Spontaneous Resolution of a Sylvian Arachnoid Cyst in a Child: A Case Report.

We report the case of a 7-year-old boy with an incidentally diagnosed left sylvian arachnoid cyst. At a clinical follow-up of 2 years, cranial computed tomography scans found the cyst to be totally resolved. The mechanism of this rare spontaneous resolution of an arachnoid cyst is discussed.

Laboratory training in the retrosigmoid approach using cadaveric silicone injected cow brain.

BACKGROUND: A neurosurgical laboratory training model is designed for trainees in microneurosurgery to learn to handle surgical microscopes and microneurosurgical instruments. The silicone injection of a fresh cadaveric cow cranium is an alternative to using a cadaveric human brain for becoming familiar with the cerebellopontine angle (CPA) via the retrosigmoid approach. To report an improved method for training in the CPA via the retrosigmoid approach, using a fresh cadaveric cow cranium injected with silicone. METHODS: The material consists of a cadaveric cow brain injected with silicone. Preparation consists of irrigation of the major vessels followed by injection of silicone, coloured either red or blue. RESULTS: A three-step approach was designed to simulate microneurosurgical dissection along with the cerebellopontine angle and to dissect cranial nerves emerging from the brain stem. CONCLUSION: This laboratory training model is useful in allowing trainees to gain experience with the use of an operating microscope and familiarity with the CPA via the retrosigmoid approach. The aim of this study was to develop a novel model and to adapt it to create a life-like neurosurgical training system.

Histopathologic and Spectrometric Evaluation of Bony Components of Synostotic Suture and Parietal Bone in Children with Sagittal Synostosis.

AIM: To understand the characterization of the ossification process both in the synostotic suture, and the adjacent parietal bone. MATERIAL AND METHODS: The surgical procedure for the 28 patients diagnosed with sagittal synostosis consisted of removing the synostotic bone as a whole, if possible, "Barrel-Stave" relaxation osteotomies, and strip osteotomies to the parietal and temporal bones perpendicular to the synostotic suture. The synostotic (group I) and parietal (group II) bone segments are obtained during osteotomies. Atomic absorption spectrometry was used to determine the amount of calcium in both groups, which is an indicator of ossification. Scanning electron microscopy and immunohistochemistry were employed to assess trabecular bone formation, osteoblastic density, and osteopontin, which is one of the in vivo indicators of new bone formation. RESULTS: Histopathologically, trabecular bone formation scores did not indicate any significant difference between the groups. However, the osteoblastic density and calcium accumulation in group I were higher than those in group II, and the difference was significant. Osteopontin staining scores in cells showing membranous and cytoplasmic staining with osteopontin antibodies significantly increased in group II. CONCLUSION: In this study, we found reduced differentiation of osteoblasts despite their increase in number. Moreover, the osteoblastic maturation rate was low in synostotic sutures, bone resorption becomes slower than new bone formation, and the remodeling rate is low in sagittal synostosis.

A laboratory training model using fresh sheep spines for pedicular screw fixation.

BACKGROUND: Laboratory training models are essential for developing and refining surgical skills prior to clinical application of spinal surgery. A simple simulation model is needed for young residents to learn how to handle instruments and to perform safe posterior lumbar approaches. Our aim is to present a practical laboratory model using a fresh sheep lumbar spine that simulates the pedicular screw fixation in spine surgery. METHODS: The material consists of a fresh cadaveric spine from a 2-year-old sheep. A two-step approach was designed for posterior lumbar approaches including placement of lumbar pedicular screws. RESULTS: The model simulates standard posterior lumbar pedicular screw fixation of the human spine. CONCLUSIONS: The cadaveric sheep spine represents a useful method to accustom trainees of neurosurgery and spine surgery residents and simulates posterior lumbar pedicular screw fixation performed in the human spine.

Angiographic Angular Adjustment: Matching Angiographic Views and Surgical Findings to Estimate the Actual Arterial Anatomy in Surgery for Intracranial Aneurysm - Technical Note.

