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.

Assessment of the MRI and Behavioral Test Results in a Focal Cerebral Ischemia-Reperfusion Model in the Rat after Separate and Combined Use of Mouse-Derived Neural Progenitor Cells, Human-Derived Neural Progenitor Cells and Atorvastatin.

AIM: To assess the efficacy of Neural progenitor cell (NPC) transplantation in ischemic stroke, and to investigate whether atorvastatin enhances therapeutic potency of NPC after stroke. MATERIAL AND METHODS: The focal cerebral ischemia-reperfusion model was performed by transient occlusion of middle cerebral artery. Rats were assigned randomly to receive intracerebral transplantation of mouse NPC alone (mNPC), human NPC alone (hNPC), mouse NPC plus oral atorvastatin (mNPC+A), human NPC plus oral atorvastatin (hNPC+A), oral atorvastatin alone, or intracerebral Dulbecco"s Modified Eagle"s medium injection (control group). Adhesive removal, rotarod, cylinder tests, and magnetic resonance imaging (MRI) were used for assessment of rats during 4 weeks. After sacrification on 28th day, rats were investigated by immunofluorescent staining. RESULTS: The hNPC and mNPC groups showed significantly improved functional outcome and reduced infarct area ratio compared with the control group. The hNPC group had significantly better performance and lower infarct area ratio than the mNPC group. Addition of atorvastatin to stem cell therapy significantly improved functional outcome, although it did not affect the infarct area ratio on MRI. Anti-inflammatory response in the infarct area was higher in the mNPC group. NPC transplantation significantly reduced the amount of microglia and a significant increase in the amount of astrocytes. CD8a+ T lymphocyte and granzyme B activities were not detected in any of the subjects. CONCLUSION: Both hNPC and mNPC treatments significantly improved functional outcome, and reduced infarct area ratio after stroke. Atorvastatin enhanced the therapeutic potency of NPCs, including neurological improvement.

Neurosurgical treatment of nonconvulsive status epilepticus due to focal cortical dysplasia.

We present a rare case of focal cortical dysplasia (FCD) and nonconvulsive status epilepticus (NCSE) treated successfully with early surgical intervention. Our case is a 9-year-old boy whose seizures, characterized by short episodes of loss of consciousness, appeared at the age of 7, and he showed progressive cognitive decline in the following years. NCSE was diagnosed, and his MRI revealed FCD in the left frontal region which was the same side as his EEG abnormality. Following lesionectomy, his NCSE disappeared and cognitive functions improved. Histopathologic analysis of the resected tissue revealed type-IIB FCD. This case illustrates the importance of early surgery to help restore cognitive functions by eliminating the clinical and electrophysiological features of NCSE.

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.

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.

Surgery for Pyogenic Brain Abscess over 30 Years: Evaluation of the Roles of Aspiration and Craniotomy.

AIM: To evaluate the roles of craniotomy and aspiration in the treatment of pyogenic brain abscess throughout 30 years of computerized tomography. MATERIAL AND METHODS: A retrospective study of 224 patients who were surgically treated at Istanbul Medical Faculty, Department of Neurosurgery between 1982 and 2012 was undertaken. The records were analyzed for demographic, clinical and radiological findings, surgical interventions (resection, free-hand aspiration and image-guided aspiration), data regarding abscesses (etiological factors, site, size, number, localization and identified microorganism), corticosteroid and antibiotic usage and complications, and the outcomes were reviewed. RESULTS: The male-to-female ratio was 2.2, and the mean age was 26.2±1.25 years. The most common presenting symptom was headache (56.7%), followed by nausea and vomiting (28.5%). Otitis media and mastoiditis were the most common causes of abscess (41.9%), and 44 patients had multiple abscesses. Aerobic gram-positive microorganisms were the most frequently isolated pathogens in culture (51.5%). Primary surgical interventions were as follows: craniotomy and resection (38.8%), free-hand aspiration (49.1%) and image-guided aspiration (12.1%). The aspiration-to-resection ratio was 1.36 (64/47) in the first decade, 2.94 (50/17) in the second decade and 1 (23/23) in the last decade. Age, level of consciousness at the time of admission and potent corticosteroid usage were found to be significantly associated with mortality (p=0.001, p≤0.001 and p=0,038, respectively). The total morbidity and mortality ratios were 4.9% and 9.8%, respectively. Seizures were more common in patients of craniotomy group (p=0.023). CONCLUSION: Treatment of pyogenic brain abscess remains challenging, despite advances in surgical and imaging technology, and craniotomy retains a significant role in surgical treatment.

A malignant transformation of a spinal epidural mass from ganglioneuroblastoma to neuroblastoma.

Ganglioneuromas are benign tumors. Surgical excision is the treatment of choice with very good prognosis. However, neuroblastomatous malignant transformation of ganglioneuromas was previously reported. We report a patient with spinal neuroblastoma recurrent from a ganglioneuroblastoma after disease free survival of 13 years. This is one of the rare examples of spinal neuroblastoma and to our knowledge the second case report with malignant transformation from a ganglioneuroblastoma or a ganglioneuroma. The present case is the only report in the literature with further genetic investigations.

