A different perspective on the dilemma of durotomy or duraplasty in Chiari type 1 malformation surgery.

PURPOSE: Symptomatic Chiari type 1 malformation (CIM) patients may elect to be treated; however, choosing the optimum surgical method remains problematic: posterior fossa decompression with duraplasty (PFDD) or without duraplasty (PFD). Many studies have compared these surgical methods from several perspectives. We looked at soft tissue density (STD) at the foramen magnum to add another perspective to the comparison of PFD with PFDD. MATERIALS AND METHODS: Eighty-six patients who underwent surgery in our clinic were included in the study. We examined preoperative and postoperative MR images taken in the 1st year. We obtained the foramen magnum area (FMA) and soft tissue at the level of the foramen magnum. The STD within the foramen magnum was calculated as the percentage ratio of soft tissue area (STA) to FMA. Anteroposterior diameters of the syrinx cavities in sagittal T2 sections were measured preoperatively and at 1-year postoperatively. Measurements were double-blind and were performed by the neurosurgeon and by the neuroradiologist. RESULTS: There was no statistically significant difference between the postoperative FMA increases, STA changes, STD changes in patients who underwent PFD and PFDD. In this study, there was no statistically significant difference between PFD and PFDD in terms of syrinx changes. CONCLUSIONS: The medium-term anatomical outcome following craniovertebral decompression for CIM, is no different whether performed PFD or PFDD.

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.

Pediatric Calvarial Tumors: 10 Years of Clinical Experience and Differences From the Literature.

ABSTRACT: Very few studies have focused exclusively on pediatric calvarial tumors. These studies have primarily addressed the similarities of the cases with those reported in the literature, as opposed to their distinctive features. In contrast, the present study is the most detailed study conducted in the last 10 years that includes only pediatric calvarial tumors and highlights their differences according to the literature. A total of 31 patients with pediatric calvarial tumor surgically treated in our center between 2010 and 2020 were included in the study. The patients' files were analyzed retrospectively and 17 different preoperative, intraoperative, and postoperative parameters were determined and compared with previous studies. Except for the tumors causing lytic or sclerotic lesions, there was at least one distinguishing aspect of our series in all parameters. Despite the many distinctive features, the consensus in the treatment of calvarial tumors is to perform complete resection of the tumor and, if possible, remove some of the adjacent healthy bone. Considering the age factor, however, closure of the resulting bone defects with cranioplasty to address issues of cosmesis and intracranial pressure is yet another aspect of pediatric calvarial tumors, because pediatric cranioplasty has its own specific complications. Using intraoperative neuronavigation and performing tumor resection alone without additional craniectomy are also methods the authors use to prevent major bone defects.

Intraventricular microcystic meningioma in a child: a case report.

BACKGROUND: Microcystic meningiomas are extra axial masses that are extremely rare in the pediatric population. Intraventricular meningiomas are also rarely seen. CASE PRESENTATION: This case reports an 18-year-old boy who had an intraventricular mass on magnetic resonance imaging at the age of 12 years and had shown growth at a 6-year follow-up after subtotal resection. The mass was removed by total resection and pathological examination indicated microcystic meningioma. CONCLUSION: The present case is the first pediatric intraventricular microcystic meningioma in the literature. We believe that this unique case presented with its radiological, pathological and clinical features will contribute to the literature.

Simultaneous transsphenoidal and transventricular endoscopic approaches for giant pituitary adenoma with hydrocephalus.

The surgical management of giant pituitary adenomas is challenging. Although most pituitary adenomas, even those with suprasellar extension, can be resected using the transsphenoidal surgery alone, the transcranial approach is still needed for approximately 1% to 4% of these tumors. The transcranial approach is usually used in large adenomas with hourglass configuration and adenomas with firm consistency impeding the adjunctive measures, which are used for delivering the suprasellar part of the tumor into the sellar area and thereby obscure the tumor resection by transsphenoidal route. In this report, we describe the successful use of transventricular endoscope as an adjunctive measure to remove giant pituitary adenoma from transsphenoidal route and discuss the limitations of this new technique. We concluded that this technique would be used safely in selected cases. Case selection and surgical strategies should be based on preoperative magnetic resonance imaging findings, ventricular size, and the availability of experienced surgeons.

Assessment of Increased T2 Signal Activity in Patients with Cervical Spondylotic Myelopathy Undergoing Posterior Cervical Fusion.