AIM: To describe a simple technique of angular adjustment of cerebral angiographic views that makes them similar to the surgical field under the operation microscope. MATERIAL AND METHODS: The technique of angular adjustment consists of three steps: 1. Upside-down 180-degree rotation of the standard angiographic anterior-posterior view, 2. Adjustment of the course of the angiographic internal carotid artery according to the actual internal carotid artery seen in surgery under the operating microscope, and 3. A final and more accurate angular adjustment by rotating the angiographic view in its final position, as soon as parent arteries to aneurysm, such as the internal carotid, anterior cerebral, and middle cerebral arteries, are seen in surgery. RESULTS: The use of the technique provided a fair approximation of a rotated angiographic view and the actual surgical point of view. The technique is simple, and no sophisticated technology is needed. CONCLUSION: The angiographic data adjusted angularly to the surgeon?s point of view at surgery, very similar to the actual directions of arteries and the fundus of the aneurysm, is likely helpful to the microneurosurgeon for safely exploring aneurysms in conjunction with proximal and distal arteries.

Reattachment of the Temporalis Muscle After Frontoorbital Advancement in Craniosynostosis Surgery.

Craniosynostosis surgery may result in temporal hollowing occasionally. Overexpansion of the normal side and undergrowth of the affected side exacerbate the problem in unilateral cases (like unicoronal synostosis). Temporalis muscle lies in the temporal fossa, and it is usually severed or detached from its origin in order to reach the lateral aspect of the fronto-orbital bar. Reattachment of the temporalis muscle is challenging especially when the orbital bar is moved forward. In this technical note, exposure of the lateral cranial vault with zigzag incision of the temporalis muscle in 35 nonsyndromic anterior plagiocephaly patients has been described in detail, and the ease of reattachment is demonstrated afterward.

Validity of serum tau protein levels in pediatric patients with minor head trauma.

BACKGROUND: The aim of this study was to investigate the relationship between intracranial injury and serum tau protein levels in pediatric patients with minor head trauma (MHT). METHODS: We included 60 pediatric patients with MHT (Glasgow Coma Scale [GCS], 14-15) and 28 control patients. The patients were divided into 3 groups as follows: those without (group 1) and with (group 2) intracranial lesions shown on cranial computed tomography (CCT) and the control group (group 3). RESULTS: The mean serum tau protein level was 96.06 +/- 70.36 pg/mL in group 1, whereas it was 112.04 +/- 52.66 pg/mL in group 2, with no statistically significant difference between the groups (p = .160). The mean serum tau protein levels between the study groups (group 1 and group 2) and control (38.52 +/- 29.01) were statistically significant (P < .001 and P < .001, respectively). The GCS score and pathologic condition in CCT were only influential variables on tau protein levels. CONCLUSIONS: We found that serum tau protein increased after MHT but did not distinguish between those with and those without intracranial lesions demonstrable on CCT.

Successful Application of the Ventriculo-Gallbladder Shunt: A Salvage Procedure.

Ventriculo-gallblader shunt is very rarely used in the treatment of hydrocephalus. A 44-year-old male with ventriculoatrial shunt dysfunction was evaluated. His ventriculoatrial shunt was not working. His medical history revealed that his hydrocephalus was treated five times by venrtriculoperitoneal shunt, and four times by ventriculoatrial shunt. Another trial for ventriculoperitoneal or ventriculoatrial shunting was not considered feasible. A ventriculo-gallbladder shunt was placed to the patient as a potential salvage procedure. Remarkably, the patient benefited from the ventriculo-gallbladder shunt and was discharged from the hospital. We think that ventriculo-gallbladder shunting is a safe and effective treatment for hydrocephalus as the last resort in complicated cases of shunt dysfunction.

Indications for brain computed tomography and hospital admission in pediatric patients with minor head injury: how much can we rely upon clinical findings?