Use of Antifibrotics to Prevent Ventriculoperitoneal Shunt Complications Due to Intra-abdominal Fibrosis: Experimental Study in a Rat Model.

BACKGROUND: Cerebrospinal fluid shunt operations have reduced the morbidity and mortality of hydrocephalus, but have potential complications. Ventriculoperitoneal (vp) shunt obstruction is one of the common complications of shunt surgery. The obstruction is caused by fibrosis and is usually located on the tip of the ventricular and/or peritoneal catheter. OBJECTIVE: In our study, we aimed to demonstrate the known antifibrotic effects of heparin, hyaluronate/carboxymethylcellulose, and icodextrin on peritoneal catheter obstruction in a vp shunt model in rats. METHODS: Thirty-two male Sprague-Dawley rats were used in this study. A shunt catheter was placed in the abdominal cavity. In the control group, isotonic solution, in the study groups, heparin, sodium hyaluronate/carboxymethylcellulose (HA/CMC), and icodextrin were intraperitoneally applied. The severity of adhesions and inflammation around the peritoneal catheter was evaluated after the rats were killed on day 30. RESULTS: One animal in the heparin group died due to intra-abdominal hemorrhage. We found the most adhesions in the control group. All three drugs (heparin, HA/CMC, icodextrin) were effective for adhesion prevention. HA/CMC was more effective than heparin, and icodextrin was most effective. There was a statistically significant difference between the icodextrin and the control group (p = 0.007). CONCLUSION: The intra-abdominal instillation of icodextrin, HA/CMC, and heparin, especially icodextrin, can decrease the rate of vp shunt dysfunction by preventing formation of intraperitoneal fibrosis.

Treatment of ruptured blood blister-like aneurysms with flow diverter SILK stents.

INTRODUCTION: Blood blister-like aneurysms (BBAs) are fragile and difficult to treat. Routine surgical and endovascular treatment methods, such as clipping, clip wrapping, primary coiling, or stent assisted coiling, have relatively high morbidity and mortality rates. In this study, we report clinical and angiographic results for treatment of ruptured BBAs using flow diverter stents. METHODS: We retrospectively reviewed patients who presented with subarachnoid hemorrhages caused by rupture of BBAs and who were treated using flow diverter stents at three neurointervention centers between January 2009 and January 2013. Clinical and angiographic findings, together with the procedural data and follow-up results, are reported. RESULTS: 11 patients were identified in this study. BBAs were located on the supraclinoid internal carotid artery (nine patients) and basilar arteries (two patients). Eight patients were treated by implantation of a single flow diverter stent. Two flow diverter stents were telescopically deployed in each of three patients. The procedures were successful in all cases. No acute complications developed in any case. One patient who had an initial Hess-Hunt grade 4 died of septicemia 2 weeks after the procedure (9%). Another patient developed a minor stroke caused by parent artery thrombosis (9%). Control angiographies performed 3 and 6 months post stenting revealed complete occlusion of the aneurysms in all of the remaining nine patients (82%). 10 of the 11 patients (92%) had good clinical outcomes (modified Rankin Scale score ≤ 2). CONCLUSIONS: Implantation of flow diverter stents seems to be a safe and feasible alternative for treatment of ruptured BBAs.

Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients.

OBJECTIVE: To evaluate the clinical outcomes of patients with lumbar disc disease undergoing fully endoscopic surgery at a single clinic. METHODS: Between August 2009 and January 2012, 163 patients (74 men and 89 women) underwent fully endoscopic lumbar discectomy. All patients were followed for 1 year after surgery. The Oswestry Disability Index and a visual analog scale were used to analyze outcomes. RESULTS: During the follow-up period, 114 (70%) patients had no complaints, 30 (18%) patients had occasional pain, and 19 (12%) patients had no improvement. During postoperative follow-up, 8 patients required repeat surgery for recurrence or residual fragments. Postoperatively, 4 patients experienced dysesthesia, which completely resolved in time. Neurologic deterioration occurred in 5 patients, 4 of whom recovered completely without any intervention. Dural tears occurred in 6 patients. CONCLUSIONS: Fully endoscopic interlaminar or transforaminal surgeries are safe and effective treatment modalities for lumbar disc herniations. Despite the difficulties of acquiring this new technique, good results can be achieved with sufficient experience.

Unilateral endoscopic optic nerve decompression for idiopathic intracranial hypertension: a series of 10 patients.