AIM: To compare the preoperative and postoperative increased signal intensity (ISI) outcomes of cervical spondylotic myelopathy (CSM) patients who underwent posterior decompression and fusion, and to assess the correlation between ISI changes and postsurgical clinical prognosis. MATERIAL AND METHODS: The results from 123 patients were evaluated. In addition to demographic data, such as age and gender, factors, including body mass index (BMI); smoking history; duration of symptoms; follow-up periods; levels of decompression and fusion; comorbidities, such as diabetes, coronary artery disease, and hypertension; ISI grading; cervical sagittal vertical axis; C2-7 cervical lordosis parameters; and Modified Japanese Orthopedic Association (mJOA) scores, were statistically analyzed preoperatively and postoperatively. RESULTS: ISI improved in 39 patients (31.7%), remained unchanged in 53 patients (latent, 43.1%), and deteriorated in 31 patients (25.2%). There were no statistically significant differences in terms of age, gender, BMI, or levels of decompression and fusion between patients with ISI improvement, latent ISI, and worsened ISI. Patients with ISI improvement had the highest postoperative C2-7 lordosis values and shortest duration of symptoms. There was no statistically significant difference in the mJOA scores between patients with and without ISI improvement. CONCLUSION: ISI improvement in CSM patients undergoing posterior cervical decompression and fusion is influenced by symptom duration and preoperative-postoperative cervical lordosis values. However, this study did not find a correlation between ISI improvement and clinical recovery based on the mJOA scores.

Lung adenocarcinoma metastasis to frontal sinus mimicking Pott's puffy tumor.

Metastasis of the lung adenocarcinoma to the paranasal sinuses is a rare clinical entity. We present a 75-year-old male patient who presented with swelling of the forehead and left upper eyelid with proptosis in left eye due to metastasis from lung adenocarcinoma. It appears as a puffy swelling of the forehead like a Pott's puffy tumor. Pott's puffy tumor is a subperiostal abscess of the frontal bone associated with osteomyelitis and usually occurs as a complication of sinusitis or trauma.

Obstructive hydrocephalus caused by giant basilar artery aneurysm.

Giant basilar artery aneurysms are rarely associated with hydrocephalus. When it occurs the treatment usually addresses the hydrocephalus rather than the aneurysm itself, especially if it is already thrombosed. The treatment options include ventriculoperitoneal shunting and endoscopic third ventriculostomy, which may be related to high complication rates. However, reducing the intracranial hypertension may produce aneurysmal growth. We report a patient with obstructive hydrocephalus due to thrombosed giant basilar artery aneurysm. The patient initially presented with symptoms of increased intracranial pressure, and was managed by ventriculoperitoneal shunting with significant symptomatic improvement. Fifteen days after operation, the patient died due to a cerebrovascular event. We report a case that deteriorated because of cerebral infarction due to aneurysmal growth after ventriculoperitoneal shunting. We also discuss the treatment options in such cases.

Intraorbital epidermoid cyst: a 5-year-old with exophthalmos and strabismus.

A 5-year-old girl with right exophthalmos and esotropia presented to ophthalmology outpatient clinics. Orbital computed tomography revealed a 20- to 30-mm oval soft tissue mass lying superolateral to the right lateral rectus muscle in the orbit. The patient was operated on by a neurosurgical team, the csyt was removed totally, and examination of the pathologic specimen, which reveals the epidermoid cyst, was performed. After the operation, exophthalmos and esotropia were improved, and visual acuity was increased. Although itis seen as a rare entity in the orbit, epidermoid cyst must be considered during the investigation of exophthalmos.

Can Dynamic Susceptibility Contrast Perfusion Imaging be Utilized to Detect Isocitrate Dehydrogenase Gene Mutation in Gliomas?

AIM: To explore the ability of dynamic susceptibility contrast perfusion imaging (DSC-PI) to detect isocitrate dehydrogenase (IDH) gene mutation in gliomas. MATERIAL AND METHODS: Preoperative DSC-PI data on histopathologically proven gliomas obtained between January 2015 and December 2019 were reviewed retrospectively. All magnetic resonance imaging (MRI) examinations were performed using a 1.5-T scanner. The maximum relative cerebral blood volume (rCBVmax), percentage signal recovery (PSR), and normalized PSR of tumor cores were calculated. Differences in these values between IDH-mutant and wild-type gliomas were compared, and receiver operating characteristic curves were generated. RESULTS: The patients (32 females, 47 males) were aged 21-76 years (mean 50.7 ± 15 years). The rCBVmax and all PSR values differed significantly between patients with IDH-mutant and those with wild-type tumors (p < 0.01 for all comparisons). CONCLUSION: The rCBVmax and PSR values obtained by DSC-PI may facilitate noninvasive detection of the IDH mutation status of gliomas. PSR provided more reliable values for differentiation of IDH-mutant gliomas from wild-type gliomas.

