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.

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.

Surgical Results of Brainstem Cavernous Malformation Haemorrhage.

AIM: To evaluate surgical treatment options, complications and neurological outcomes of patients with cavernous malformations (CMs) in the pons and medulla oblongata. MATERIAL AND METHODS: We retrospectively evaluated 25 brain stem CMs that we operated between 2009 and 2019. We operated all cases in the first month with suboccipital retrosigmoid and paramedian approach. The cases were evaluated concerning their demographic characteristics, lesion characteristics, radiological imaging results, surgical approach and neurological status. RESULTS: Overall, 15 patients had CMs in the pons and 10 in the medulla oblongata. The mean age of the patients was 33.48 years, and the cases included 15 male and 10 female patients. The average modified Rankin Score (mRS) score had a mean of 2.36 and median of 2 at the time of admission (Table I). The mean follow-up period was 4.64 years (1?10 years). In the last follow-up assessment, the average mRS score was mean = 1.84 and median = 1. In addition, 14 (56%) patients recovered, 7 (28%) did not show any changes, 3 (12%) got worse, and 1 (4%) died. In our case series, the admission complaints were cranial nerve paralysis (24%) in 6 cases, nausea and vomiting in 1 (4%) and hemiparesis in 17 (68%). CONCLUSION: Experience, correct surgical approach and good knowledge of neuroanatomy are important in brainstem CM haemorrhages. Imaging methods, neuronavigation and neuromonitoring use are essential for patients undergoing surgery. In the presence of all these factors, the prognosis of patients will be better.

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.

Furuncular Myiasis Caused by Dermatobia hominis in a Traveler Returning from the Amazon Jungle.

A 39-year-old man who was returning from the Amazon Jungle and had no medical history presented with a furuncular lesion on his right parietal scalp. Despite receiving appropriate antimicrobial treatment, his lesion did not heal. After surgical intervention, a Dermatobia hominis larva was extracted. The human botfly D. hominis is the most common causative agent of furuncular myiasis among travelers returning from Central and South America. Surgery is the main treatment option, and secondary bacterial infection should be kept in mind.

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.

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.

The Outcomes of Late Term Surgical Treatment of Penetrating Peripheral Nerve Injuries.

AIM: The aim of this retrospective study was to evaluate the follow-up results of patients who received late-term surgical treatment for peripheral nerve lesions caused by penetrating injuries. MATERIAL AND METHODS: The study included 25 patients who underwent surgery for peripheral nerve injuries in our clinic between 2007 and 2013. The patients were evaluated with respect to age, gender, etiology of the trauma, the affected nerve, clinical examinations, electrophysiological findings, surgical techniques and functional outcomes. RESULTS: The study included 30 nerves of 25 patients (19 male, 6 female; mean age 30.1 years). The mean time between the initial injury and admission to our clinic was 11.5 months (range, 3 to 30 months). Cuts caused by glass were the most common cause of injury (68.5%). The most commonly injured nerves in our patients were the median nerve (43.4%) and ulnar nerve (26.6%). External neurolysis and decompression were performed in eleven patients, epineurotomy and internal neurolysis were performed in eight patients, epineural repair was performed in fourteen patients, fascicular repair was performed in three patients, and interfascicular anastomosis using sural nerve grafting was performed in five patients. Postoperative motor strength and electrophysiological analyses showed significant improvements. Better outcomes were obtained in cases with median nerve injuries rather than other nerve injuries. Additionally, patients undergoing external neurolysis and decompression exhibited better outcomes than those undergoing other surgical approaches. CONCLUSION: Although surgical treatment is recommended as early as possible for peripheral nerve injuries, late-term surgical treatments may provide positive outcomes.

A spinal dermoid cyst with spontaneous rupture into the syrinx cavity: a case report.

Dermoid cysts are rare benign congenital tumors comprising 1.1 % of the spinal tumors, with lumbosacral region and cauda equina being the common sites. Many cranial cases with spillage of cyst contents into the subarachnoid space have been reported. We report an extremely unusual case of symptomatic spinal dermoid cyst that ruptured into the syrinx cavity. The gold standard treatment is complete resection of both cyst wall and content in dermoid cysts. However, there is no consensus for the treatment of the syrinx cavity. Observation of similar cases would give us more information about treatment options and the progression of these lesions.

Dyke-davidoff-masson syndrome associated with epidermoid tumour and arachnoid cyst: a case report.

BACKGROUND: Dyke-Davidoff-Masson Syndrome (DDMS) is a rarely seen clinical entity which is characterised by cerebral hemiatrophy, contralateral hemiparesis and epilepsy. Radiological features are typical, such as unilateral atrophy of the cerebral hemisphere and associated compensatory bone changes in the skull, like thickening, enlargement of the paranasal sinuses and mastoid air cells. CASE REPORT: In this article, we report the first case of DDMS associated with epidermoid tumour and arachnoid cyst, who underwent operation for an epidermoid tumour in the inter-hemispheric region. To our knowledge, this is the first report of DDMS associated with multiple intracranial pathologies and this association has not been previously described in the literature. CONCLUSION: Any patient who receives DDMS in the light of clinical and radiological findings should be investigated for concomitant pathologies. Different sequences of MRI may be useful in the diagnosis of other intracranial lesions.

Echinococcus alveolaris: presenting as a cerebral metastasis.

Echinococcus multilocularis (EM) is caused by the larval stage of the tapeworm. The main endemic regions for human alveolar echinococcosis are Central Europe, Russia, Turkey, Japan, China, Eastern France, North America. EM is an endemic disease in Turkey and especially common in the eastern Anatolia Region as seen in our case. The liver is the primary focus of the disease, cerebral localization is rare. Cerebral hydatid disease is approximately 5% of alveolar hydatid cases and generally considered to be fatal. Surgical treatment should be considered whenever possible. We present a case of cerebral alveolar hydatid disease that was thought to be cerebral metastasis.