The Predictors of Postoperative Cerebrospinal Fluid Leak in Endoscopic Endonasal Pituitary Surgery: The Role of Tumor Volume.

Objectives Postoperative cerebrospinal fluid (Po-CSF) leak is still a challenging complication of endoscopic endonasal skull base surgery. However, data describing the predictive factors of Po-CSF leak in pure pituitary adenomas is lacking. Aim of this study is to determine the risk factors of Po-CSF leak in a pituitary adenoma group operated via pure transsellar endoscopic approach. Design This is a retrospective cohort study. Setting A single-center academic hospital. Participants Patients operated for a pituitary adenoma between 2015 and 2021 and followed up until June 2022 were included. Main Outcome Measures Demographics, comorbidities, imaging, and outcome were recorded. Univariate and multivariate logistic regression analyses were used to determine the risk factors of Po-CSF leak. Results Of the total 170 patients with a mean age of 47.5 ± 13.8 (min: 15; max: 80), 11 (6.5%) had Po-CSF leak. Univariate analysis revealed age, diabetes mellitus (DM), and tumor volume as predictors of Po-CSF leak. According to the receiver operating characteristic analysis, 7.5 cm 3 of tumor volume was found to be a good cutoff value with a sensitivity of 82% and a specificity of 75%. Hence, multivariable logistic regression model adjusted by age showed that a tumor volume of > 7.5 cm 3 (odds ratio [OR]: 22.9; 95% confidence interval [CI]: 3.8-135.9, p = 0.001) and DM (OR: 8.9; 95% CI: 1.7-46.5; p = 0.010) are strong independent risk factors of Po-CSF leak in pure endoscopic endonasal pituitary surgery. Conclusion Besides younger age and DM, a cutoff value for tumor volume > 7.5 cm 3 is the most remarkable risk factor for Po-CSF leak in pure endoscopic pituitary surgery. These patients should carefully be assessed preoperatively and potential preemptive surgical strategies should be taken into consideration to avoid complications.

Percutaneous Ventriculoatrial Shunting as a Salvage Method in the Pediatric Hydrocephalus Patients with Peritoneal Problems.

AIM: To evaluate the efficacy of percutaneous ventriculoatrial shunting as a salvage method for pediatric patients with abdominal complications. MATERIAL AND METHODS: Data obtained from 9 patients with ventriculoperitoneal shunt dysfunctions owing to abdominal complications, who underwent ventriculoatrial shunting as salvage treatment at a single institution between January 2019 and September 2021 were retrospectively analyzed. All operations were conducted under the guidance of intraoperative fluoroscopy and ultrasound. RESULTS: The mean age of the enrolled patients was 8.1 ± 1.2 years (2-15 years). Six (67%) patients were male and 3 (33%) were female. The mean number of the patients? ventriculoperitoneal shunt revisions until atrial catheter placement was 7.5 times. The reasons for intraperitoneal catheter failure included peritoneal adhesions in 4 (44.5%) patients, pseudocyst formation in 3 (33.3%), and peritonitis in 2 (22.2%). Seven patients from the study cohort had no problem after ventriculoatrial shunt placement. Only 1 patient had shunt dysfunction related to the ventricular catheter, and ventricular catheter and shunt valve revision was performed 26 months after ventriculoatrial shunt placement. The atrial catheter of the patient was intact. One patient died from the progression of her primary disease (medulloblastoma in the 4 < sup > th < /sup > ventricle), which was unrelated to the ventriculoatrial shunt. CONCLUSION: Percutaneous ventriculoatrial shunting under the guidance of intraoperative fluoroscopy and ultrasound is a safe, effective, and easy alternative in patients with peritoneal complications and a history of multiple operations.

Extraskeletal Myxoid Chondrosarcoma of the Jugular Foramen in a Pediatric Patient: A Case Report and Comprehensive Review of the Literature.

INTRODUCTION: Extraskeletal myxoid chondrosarcoma of the jugular foramen is a rare clinical entity, especially in the pediatric population. Thus, it can be confused with other pathologies. CASE PRESENTATION: We report an extremely rare case of a 14-year-old female patient with jugular foramen myxoid chondrosarcoma that was completely removed through microsurgical resection. CONCLUSION: The primary purpose of the treatment is gross total resection of the chondrosarcomas. However, adjuvant methods such as radiotherapy should additionally be applied in patients who have high-grade diseases or cannot undergo gross total resection because of anatomic localization.

Endonasal endoscopic approach for sellar metastatic pathologies: a national observation.

PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Impact of Adjuvant Radiotherapy on Recurrence of Surgically Treated Atypical Meningiomas and Retrospective Analysis of Prognostic Factors.

AIM: The role of adjuvant radiotherapy after surgery for atypical meningiomas remains controversial. The present study was designed to investigate the recurrence rate of atypical meningiomas after surgery (with or without adjuvant radiotherapy) and determine which factors were related with recurrence. MATERIAL AND METHODS: Data obtained from 83 patients who underwent surgery and histopathologically diagnosed with atypical meningioma at a single institution between January 2009 and June 2019 were retrospectively reviewed. Then, the patients were divided into two groups: the surgery-only (n = 43) and surgery + adjuvant radiotherapy (n = 40) groups. RESULTS: The mean age of the patients was 53.5 ± 14.6 years. Among them, 51 (61.4%) were female and 32 (38.6%) were male. The recurrence rates were 30.2% (n = 13) in the surgery-only group and 17.5% (n = 7) in the surgery + adjuvant radiotherapy group. A statistically significant decrease in the recurrence rate was observed after adjuvant radiotherapy application (p = 0.046). Moreover, adjuvant radiotherapy significantly increased progression-free survival (p = 0.042). Peritumoral edema, sinus invasion, brain invasion, subtotal tumor resection, and complications were significant predictors of tumor recurrence, and the main risk factors for the recurrence of atypical meningiomas were brain invasion (p = 0.019) and subtotal tumor resection (p = 0.006). Progression-free survival and overall survival of the study group were 45.50 ± 27.56 and 56.69 ± 28.17 months, respectively. The parameters examined in the study, except for tumor recurrence, did not show a statistically significant influence on overall survival. CONCLUSION: This study revealed that the important prognostic factors for tumor recurrence are subtotal tumor resection and brain invasion. Moreover, adjuvant radiotherapy in addition to surgical resection reduces the recurrence rate of atypical meningiomas and improves progression-free survival of the patients. However, adjuvant radiotherapy did not show a significant influence on overall survival.

Symptomatic bilateral choroid plexus xanthogranuloma in a pediatric patient.

INTRODUCTION: Central nervous system xanthogranulomas are uncommon clinical entities, and symptomatic bilateral choroid plexus xanthogranulomas are rare. CASE PRESENTATION: We present the case of a 15-year-old male patient with bilateral choroid plexus xanthogranulomas with symptoms of increased intracranial pressure. Gross total resection of the tumor in the left lateral ventricle was performed. The patient improved, and asymptomatic right-sided tumor was monitored at follow-up. CONCLUSION: The main treatment objective in these tumors is gross total resection. Asymptomatic tumors can be followed without intervention. However, surgery should be performed for symptomatic tumors that cause hydrocephalus or symptoms of increased intracranial pressure.

Extensive Extraneural Metastases of Cerebral Glioblastoma in a Pediatric Patient: An Extreme Case Report and Comprehensive Review of the Literature.

INTRODUCTION: Extraneural metastases of glioblastoma are very rare clinical entities, especially in pediatric patients. Because of their rarity, they can be confused with other pathological processes. CASE PRESENTATION: We report a case of 16-year-old boy with extensive extraneural metastases of glioblastoma. Lung, liver, cervical lymph nodes, skin, and bone metastases were detected in the patient. CONCLUSION: We describe the presentation, evaluation, and diagnosis of this rare condition with regard to pertinent literature.

Efficacy of prophylactic application of vancomycin powder in preventing surgical site infections after instrumented spinal surgery: A retrospective analysis of patients with high-risk conditions.

OBJECTIVE: This study aimed to determine the efficacy of prophylactic use of vancomycin powder against surgical site infections in patients with high-risk conditions who underwent posterior spinal instrumentation. METHODS: Data obtained from 209 patients who underwent posterior spinal instrumentation at a single institution from 2014 to 2017 were retrospectively reviewed. Patients were then divided into two groups: control group, including 107 patients (61 females, 46 males; mean age=54 years; age range=16-85 years), and treatment group, including 102 patients (63 females, 39 males; mean age=53 years; age range=14-90 years). All patients received the same standard prophylactic antibiotic regimen. In addition to the prophylactic antibiotic, vancomycin powder was applied locally to the surgical site in the treatment group. All patients were followed up for at least 90 days postoperatively. Infections were categorized as superficial and deep infections. Subgroup analysis of high-risk patients (Syrian refugees) was also performed. RESULTS: The infection rates were 1.96% (two patients) in the treatment group and 6.54% (seven patients) in the control group. A significant decrease in the infection rates was observed with local vancomycin powder application. Advanced age (>46 years) and prolonged surgical duration (>140 min) were found to be the main risk factors for surgical site infections (p=0.004 and p=0.028, respectively). The infection rates were 3.22% and 8.11% in the treatment and control groups of refugees, respectively. There were three superficial and four deep infections in the control group and one superficial and one deep infection in the treatment group. A dominance of staphylococcus infections was observed in the control group, whereas no significant dominance was observed in the treatment group. Three patients in the control group and one patient in the treatment group received implant removal. CONCLUSION: Evidence from this study has revealed that local application of vancomycin powder reduces the rate of surgical site infections after instrumented spinal surgery. The benefit of vancomycin application may be most appreciated in higher risk populations or in clinics with high baseline rates of infection. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