OBJECTIVE: Several surgical treatment modalities, including lumboperitoneal or ventriculoperitoneal shunt surgery, subtemporal decompression, endovascular venous sinus stenting, optic nerve decompression (OND), were used in the management of idiopathic intracranial hypertension (IIH). Each surgical technique has different advantages and disadvantages. Endoscopic OND is rarely used in the management of IIH. There are only four reported cases. The aim of this study is to describe the surgical results of patients treated with this less invasive surgical technique. METHODS: A series of 10 consecutive cases of unilateral OND was reviewed. Between December 2008 and December 2012 these patients underwent the endoscopic approach without nerve sheath opening. Presenting symptoms, neurological examination findings, magnetic resonance venography imaging results, fundoscopic and visual acuity examination findings, and automated perimetry test results were recorded. Perioperative results, including complications and length of hospital stay, were evaluated. Findings at follow-up evaluations were also recorded. RESULTS: This report is the first series of unilateral OND performed using the endoscopic approach. The mean patient age was 34.1 years (range, 9-49 years); there were nine female and one male patients. Visual impairment was the main symptom in this patient group, whereas headache was a secondary complaint. The patients were first managed with medical treatment for at least 3 months. Unilateral endoscopic OND was performed on the side with the most visual failure. Mean follow-up was 28.4 months (range, 8-55 months). The visual field defects and visual acuity improved in eight of nine patients, whereas papilloedema improved in seven of nine patients. Also headaches resolved in four of seven patients. There were no complications in this relatively small series. CONCLUSIONS: The surgical treatment of IIH by using the unilateral endoscopic OND technique is a safe and effective method in the hands of experienced surgeons with advanced endoscopic skills. A collaboration with the ophthalmology team is needed for the follow-up. Further studies with larger patient numbers is needed to compare unilateral endoscopic OND technique with the current techniques used in the surgical management of IIH.

Effects of sodium hyaluronate and methylprednisolone alone or in combination in preventing epidural fibrosis.

OBJECTIVE: Epidural fibrosis and leptomeningeal adhesion formation are common causes of failed back surgery syndrome (FBSS). We employed a rat model of lumbar laminectomy to evaluate the histopathological effects of sodium hyaluronate (HA) and methylprednisolone (MP) alone or in combination on post-laminectomy epidural fibrosis. METHODS: Thirty-two male Sprague-Dawley rats were divided into four groups. All rats underwent three-level lumbar laminectomy. In the treatment groups, HA solution, MP, or a combination of both was applied locally to the epidural spaces of the laminectomy fields. No neurological deficits or pathological wound site changes were observed in any of the groups. At the end of the sixth week, all rats were sacrificed, and the laminectomy vertebral column areas were removed en-bloc. Specimens were evaluated by an expert neuropathologist according to histopathological criteria. RESULTS: The results of the three treatment groups were separately compared with the control group to assess epidural fibrosis. Minimal reduction in the rate of epidural fibrosis was observed in the groups treated with HA or MP compared with the control group. However, no significant difference in epidural fibrosis was noted between the combined treatment group and the control group. CONCLUSIONS: Our study showed that MP and HA, given separately, significantly reduce post-laminectomy epidural fibrosis; however, the combination of these drugs is not effective. Further investigation is needed to address the causative drug interactions.

The effects of protein kinase C activator phorbol dibutyrate on traumatic brain edema and aquaporin-4 expression.

BACKGROUND: Aquaporin-4 (AQP4) is the major water channel in the central nervous system. Brain edema emerges from increased AQP4 expression in traumatic brain injury (TBI). Cell line studies have shown that the protein kinase activator phorbol ester exerts a suppressive effect on AQP4 and water permeability. The aim of this study was to investigate the effects of a phorbol ester, phorbol dibutyrate (PDBu), on increased TBI AQP4 expression and accompanying brain edema. METHODS: Fifty-six male Wistar rats were first divided into two groups: the edema group, in which the percentage of water in brain tissue would be evaluated, and the immunohistochemical group, allowing AQP4 expression to be determined. Both groups were further sub-divided into four groups consisting of 7 subjects. These four groups were as follows: sham-operated control group, severe diffuse TBI group, 0.9% saline-treated diffuse TBI group, and the PDBu-treated diffuse TBI group (2300 µg/kg, iv). The results were evaluated statistically. RESULTS: PDBu treatment significantly reduced brain water concentration (p<0.001). Furthermore, PDBu was found to reduce trauma-induced AQP4 upregulation (p<0.05). CONCLUSION: This study showed that traumatic brain edema was prevented by intravenous PDBu administration via AQP4 downregulation, supporting the idea emphasizing the importance of AQP4 expression control in TBI.

Traumatic epidural hematomas of the posterior cranial fossa.

BACKGROUND: Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF. METHODS: Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively. RESULTS: Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery. CONCLUSION: When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans.

Surgical results in pediatric Spetzler-Martin grades I-III intracranial arteriovenous malformations.

OBJECTS: The goal of cerebral arteriovenous malformation (AVM) therapy in pediatric patients should be complete resection or obliteration of the AVM to eliminate subsequent hemorrhage, because of high mortality and morbidity rates related to hemorrhage in addition to the longer life expectation. Despite advances in Gamma knife radiosurgery and in endovascular embolization, surgical resection is still the gold standard for treating cerebral AVMs. METHODS: Between 1986 and 2003, 20 children were surgically treated for cerebral AVMs. The AVMs were graded I, II, and III using the Spetzler-Martin (S-M) Grading Scale. Good recovery was achieved in 18 out of 20 patients (90%) and only 1 patient was moderately disabled (5%). There was one mortality (5%) related to the preoperative deep comatose state of the patient. The total obliteration rate was 89% (17 out of 19). CONCLUSION: For S-M grade I-III AVMs, surgical resection is the treatment of choice, considering its high cure rate and low morbidity and mortality rates.