OBJECTIVES: The aim of this study was to describe the characteristics of patients with a minor head injury (MHI) who were admitted to a pediatric emergency unit and to identify the clinical signs and symptoms that most reliably predict the need for cranial computed tomography (CCT) and hospital admission following MHI. METHODS: All patients were retrospectively evaluated according to age, gender, details of injury, presenting symptoms, physical examination findings, radiological investigations ordered and results, length of stay, outcome of the injury and hospitalization rates. RESULTS: The factors affecting indications for computed tomography and hospitalization were retrospectively analyzed in 916 patients--585 males and 331 females, aged between 1 month and 15 years (mean: 5.01 +/- 3.58 years), with MHI. A multivariate analysis revealed significant correlations between CCT abnormalities and Glasgow Coma Scale scores of 13 or 14, headache, posttraumatic amnesia, blurred vision, cephalohematomas, periorbital ecchymoses, otorrhea and abnormal neurological findings. CCT abnormalities were identified in 67 (19.8%) of the 338 CCT scans. Twenty of the 67 patients (29.9%) with CCT scan abnormality had no clinical signs. Of all cases, 125 (13.6%) were hospitalized, 617 (67.4%) were treated as outpatients, and 174 (19.0%) left the emergency department based on a personal decision. CONCLUSION: Some clinical risk factors can be used as predictors of abnormalities in CCT scans following MHI, but the absence of such clinical findings does not exclude the possibility of intracranial injuries.

Spontaneous Intracystic Haemorrhage of an Arachnoid Cyst Associated with a Subacute Subdural Haematoma: A Case Report and Literature Review.

Arachnoid cysts (ACs) are congenital malformations that may develop anywhere in the subarachnoid space along the cerebrospinal axis, but are mostly observed in the temporal fossa and Sylvian fissure, predominantly on the left side. ACs account for 1% of all intracranial space-occupying lesions. ACs are potential risk factors for subdural haematoma in all age groups following a traumatic head injury. Although an intracystic haemorrhage of AC without evidence of a head trauma is very rare, it may particularly develop in children and young adults who spend much more time engaged in games and forced physical exercises. Here we present a rare case of spontaneous intracystic haemorrhage of AC with a subacute subdural haematoma and provide a review of the literature.

A laboratory training model in fresh cadaveric sheep brain for microneurosurgical dissection of cranial nerves in posterior fossa.

A neurosurgical laboratory training model is designed for residents of neurosurgery to handle surgical microscopes and microneurosurgical instruments. The material consists of a one-year-old fresh cadaveric sheep cranium. A four-step approach was designed to simulate microneurosurgical dissection along the posterior fossa cisterns, and to dissect cranial nerves emerging from the brain stem. We conclude that this laboratory training model is useful to allow trainees to gain experience with the general use of an operating microscope, and familiarity with handling cranial nerves.

Children with Metopic Ridge.

AIM: The premature closure of the metopic suture results in metopic synostosis, also known as trigonocephaly. However, there is a group of children who have only a frontal metopic ridge, obvious with inspection and fingertip palpation, without the clinical features of trigonocephaly. This study aims to report a group of children with metopic ridge with a special emphasis on the definition and the diagnostic features. MATERIAL AND METHODS: Thirty-eight children with a diagnosis of metopic ridge were followed up with clinical examinations and photographs in the pediatric neurosurgery outpatient clinic between January 2010 and November 2015. RESULTS: Children were between 3 and 30 (mean=14) months of age at diagnosis. Twenty-five (65.8%) of the children were boys and 13 (34.2%) were girls. A midline metopic ridge without fronto-orbital trigonocephalic deformity was the only diagnostic criterion. The parents" concern about the metopic deformity at initial diagnosis was a common feature in every case. Seven (18.4%) of the children had a sibling with either metopic ridge (n=4) or trigonocephaly (n=3). None of the children had worsened or had received surgery in the follow-up period. CONCLUSION: The metopic ridge is a pathology of the metopic suture and is a concern for parents in the context of craniosynostosis. Radiological investigation and craniosynostosis surgery are unnecessary in children with a metopic ridge.This clinical entity may be considered the mildest form of metopic synostosis.

