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.

Pituitary macroadenomas (>3 cm) in young adulthood: Pathologic and proliferative characteristics.

BACKGROUND: There are scarce data regarding the significance of the tumor size, hormonal activity and size of the pituitary tumor of the young; therefore, the study was designed to define the relation of the hormonal status of the large pituitary adenomas. OBJECTIVE: We compared those features with tumors of the elderly (>40) with the young patients, and analyzed the clinicopathologic and proliferative features of pituitary macroadenomas in young adulthood (≤40). METHODS: 20-year archives of pituitary tumors in our clinics were reviewed and macroadenomas with diameter≥3 cm were included in the study. We identified 46 pituitary adenomas and immunohistochemically stained them with pituitary hormones, p53 and Ki-67. Twenty-four cases were ≤40-year with an age range of 11-40 years (mean 28.0). Twenty-two cases were >40 with an age range of 44-78 years (mean 58.8). RESULTS: In the young patient group, 15 (62.5%) were functional adenomas (6 prolactinomas, six growth hormone [GH], one adrenocorticotrophic hormone [ACTH] adenoma, two multihormonal [GH+ACTH]) and nine (37.5%) were either gonadotrophic or null cell adenomas. In the elderly group, five (22.7%) were functional adenomas (two adrenocorticotrophic hormone [ACTH] adenoma, one prolactinoma, one growth hormone [GH], one multihormonal [GH+ACTH]) and 17 (77.3%) were either gonadotrophic or null cell adenomas. Ki-67 proliferation index in adenomas of the young was approximately two-folds higher than the elderly (2.7% vs. 1.2%). CONCLUSION: In both groups, rare p53 positivity was identified. In conclusion, pituitary macroadenomas of the young show hormonal expression frequently with relatively high Ki-67 proliferation indices.

An evaluation of the effectiveness of pre-ischemic hyperbaric oxygen and post-ischemic aminoguanidine in experimental cerebral ischemia.

OBJECTIVE: To study the effects of pre-ischemic hyperbaric oxygen (HBO) and post-ischemic aminoguanidine (AG) on the infarct volume in permanent middle cerebral artery occlusion. METHODS: This study was approved by the Animal Experiments Ethics Committee of Gulhane Military Medical Academy, Ankara, Turkey and carried out from March 2006 to August 2006. A total of 28 Sprague-Dawley rats (200-320 g) were divided into 4 groups: control (K) group (n = 7); HBO group (n = 7); HBO + AG group (n = 7); and the AG group (n = 7). All rats underwent middle cerebral artery occlusion (MCAO) by subtemporal craniectomy, and permanent ischemia was created. A 2.8 atmospheric pressure of HBO was first applied to the HBO and HBO + AG groups for 45 minutes, and occlusion was created after 2 hours. In the HBO + AG group, intraperitoneal administration of AG hemisulfate (100 mg/kg) was started 6 hours after MCAO, and was continued twice a day for 3 days. RESULTS: The rate of infarction was found to be 22.2+/-3.1% in the control group, 16.1+/-2.7% in the HBO group, 15.2+/-1.9% in the HBO+AG group, and 14.4+/-3.3% in the AG groups. The rate of infarctions (therefore the volume of infarct) in the HBO, HBO + AG, and AG groups were found to be significantly decreased compared with the control group (p=0.002, p=0.001, and p=0.001). CONCLUSION: In permanent MCAO-induced ischemia in rats, HBO and AG were observed to have a lowering effect on the infarct volume, but no additive effect was observed. This situation can be explained by different mechanisms of action.

Transconjunctival Approach: A Safe and Effective Access to Mass Lesions in the Anterior Orbit.

BACKGROUND: The orbit is an eloquent organ of the body. Safe surgical access to the orbit could be challenging due to the dense network of critical structures confined to it. There are versatile approaches to different parts of the orbit that could be used by neurosurgeons without causing injury to critical neurovascular structures. In this study, we aimed to present our surgical experience with the transconjunctival approach through the bulbar conjunctiva to anterior intraorbital lesions caused by diverse pathologies. METHODS: We conducted a retrospective review of cases with intraorbital lesions operated via the transconjunctival approach by the same senior surgeon between 2015 and 2017. All patients were evaluated before the surgery by computed tomography, magnetic resonance imaging, and plain anteroposterior and lateral radiographs. RESULTS: Five patients underwent surgery by the transconjunctival approach through the medial or lateral routes for different pathologies: cavernoma, lymphoma, inflammatory reaction, meningocele, and foreign body. No complications were recorded, and all patients were satisfied with their clinical and esthetic results. CONCLUSIONS: The transconjunctival approach is a safe, effective, and time-sparing surgical approach to diverse pathologies in the anterior orbit. Navigation systems enhance the ability to maneuver in selected cases. The transconjunctival approach could be performed in collaboration with ophthalmologists since it provides better esthetic outcomes and higher satisfaction rates in operated patients.