Proptosis, congestion, and secondary glaucoma due to carotid-cavernous fistula after embolization.

Carotid-cavernous fistulas (CCFs) are traumatic or spontaneously occurring communications between the carotid artery and the cavernous sinus. Carotid-cavernous fistulas can be due to a direct connection or indirect connections between the carotid artery system and the cavernous sinus. According to the etiologic classification, they may be of traumatic or spontaneous origin, and according to the angiography classification, they may be of direct or dural. Most CCFs are of spontaneous origin, and these are reported as frequently self-healing lesions. Spontaneous CCFs are mostly secondary to arteriosclerotic changes, which explains the increased ratio of elderly patients. Traumatic CCFs are usually of high-flow type and need intervention. The symptoms are various usually correlated to the size and type of venous drainage. The most frequent symptoms on presentation are proptosis, conjunctivitis, and chemosis; however, this picture may be complicated by optic nerve edema, cranial nerve palsies, and intracranial hemorrhage. We report a case with right low-flow dural CCF, which has worsened after angiography and recovered totally soon after endovascular embolization process.

Myelomeningocele and Kyphosis: Natural History of the Disease and the First Results of a New Surgical Technique.

AIM: To define the natural course of kyphosis, and to evaluate the efficiency of a new technique in surgical correction of kyphosis seen in myelomeningocele(MM) patients. MATERIAL AND METHODS: We retrospectively reviewed our patients with MM. The rate of kyphosis, mean angle of progression and mean angle of surgical correction were evaluated. Surgical correction was achieved with the same technique in all patients; kyphectomy, short segment instrumentation with plate system and long segment instrumentation with screw-rod system. RESULTS: A total of 14 patients were treated surgically and the mean age at the surgery was 39 months. The incidence of kyphosis rate was %21 in this study. The mean angle of kyphosis was 85.8°. Average angle of progression was 15.7° whereas it was 6.3° degree in patients whose kyphosis angle ?90 and > 90 degree, respectively, at birth. 14 patients were treated surgically and the mean age at the surgery was 39 months. The mean angle of correction of kyphosis was 86 degree. The most common complications were wound dehiscence and cerebro-spinal fluid leak. One patient died 3 months after surgery, and one patient was reoperated due to pull-out of screws. CONCLUSION: Effective surgical correction of kyphosis in MM patients can be achieved with the described surgical technique even in younger ages. Prospective studies in larger study population are necessary for more accurate definition of natural history of kyphosis in MM patients.

A new approach to the treatment of cerebral vasospasm: the angiographic effects of tadalafil on experimental vasospasm.

BACKGROUND: The pathogenesis of cerebral vasospasm is likely to be multifactorial. Strong evidence has indicated that decreasing levels of NO after SAH seem to be important. A PDE-V inhibitor, tadalafil, theoretically increases NO levels. Our study investigated the vasodilatory efficacy of tadalafil on the cerebral arteries with measurement of basilar artery diameters on angiography. METHODS: We used 42 male Wistar-Albino rats to test our hypothesis. They were assigned randomly into the following seven groups: group 1: control (only saline), group 2: SAH only (killed on day 2), group 3: SAH + tadalafil (killed on day 2), group 4: SAH only (killed on day 4), group 5: SAH + tadalafil (killed on day 4), group 6: saline + tadalafil (killed on day 2) and group 7: saline + tadalafil (killed on day 4). The three different parts of basilar artery diameters were measured angiographically. RESULTS: There were statistically significant differences between the SAH and SAH groups treated with tadalafil at days 2 and 4. Comparison between control and tadalafil groups showed no significant differences. This result indicated that tadalafil has a vasodilatory effect on vasoconstricted arteries, but no effect on normal basilar arteries. CONCLUSION: Our study results showed that tadalafil has a vasodilatory effect on both acute and chronic periods of cerebral vasospasm. We also concluded that cerebral angiography can be used safely for investigation of cerebral vasospasm in animal studies.

Corpus Callosum Lipomas in Children.