The Causes of Postoperative Meningitis: The Comparison of Gram-Negative and Gram-Positive Pathogens.

AIM: To determine the microbiological etiology in critically ill neurosurgical patients with nosocomial meningitis (NM) and to show the impact of Gram-negative rods and the differences between patient characteristics and the clinical and prognostic measures in Gram-negative and Gram-positive meningitis. MATERIAL AND METHODS: In this prospective, single-center study, we reviewed all adult patients hospitalized during a 12-year period and identified pathogens isolated from post-neurosurgical cases of NM. Demographic, clinical, and treatment characteristics were noted from the medical records. RESULTS: Of the 134 bacterial NM patients, 78 were male and 56 were female, with a mean age of 46±15.9 and a median age of 50 (18-80) years. One hundred and forty-one strains were isolated; 82 (58.2%) were Gram-negative, 59 (41.8%) were Grampositive. The most commonly isolated microorganism was Acinetobacter baumannii (34.8%). Comparison of mortality data shows that the patients who have meningitis with Gram-negative pathogens have higher mortality than with Gram-positives (p=0.034). The duration between surgery and meningitis was shorter in Gram-negative meningitis cases compared to others (p=0.045) but the duration between the diagnosis and death was shorter in Gram-positive meningitis cases compared to Gram-negatives (p=0.017). Cerebrospinal fluid protein and lactate levels were higher and glucose level was lower in cases of NM with Gram-negatives (p values were respectively, 0.022, 0.039 and 0.049). CONCLUSION: In NM, Gram-negative pathogens were seen more frequently; A. baumanni was the predominant pathogen; and NM caused by Gram-negatives had worse clinical and laboratory characteristic and prognostic outcome than Gram-positives.

Progressive Kyphosis Associated with Tethered Cord Syndrome Treated by Posterior Vertebral Column Resection in a Pediatric Patient.

Posterior vertebral column resection is a novel surgical approach for the treatment of progressive kyphosis associated with tethered cord syndrome that was first treated with untethering surgery. A patient with tethered cord syndrome associated with kyphosis first underwent untethering surgery, resulting in progressive kyphosis. Posterior vertebral column resection was performed to correct the kyphosis while shortening the spinal column to prevent the spinal cord from stretch injury. Good correction of kyphosis and reduction of tension on the neural elements were achieved without any neurological deficits. In progressive kyphosis associated with tethered cord syndrome, posterior vertebral column resection after untethering surgery represents a safe and efficacious but technically challenging option.

Giant Cavernous Malformations in Childhood: A Case Report and Review of the Literature.

Cavernous malformations (CMs) of the central nervous system are benign, angiographically occult vascular lesions and are diagnosed by magnetic resonance imaging techniques. Giant CMs do not differ from smaller-sized CMs in their clinical, surgical or histopathological presentation but may be radiologically different. In this paper, we report a 10-year-old male with a giant CM of 8 × 7.5 × 7 cm in diameter that was completely removed by microsurgical treatment. This case addresses important points for practicing neurosurgeons to consider when making a differential diagnosis of large intracranial mass lesions in pediatric patients. In this report, the radiological features of this vascular malformation are described based on a pertinent literature review.

A Patient with Eight Intracranial Aneurysms: Endovascular Treatment in Two Sessions.