The effect of about one third craniectomy on the cerebrospinal fluid flow rate as estimated by radionuclide cisternography in normal rabbits.

Since, the effect of a large cranial defect on the cerebrospinal fluid (CSF) flow rate is still not clear, this study was designed to evaluate the effect of craniectomy in rabbits by using a radionuclide technique, under in vivo physiologic conditions. Eleven male New Zealand white rabbits were examined. After the injection of technetium-99m-diethylene-triaminepenta-acetic acid into the fourth ventricle of each rabbit, dynamic acquisition for 60 min (1 min per frame) was performed pre-op followed by about one third craniectomy to each animal. Injection of the radiopharmaceutical and the imaging steps were repeated at 24 h (post-op 24 h) and at 7 days (post-op 7 d) after craniectomy. The region of interest (ROI) was drawn around the injection site and a time activity curve was generated. Slopes of each curve were calculated to detect the flow rate of the radiopharmaceutical from the injection site during 60 min. Besides, the count decreased ratio (ROIcounts of the last frame ROI counts of the first frame X100) was calculated. Our results showed that the pre-op values of the slope of the time-activity curve and the count decreased ratio were decreased 24 h and 7 d post-op but statistically significant was only the difference between the above values pre-op and 7 d post-op (P=0.04, P=0.01 respectively). In conclusion, the data of the present study indicate that the CSF flow rate in rabbits decreased 7 d after one third craniectomy.

Meta-analyses of intracerebral hematoma treatment.

AIM: The aim of this study is to define the position of surgery preference in the treatment choice for spontaneous intracerebral hematoma (ICH) and to compare the efficacy of surgery with the medical treatment based on data from 18 previously reported randomized prospective studies on this topic. MATERIAL AND METHODS: Literature databases and articles were searched from 1960 to 2010. Eighteen randomized studies on this topic were evaluated. RESULTS: Among these 18 studies, 7 (38.9%) were multicenter and 11 (61.1%) were single center. Totally 204 centers were involved. 1769 patients were treated surgically and 3200 medically. Craniotomy was the most preferred method (n = 14; 77.8%). Follow-up time was mostly 6 months. In general, the effect of surgical versus medical treatment on outcome (mortality/morbidity) after a supratentorial spontaneous ICH do not differ significantly. In individual analysis, the mortality was found to be significantly lower in the operated group than the nonoperated group in only two studies (Kurtsoy's and Miller's studies). Meta-analysis of subgroup analysis revealed surgical treatment results were significantly better for hematoma volume > 40 ml, early surgery (before 24 hours), and Glasgow Coma Scale (GCS)≥ 6. CONCLUSION: Surgical treatment results were found to be superior to medical treatment in cases with hematoma volume > 40 ml, and GCS ≥ 6. The studies are not adequate to analyze the best type of surgery.

Analysis of proximal radial nerve injury in the arm.

BACKGROUND: Radial nerve is the most frequently injured major nerve in the upper extremity. Proximal part of the radial nerve involvement can result from a humerus fracture, direct nerve trauma, compression and rarely from tumors. OBJECTIVES: The aim of the study is to determine the clinical characteristics and electrodiagnostic findings in patients with proximal radial nerve injuries, and also the outcome of surgical treatment. MATERIALS AND METHODS: The study subjects included 46 patients with radial nerve injuries seen between June 2000 and June 2008 at our hospital. The analysis included demographics, clinical features, etiology, pre-and postoperative EMNG (Electromyoneurography) findings. RESULTS: Surgical decompression resulted in neurological improvement in patients with radial entrapment neuropathies. Good neurological recovery was observed from decompression of callus of old humeral fracture. The worst results were observed in the direct missile injuries of the radial nerve. CONCLUSIONS: A detailed clinical and electrodiagnostic evaluation is of importance in patients with radial nerve injury to ensure an appropriate treatment. The choice of treatment, conservative or surgical, depends on the clinical presentation and the type of injury.