AIM: To determine the clinical and radiographical aspects of six patients diagnosed with pericallosal lipomas (PCL). MATERIAL AND METHODS: A retrospective analysis of patients who presented to the neurosurgery outpatient clinics of Selcuk Faculty of Medicine between 2009 and 2019, revealed that six patients were diagnosed with PCL. The clinical and magnetic resonance imaging (MRI) data were obtained by reviewing patients? records. RESULTS: A total of six patients (two girls and four boys), with a mean age of 53.8 months (38?72 months), were included in this study. They were followed up for a mean period of 36.5 months (32?41 months). PCL were detected on MRIs, which were obtained to investigate headache in two patients, epilepsy in one patient, frontal dermal sinus tract and left frontal epidermoid tumor in one patient, and subcutaneous lipoma associated with PCL in one patient. Five patients displayed tubulonodular lipomas and one patient displayed curvilinear lipomas. Agenesis or dysgenesis of the corpus callosum (CC) was observed in four (66%) patients. Two patients received surgical treatment for cosmetic skin problem. CONCLUSION: Because of the benign course of PCL, i.e. no growth or very slow growth, and close proximity to the surrounding neurovascular structures, surgical removal should be considered only in symptomatic PCL. Furthermore, other malformations and anomalies may accompany PCL.

Comparison of Immunogenetic Properties of Glial Tumors with Advanced Magnetic Resonance Imaging Findings.

AIM: To investigate the immunogenetic properties of glial tumors according to the World Health Organization 2016 glial tumor classification and develop an accurate diagnosis and treatment strategy by comparing preoperative advanced magnetic resonance (aMRI) technique findings of these results. MATERIAL AND METHODS: This study was conducted at the Department of Neurosurgery at the Medical Faculty Hospital of Selcuk University between January 1, 2010 and January 4, 2017 and included 50 patients. MR spectroscopy (MRS), MR perfusion (PWI), and MR diffusion (DWI) were performed in 50 patients preoperatively. Patient data were obtained from the hospital’s information system. Pathological diagnosis of all patients was taken from the department of pathology at the same medical faculty. RESULTS: Among the patients included in the study, 11 were grade II (22%), 7 were grade III (14%), and 32 were grade IV (64%). All patients were IDH1 stained: 22 were IDH mutant (44%) and 28 were IDH wild-type (56%). A statistically significant difference in the survival time was observed between IDH mutant and wild-type. IDH-mutant tumors were commonly located in the frontal lobe and IDH wild-type tumors in the parietal and temporal lobes. A significant difference in PWI relative cerebral blood volume (rCBV) and DWI apparent diffusion coefficients (ADC) was noted among grade II, III, and IV tumor groups. The PWI rCBV cut-off value for grade IV tumors was 2.05 (90% sensitivity, 78% specificity). No difference in the Cho/Cr ratio among grade II, III, and IV tumor groups was noted. A significant difference was noted between the IDH mutant and wild type in terms of PWI rCBV. The PWI rCBV cut-off value of IDH mutantâ€"wild type was 2.15. No difference in the Cho/Cr, Cho/NAA, and DWI apparent diffusion coefficients (p > 0.05) was noted between the IDH mutant and wild type. CONCLUSION: PWI rCBV is the most important prognostic value of aMRI used in tumor grading. PWI rCBV values could be significant in distinguishing IDH wild and mutant.

Giant cell reparative granuloma of the axis.

Giant cell reparative granuloma (GCRG) is a rare, benign fibroosseous lesion. It typically arises in the mandible and maxilla, and less frequently in the skull bones. We report a case of GCRG of the axis, which is the first to be reported in the literature. A 35-year-old man was admitted to our clinic with the complaint of pain at his neck. There was no neurological deficit. CT and MRI showed a lesion destructing the body of the axis. Biopsy specimens were taken through the transoral-transpharyngeal route. Histopathological diagnosis was GCRG. The lesion was removed subtotally by the same route. We filled the tumor cavity with a bone graft and the patient was discharged with a halo brace without any neurological deficits. The follow-up CT revealed one year after the surgery showed sclerosis at the tumor site. The etiopathogenesis of GCRG is still controversial and the differential diagnosis, especially from giant cell tumor of bone is quite difficult. The treatment of choice for these lesions is complete surgical removal. Some authors recommend radiotherapy if total removal fails.

Small Cell Lung Carcinoma Metastasis to Atypical Meningioma: Importance of Perfusion Magnetic Resonance Imaging Graphics in Differential Diagnosis.