The frequency of multiple intracranial aneurysms seen in patients with or without subarachnoid hemorrhage is high. The advancement of the endovascular technique and devices has ensured that endovascular treatment of intracranial aneurysms is the first choice in most cases, especially in unruptured ones. Different combinations of treatment modalities and techniques can be used in the management of multiple aneurysms. But in selected patients without subarachnoid hemorrhage, treatment of all aneurysms in one or more sessions with endovascular techniques is less traumatic than that with surgery. In the literature, the maximum number of aneurysms in one patient treated endovascularly and/or surgically is seven. In this case report, we present, with a review of the literature, a patient with eight intracranial aneurysms, all of which were treated in two sessions with various endovascular techniques. A 40-year-old female patient was admitted due to headache. Angiography showed eight aneurysms in the posterior circulation and, bilaterally, in the anterior circulation. All aneurysms were treated endovascularly in two sessions. In the treatment of the aneurysms, different endovascular techniques were used including flow diverters stents, stent-assisted coiling, Y-stent-assisted coiling, and coiling alone.

Intramedullary mature teratoma of the conus medullaris.

Teratoma is a tumor that derivatives from all three primitive germ layers and spinal intramedullary teratomas are very rare lesions. The primary treatment modality for these tumors is surgical resection, and total resection should be the aim. However, subtotal resection is a valid alternative to prevent traumatizing adjacent functional neural tissue. In this report, we presented a case of a 12-year-old male patient with spinal teratoma of the conus medullaris. We describe the presentation, evaluation, and treatment of this rare disease.

Pure Endoscopic Endonasal Clipping of an Incidental Anterior Communicating Artery Aneurysm.

Anterior communicating artery (AcoA) aneurysm is the most common form of intracranial aneurysm. It occurs rarely together with other intracranial lesion. Today, microsurgical techniques and endovascular methods are used in the treatment of these aneurysms. Endoscopic endonasal approach is a useful technique for midline lesions of the skull base and is underpinned with extensive experience. In this article, we present a 72-year-old female patient who underwent endoscopic endonasal transplanum-transtubercular surgery for tuberculum sellae meningioma followed by clipping of the incidental AcoA aneurysm. After complete removal of a tuberculum sellae meningioma via an endoscopic endonasal approach, an anterior and superior projected saccular AcoA aneurysm in the gyrus rectus area was totally clipped successfully via pure endoscopic endonasal transplanum-transtubercular approach, without any damage to parent arteries. The patient was discharged from the hospital within a short period of time without any postoperative complication. Endoscopic endonasal approach is a new paradigm in the treatment of aneurysm. Although this technique cannot be routinely used due to lack of experience, it is an effective and safe method in selected and anatomically appropriate cases. We believe that increased knowledge and experience will create successful results in this approach, and it can offer an alternative method for selected aneurysm cases.

Biochemical and histopathological effects of catechin on experimental peripheral nerve injuries.

AIM: Catechin is a type of polyphenol, along with epicatechin, epigallocatechin, and epigallocatechin-gallate (EGCG). This study aims to investigate the effect of EGCG, a major metabolite of catechin, which is the principle bioactive compound in green tea, on rats with peripheral nerve injury. MATERIAL AND METHODS: A total of 74 rats were divided into six groups, namely the control, the trauma, the normal saline, a 25mg/kg EGCG, a 50mg/kg EGCG and a daily consumption group (10mg/kg EGCG was given intraperitoneally for 14 days before the trauma). Except the first group, the other groups underwent a 1-minute sciatic nerve compression by clip with 50gr/cm2 pressure. Nerve samples were obtained at 28 day after trauma for the biochemical and histopathological analysis. RESULTS: Our study showed that the Daily consumption, 25mg/kg EGCG and 50mg/kg EGCG groups demonstrated statistically significant decreased lipid peroxidation levels and particularly daily consumption, and the 25mg/kg EGCG group showed a favourable reduction of degeneration and edema histologically. CONCLUSION: This study shows that Catechin and its derivatives have a protective effect on peripheral nerve injury.

Primary non-necrotizing granulomatous hypophysitis mimicking pituitary adenomas.

AIM: The authors review their experience in the endoscopic endonasal transsphenoidal treatment of 5 patients, finally diagnosed as primary hypophysitis but initially assumed to be pituitary adenomas. MATERIAL AND METHODS: A retrospective study was undertaken to review 5 cases of primary non-necrotizing granulomatous hypophysitis (1.61%) through 310 endoscopic transsphenoidally operated cases with the diagnosis of pituitary adenoma between 2009 and 2013. All 5 cases were female without any background of autoimmunity or recent pregnancy. The initial presumptive diagnosis was pituitary adenoma for all patients. The endocrinological diagnoses of the patients were suspected Cushing's Disease, anterior pituitary deficiency with hyponatremia, hyperprolactinemia, and acromegaly. One of the patients had normal hormonal levels. All patients had macroadenomas including one invasive adenoma with skull base involvement. One of the patients (20%) had visual field defects. All patients underwent endoscopic endonasal transsphenoidal surgery (EETS). RESULTS: All patients had improvement of hormonal levels postoperatively except the one with anterior pituitary deficiency who required long term hormone replacement after the surgery. Mean follow-up duration was 14.8 months. CONCLUSION: Primary granulomatous hypophysitis without any known etiological factors is very rare in the literature. It can mimic pituitary adenomas in radiological and endocrinological aspects. EETS is an effective and safe treatment especially for visual and compression symptoms.