Electrophysiological findings in patients with adult tethered cord syndrome.

AIM: This study was planned for detailed evaluation of electrophysiological findings in patients with adult TCS. MATERIAL AND METHODS: Patients were retrospectively assessed for clinical, radiological and electrophysiological data between 1999 and 2008. Tibial somatosensorial evoked potentials, needle electromyography, nerve conduction studies and late responses (H reflex and F response) were studied in thirty (1 female, 29 males) TCS patients diagnosed by lumbar magnetic resonance imaging. RESULTS: Tibial somato-sensorial evoked potentials cortical response latency was abnormal in 18 (60%) patients. Needle electromyography revealed chronic neurogenic involvement in 13 (43.3%) patients. In nerve conduction studies, motor unit action potential amplitudes were reduced in 5 (16.6%) patients and H reflexes were abnormal in 13 (43.3%) patients. CONCLUSION: Different electrophysiological abnormalities may be seen in patients with adult TCS. Our results indicated that tibial SEP abnormalities are most sensitive electrophysiological finding in patients with adult TCS. Patients with TCS should undergo electrophysiological examinations whether they have subjective or objective complaints. These examinations should evaluate different systems and treatment planning should be done with the data obtained.

Does hypothermic treatment provide an advantage after spinal cord injury until surgery? An experimental study.

We compared the effects of early and late stage hypothermia treatment after spinal cord injury. Five groups each consisting of seven rats were included in this study. In Group 1a (Clip applied-non-treatment group) and Group 1b (Clip applied-treated group) the spinal cords were harvested 1 h after the injury. In Group 2a (clip applied, non-treated group) and Group 2b (clip applied-treated group) the injured segments were harvested 24 h after injury. Group 3 was designed as the sham-operated group. The significantly lower levels of TBARS and GSH-Px in Group 2a, as compared with Group 1b suggests that the hypothermia was effective in the early stage of treatment (P < 0.05). In contrast, TBARS and GSH-Px levels were significantly increased at the 24 h timepoint following treatment (P < 0.05). Short-term systemic hypothermia reduces lipid peroxidation in the early stages after spinal cord injury. This beneficial effect disappears 24 h following systemic hypothermic treatment.

Traumatic brain injury due to gunshot wounds: a single institution's experience with 442 consecutive patients.

AIM: Traumatic brain injury (TBI) caused by a gunshot wound is a complex injury with a broad spectrum of symptoms and high rates of mortality and morbidity. This study presents an evaluation of TBI caused by gunshot wounds presenting at a single institution and discusses possible predictive factors for the outcome of surgical intervention. MATERIAL AND METHODS: The study sample consisted of 442 patients who underwent surgery for TBI over a 16-year period. All injuries were caused by gunshot wounds, such as bullets and shrapnel. All patients underwent surgical intervention. RESULTS: Almost all patients (99.3%) were male, and the mean patient age was 22.3 years. Wounds were caused by shrapnel in 68 percent of patients. The Glasgow Coma Scale (GCS) score at admission was below 8 in 116 patients (26.2%) and above 8 in 326 patients (73.8%). In total, 47 patients (10.6%) died despite surgical management, with diffuse brain injury the most common cause of death. CONCLUSION: Low GCS scores, ventricular injuries and bihemispheric injuries are correlated with poor prognosis. Early and less invasive surgery in conjunction with short transportation time to the hospital could decrease mortality rates.

DFT study of the 1-octene metathesis reaction mechanism with WCl6/C catalytic system.

A catalytic system consisting of tungsten carbene generated from WCl(6) and an atomic carbon is investigated theoretically for the metathesis of 1-octene at B3LYP/extended LANL2DZ level of DFT. The ground-state geometries and charge distributions of the structures belonging to the reaction mechanism are located. Energetics for the complete set of reactions, involving the formation of the tungsten carbene precatalyst, Cl(4)WCCl(2), the formation of tungsten methylidene and tungsten heptylidene with this precatalyst, and finally productive and degenerative metathesis steps with these alkylidene species are calculated in terms of total electronic energy and thermal energies. The free-energy (ΔG(298)) surfaces of the structures involved in the related reactions are constructed. In addition, solvent effects on the single point energies of the structures are investigated for two different solvents, namely, cyclohexane and chloroform. The results indicate that the formation of the catalytically active heptylidene is energetically favored in comparison to the formation of methylidene, while the degenerative and productive metathesis steps are competitive. In the catalytic cycle, the formation of ethylene is exothermic, while the formation of 7-tetradecene is endothermic. As expected, solvent effects on the metathesis reactions are minor and solvation does not cause any change in the directions of the overall metathesis reactions.