Stepwise Removal of the Fused Midline Parietal Bone to Avoid Superior Sagittal Sinus Injury in Infants with Sagittal Synostosis.

This work describes a simple technique for the safe removal of the midline parietal bone with the synostotic sagittal suture in infants with sagittal synostosis to avoid dural tearing and bleeding from the superior sagittal sinus. The technique consists of stepwise removal of the midline parietal bone in three pieces instead of one piece, starting with the anterior one-third midline bone being safely freed from the underlying dural sinus and then transversely cut using a craniotome. The step is repeated twice for the middle and distal one-third of the bone respectively. Once the midline bone is bilaterally cut along its entire length, the stepwise elevation of the superior sagittal sinus dura using an elevator and removal of the midline bone in three pieces allows a safer, controlled procedure minimizing the risk of tearing the underlying dural sinus and preventing sinus bleeding in infants with sagittal synostosis.

Simulation of surgery for craniosynostosis: a training model in a fresh cadaveric sheep cranium. Technical note.

The authors present a training model in sheep crania that allows residents in neurosurgery and plastic surgery to practice the frontoorbital remodeling procedure used in the surgical correction of simple craniosynostoses such as plagiocephaly, trigonocephaly, and brachiocephaly. The model comprises a three-step approach: subperiosteal and subperiorbital dissection; elevation of the bifrontal bone flap and the supraorbital bar; and finally, frontoorbital remodeling. The authors conclude that this training model, based on the use of cadaveric sheep crania, represents a fairly useful method to accustom trainees to the required surgical techniques and simulates well the steps of standard pediatric and adult craniofacial surgery for simple craniosynostosis.

Paraplegia due to spinal subdural hematoma as a complication of posterior fossa surgery: Case report and review of the literature.

Although blood contamination of cerebrospinal fluid (CSF) after an intracranial operation is possible, development of a symptomatic spinal hematoma after a posterior fossa surgery has never been reported. A 43-year-old woman underwent a posterior fossa tumor removal in the prone position with no intraoperative difficulty. On the second postoperative day, she complained of severe epigastric pain and developed a rapid onset of paraplegia with anesthesia below the thoracic 5 spinal level. The emergency cranial and spinal MRIs revealed a spinal extramedullary hemorrhage spreading to the whole spinal regions, just sparing the cauda equina area. There was a prominent localized hematoma formation surrounding and compressing the spinal cord at the upper thoracic levels, which was evacuated via an urgent laminectomy. The patient showed partial neurological recovery after the decompression. Development of the spinal hematoma was explained by the movement of blood from the tumor bed into the spinal canal under the effect of gravity, during or after the operation. A 30 degrees head elevation might facilitate the accumulation of blood. Localization of the hematoma formation may be caused by the fact that the upper thoracic levels constitute the apex of the kyphosis. We conclusively suggest that a spinal hematoma should be taken into consideration as a rare but potentially severe complication of a posterior fossa surgery. Meticulous hemostasis and isolation of the surgical area from the spinal spaces are essential. Overdrainage of CSF should be abandoned. Postoperatively, patients should be monitored for spinal findings as well as cranial signs.

Giant subdural empyema in a child: a case report.

An unusual case of a giant (8 x 6 x 6 cm) frontoparietal SDE of Streptococcus pneumoniae in a 17-month-old child is reported. The initial diagnosis was made with emergency CT. The purulent material was removed via a frontoparietal craniotomy. A series of postoperative MR imaging showed the gradual reduction in size of the lesion, although collapsed capsule, fibrous thickening of meningeal structures and associated displacement of the underlying brain persisted. The child was symptom-free in a follow-up period of 15 months. This case showed that SDE may reach a giant size and thus may mimic an intra-axial lesion; the coronal MR imaging is a more reliable diagnostic tool than the emergency axial CT in giant SDE of upper convexity localization, and the clinical improvement may be more impressive than the radiological changes.

