morphometric analysis of TWZ. Understanding the foraminal anatomy is crucial for safely performing transforaminal endoscopic surgery. The learning curve of transforaminal surgery can be reduced by garnering knowledge of TWZ anatomy.

Transcortical Removal of Third Ventricular Colloid Cysts: Comparison of Conventional, Guided Microsurgical and Endoscopic Approaches and Review of the Literature.

AIM: To compare the clinical results of different transcortical approaches for the removal of third ventricular colloid cysts (CC). MATERIAL AND METHODS: Records of 41 colloid cyst patients who underwent transcortical conventional microsurgical, microsurgical with the aid of stereotactically guided cylindrical retractor (minitubular), and endoscopic removal between 1999 and 2015 were retrospectively analyzed. The clinical results of these three different transcortical surgical approaches were compared and a literature review of published series was conducted. RESULTS: Ages ranged between 16 and 66 years (mean: 36.8). There were 18 female and 23 male patients. Headache was the main presenting symptom. The mean CC diameter was 15.5 mm. Intraventricular hemorrhage was encountered in 2 patients. Three patients needed postoperative ventriculoperitoneal shunt surgery. Postoperative seizures were seen in 3, postoperative neurological deficit in 3 and residual tumor in 2 patients. The conventional approach resulted in significantly higher rates of postoperative seizure compared to the minitubular and endoscopic approaches (p=0.012). The rate of residual cyst was significantly higher in endoscopic approach compared to conventional and minitubular approaches (p=0.024). Conventional approach led to significantly higher rates of neurological deficit compared to the two other approaches (p < 0.05). CONCLUSION: With respect to complication rates, the stereotactic and endoscopic approaches are both safe and reliable compared to conventional microsurgical approach that has unacceptably high rates of seizures and neurological deficit. Concerning completeness of removal, both microsurgical approaches are by far superior to neuroendoscopy. The stereotactic microsurgical approach compares favorably in both respects with endoscopic and conventional microsurgical approaches.

Retraction: Primary cerebellopontine angle Rathke's cleft cyst: case report.

On behalf of all authors, I respectfully request the retraction of our article, "Primary Cerebellopontine Angle Rathke's Cleft Cyst: Case Report" (Turk Neurosurg, published online 2014, Vol: 24, No: 3; DOI: DOI: 10.5137/1019-5149. JTN.8084-13.1). This request is based on multiple problems with our study.