We described the imaging findings of small cell lung carcinoma metastasis to atypical meningioma and the importance of magnetic resonance imaging perfusion graphics at the differential diagnosis. To be able to determine subtypes of meningiomas and differentiate whether they are malignant or benign may provide a preoperative idea to determine prognosis and surgical procedure.

Iliac Artery Injury During Lumbar Disc Hernia Surgery.

BACKGROUND: Vascular injury complications during lumbar discectomy are rare but potentially life-threatening. Therefore, an early diagnosis and effective treatment management is required for these complications. CASE DESCRIPTION: A 50-year-old female patient was admitted to our outpatient clinic with severe back and right leg pain. She underwent surgery for right L4-5 extruded disc herniation with general anesthesia. Sudden arterial hemorrhage occurred during discectomy performed with straight disc forceps and was controlled using hemostatic materials, with no significant decrease in blood pressure. However, the patient became hypotensive near the end of the operation. The incision was quickly closed, and she was turned to supine position. Emergency abdominal ultrasound, computed tomography, and computed tomography angiography revealed an injury of the left main iliac artery, which was repaired by endovascular stenting. Laparotomy and Bogota bag were applied because of increased intrabdominal pressure at 3 hours postoperative. In addition, a retroperitoneal catheter was placed into the area of the right retroperitoneal hematoma on the first postoperative day. Tissue plasminogen activator was administered through the catheter. On postoperative day 3, the Bogota bag was removed, and the abdomen was closed. The patient was discharged without neurodeficit on day 27. Her abdominal fascial defect was closed with a synthetic graft after 5 months. CONCLUSIONS: Although lumbar discectomy is one of the most commonly performed neurosurgical procedures, the routine rules of discectomy should not be neglected. Early detection and a multidisciplinary approach can help prevent mortality in the event of vascular injury.

[A case of vancomycin resistant Leuconostoc meningitis]. / Vankomisine dirençli bir Leuconostoc menenjiti olgusu.

Although Leuconostoc species are rarely pathogenic for humans, they may sometimes give rise to serious infections. In this report, a case of meningitis caused by vancomycin resistant Leuconostoc spp. was reported. Fifty-seven years old female patient was admitted to the hospital with the complaints of headache and sudden onset of unconsciousness and hospitalized in the neurosurgery department because of subarachnoidal hemorrhage. Patient was followed up with dexamethasone treatment and daily lumbar puncture without any surgical intervention. The findings of hemorrhage were receded in the cerebrospinal fluid (CSF) and the consciousness of the patient improved gradually. However, on the ninth day of the hospitalization, the patient became febrile and confused; white blood cell count was 7920/mm3, protein level was 1952 mg/l in the CSF examination. Nosocomial meningitis was diagnosed and empirical treatment with ceftazidime (3 x 2 g/day) and vancomycin (4 x 500 mg/day) was started. CSF culture revealed growth of gram-positive cocci which were identified as Leuconostoc spp. by VITEK 2 Compact (Biomerieux, France) and Phoenix Instrument (Becton-Dickinson, USA) systems. Since the isolate was found susceptible to penicillin, ampicillin, cefotaxime, cefepime, chloramphenicol, clindamycin, erythromycin and linezolid, and resistant to vancomycin by disk diffusion and miniAPI ATB STREP 5 (Biomerieux, France) methods, the treatment was switched to linezolid (2 x 600 mg/day). Vancomycin and teicoplanin resistance was confirmed by E-test. The treatment was continued with linezolid and the patient's clinical condition improved after 14 days of treatment. The possible way of Leuconostoc transmission in this case was thought to be the lumbar punctures performed during the follow-up of subarachnoid hemorrhage. This presentation which demonstrated that Leuconostoc spp. might rarely lead to meningitis, also pointed out that when a vancomycin resistant gram-positive coccus was identified, Leuconostoc spp. should always be kept in mind.

Intracranial foreign body.

Intracranial foreign bodies due to nonmissile intracranial penetrations occur rarely. Most of these penetrating injuries result from industrial accidents or criminal assaults. The complications which cause mortality in early stage are intracerebral hemorrhage, contusion, major vascular injury and meningitis. In case of such injuries, foreign bodies near the major vascular structures should not be attempted to taken out. Total excision of the foreign body via craniotomy should be planned and possible dural and vascular injuries should be repaired during surgery. Urgent surgery should be performed as there is 53% morbidity in case of late surgery and 62% morbidity in nonoperated cases. We herein report a 20-year old man who attempted suicide by introducing a nail into his brain and review the related literature.