Microneurosurgical training model in fresh cadaveric cow brain: a laboratory study simulating the approach to the circle of Willis.

BACKGROUND: Residents of neurosurgery need many years to develop microneurosurgical skills, and laboratory training models are essential for developing and refining surgical skills before clinical application of microneurosurgery. A simple simulation model is needed for young residents to learn how to handle microneurosurgical instruments, and to perform safe dissection of intracranial vessels and nerves. METHODS: The material consists of a 2-year-old fresh cadaveric cow cranium. A 4-step approach was designed to dissect the internal carotid artery and its proximal branches, the optic nerve, the optic chiasm, and the pituitary stalk. RESULTS: The model simulates standard microneurosurgery using a variety of approaches to vessels and neural structures in and around the circle of Willis of the human brain. CONCLUSION: The cadaveric cow brain, besides being cost-effective, represents a fairly useful method to accustom residents of neurosurgery, especially junior residents, to dissecting intracranial vessels and nerves, and it simulates intracranial microneurosurgical procedures performed in the human brain.

Giant cervicothoracic extradural arachnoid cyst: case report.

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid-filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4-T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

Nocardial brain abscess: review of clinical management.

Nocardiosis has become a significant opportunistic infection over the last two decades as the number of immunocompromised individuals has grown worldwide. We present two patients with nocardial brain abscess. The first patient was a 39-year-old woman with systemic lupus erythematosus. A left temporoparietal abscess was detected and aspirated through a burr-hole. Nocardia farcinica infection was diagnosed. The patient had an accompanying pulmonary infection and was thus treated with imipenem and amikacine for 3 weeks. She received oral minocycline for 1 year. The second patient was a 43-year-old man who was being treated with corticosteroids for glomerulonephritis. He was diagnosed with a ring-enhancing multiloculated abscess in the left cerebellar hemisphere, with an additional two small supratentorial lesions and triventricular hydrocephalus. Gross total excision of the cerebellar abscess was performed via a left suboccipital craniectomy. Culture revealed Nocardia asteroides, and the patient was successfully treated with intravenous ceftriaxone, then oral trimethoprime-sulfamethoxazole for 1 year. The clinical course, radiological findings, and management of nocardial brain abscess are discussed in light of the relevant literature, and current clinical management is reviewed through examination of the cases presented here.

Hip joint subluxation after selective dorsal rhizotomy for spastic cerebral palsy.

OBJECT: The effects of selective dorsal rhizotomy (SDR) procedures on the hip joints of children with spastic cerebral palsy (CP) are not well described. This study was performed to determine the incidence of hip subluxation in children with CP who underwent SDR at a single institution. METHODS: The study group comprised 82 patients (164 hip joints) with a mean follow up of 3.9 years. Forty-four patients had spastic diplegia (53.6%), 35 had spastic quadriplegia (42.7%), two had spastic triplegia (2.4%), and one had spastic hemiplegia (1.2%). The mean patient age at SDR was 5.2 +/- 2.4 years. Preoperative and postoperative hip radiographs were reviewed and the femoral head center edge (CE) angles were recorded. The mean pre- and postoperative right CE angles were 14.1 and 17.2 degrees, respectively, and those of the left were 13.6 and 15.1 degrees, respectively. Considering a change in CE angle greater than 5 degrees as clinically significant, 72 hips (43.5%) remained unchanged, 63 (38.4%) improved, and 29 (17.7%) worsened. Of a number of preoperative variables, including age at time of surgery, Gross Motor Function Classification System (GMFCS) level, ambulatory status, extent of hip subluxation, preoperative scoliosis, and asymmetry of hip subluxation, only GMFCS level was associated with worsening of hip subluxation. CONCLUSIONS: Selective dorsal rhizotomy is more likely to have a positive effect or no effect on hip joint subluxation rather than to have a negative effect. More severe involvement, as measured using the GMFCS, may predispose to worsening of hip subluxation after SDR.