An uncommon intramedullary tumor: primary spinal cord melanoma.

A 47-year-old woman was admitted with complaints of progressive weakness in the lower extremities and pain in the back and left leg. Thoracic magnetic resonance imaging (MRI) revealed a spinal intramedullary tumor between the T9 and L1 levels, which were iso- to hypointense on T2 and slightly hyperintense on T1-weighted images. The tumor was resected as total, and the diagnosis was malignant melanoma confirmed with histopathology. Neurological findings improved at the postoperative period and no residual or recurrence was noted on postoperative MRI at the 9-month follow-up. Primary melanoma of the spinal cord, particularly intramedullar localization, is seldomly reported in the literature. We report a primary malignant melanoma of the spinal cord and emphasize the diagnostic and prognostic challenges.

Endoscopic endonasal repair of spontaneous sphenoid sinus lateral wall meningocele presenting with cerebrospinal fluid leak.

Spontaneous sphenoid sinus lateral wall meningoceles are rare lesions with an unknown etiology. Endoscopic endonasal technique is a considerable route in the treatment of this condition. The aim of this paper is to report the etiology, surgical technique, and outcome in a patient repaired via endoscopic endonasal approach. A 51-year-old male patient applied with rhinorrhea started three months ago after an upper respiratory infection. There were no history of trauma or sinus operation. Biochemical analysis of the fluid was positive for beta-2-transferrin. This asypthomatic patient had undergone for repairment of lateral sphenoid sinus meningocele with endoscopic endonasal transsphenoidal approach. After endoscopic endonasal meningocele closure procedure no complications occured and a quick recovery was observed. Endoscopic endonasal approach is an effective and safe treatment modality of spontaneous lateral sphenoid sinus meningoceles and efficient in anterior skull base reconstruction.

Systemic administration of atorvastatin improves locomotor functions and hyperacute-acute response after experimental spinal cord injury: an ultrastructural and biochemical analysis.

AIM: Spinal cord injury (SCI) is characterized by posttraumatic inflammatory cascades including excitotoxicity, oxidative stress, and apoptosis. Agents against neuroinflammation are the current scope of studies on experimental SCI with promising results. MATERIAL AND METHODS: Thirty-two male Sprague-Dawley rats weighing 250-320 gram were used. They were randomized and divided into four groups with eight animals in each as sham, control, SCI+PEG (polyethylene glycol) and SCI+atorvastatin group. Rats were anesthetized with intraperitoneal ketamine (80 mg/kg) and xylazine (10 mg/kg) and SCI was induced by the weight-drop model. A single level laminectomy was performed at T10 and the spinal column was immobilized with a stereotactic device. Rats in the treatment group received ip atorvastatin at 0.2 mg/kg. Neurological impairments were examined through Modified Tarlov's and inclined angle scores. The SCI section was resected for electron-microscopic analysis, IL-1ß and IL-6 level. All data were analyzed using one-way ANOVA and Dunnet T3 test. RESULTS: Atorvastatin improved locomotor recovery after rat SCI. The results were further confirmed with a statistically significant decrease of IL-1ß, IL-6 and lipid peroxide levels. This finding revealed the anti-inflammatory and beneficial effect of atorvastatin on rat SCI. CONCLUSION: The present study focused on both B and T cell mediated immunity and confirmed the beneficial effect of atorvastatin with decreased expressions of IL-1ß and IL-6.

Endoscopic endonasal removal of a sphenoidal sinus foreign body extending into the intracranial space.

Sphenoidal sinus foreign bodies are very rare entities that are often associated with a cranial and/or orbital trauma. In this paper, a case of a metallic foreign body that pierced the sphenoid sinus and penetrated into the intracranial space due to a work accident is presented. A 29-year-old male was referred to our clinic due to a right orbital penetrating trauma. Skull X-ray and computed tomography (CT) scans demonstrated a foreign body inside the sphenoidal sinus, extending to the left temporal fossa. The foreign body was removed using an endoscopic endonasal technique, and the skull base was reconstructed with a multilayer closure technique. There were no complications during or after the operation. Postoperative result was perfect after three months of follow up.