Transsphenoidal approaches to the pituitary: a progression in experience in a single centre.

BACKGROUND: Evolving of a single centre by means of different transsphenoidal approaches during the survey of methodological advances in pituitary surgery is presented. MATERIALS AND METHODS: Ninety-three consecutive patients with pituitary adenomas underwent transphenoidal pituitary operations at Gulhane Military Medical Academy from January 1996 to October 2007. Retrospective chart-based analysis of the surgical methods of transsphenoidal pituitary adenoma operations were done. Surgical methods were described. Outcomes and complications were presented. Attention is focused on the methodology of different surgical techniques of pituitary surgery. FINDINGS: During the evaluation period, 12 Sublabial approaches (1996-1998), 13 transseptal transsphenoidal approaches (1999-2000), 15 endonasal transsphenoidal approaches (2000-2004), 25 endoscopy assisted endonasal approaches (2002-2006) and 28 pure endoscopic endonasal approaches (2006-2007) were performed. CONCLUSIONS: Technologic advancements in endoscopy and gaining experience in pituitary surgery drives neurosurgeons toward less invasive approaches.

Comparison of the efficacies of antibiotic-impregnated and silver-impregnated ventricular catheters on the prevention of infections. An in vitro laboratory study.

BACKGROUND AND OBJECTIVE: Infection of the cerebrospinal fluid is a life-threatening condition which is usually treated with systemic antibiotics and continued ventricular drainage in children. The aim of this study was to analyze the antimicrobial activities of two antimicrobial-agent-impregnated ventricular catheters and to compare their efficacies on the bacterial cultures. METHODS: Antibiotic-impregnated (clindamycin and rifampicin), silver-impregnated, and standard ventricular catheters were used in this study. The experiment was performed in 2 steps. In the first step, small pieces of the catheters were cut and incubated. Then, they were washed and placed in agar medium. Finally, the number of colonies was counted. In the second step, the pieces of catheters were placed on agar plates containing Staphylococcus aureus,Staphylococcus epidermidis, and Pseudomonas aeruginosa. The plates were incubated, and then, the inhibition zone for each catheter was measured. RESULTS: An inhibition zone was observed only in the plates for antibiotic-impregnated catheters. In the other plates, no inhibition zone was detected. The number of colonies was lowest in the plate with the silver-impregnated catheter, followed by the antibiotic-impregnated and standard catheters. CONCLUSION: The antibiotic-impregnated catheter seems more effective for antimicrobial treatment. Although no inhibition zone was found in the plates for silver-impregnated catheters, these catheters allow the lowest bacterial colonization in agar.

Tethered cord syndrome in adulthood.

OBJECTIVE/BACKGROUND: The standard treatment for tethered cord syndrome (operative vs nonoperative management) that presents in adulthood remains controversial. A comparative study of tethered cord syndrome in adulthood is needed. DESIGN: A retrospective chart-based analysis. METHODS: Patients admitted to Gulhane Military Medical Academy Department of Neurosurgery for management of caudal spinal cord tethering from June 1999 through December 2006 (N = 22). RESULTS: Conus level was normal in 1 patient with split cord malformation and dermal sinus. Tight terminal filum was found in 21 patients, including postrepair myelomeningocele tethered cord in 4, lipomyelomeningocele/meningocele in 8, split cord malformation in 3, dermal sinus in 7, and syringomyelia in 3. The most common complaints were back pain (15 patients, 68.1%), bladder dysfunction (8, 36.3%), fecal incontinence (2, 9.09%), and leg pain (7, 31.8%). One patient had hydrocephalus (4.5%). Ten of 22 patients underwent surgery; 8 of 10 patients had detethering; and 12 patients refused surgery. Postoperative cerebrospinal fluid leakage requiring reinforcement sutures occurred in 1 patient. There were no infectious complications. Neurologic status and outcomes were compared with preoperative findings. CONCLUSIONS: Some patients refuse surgery despite severe neurologic disturbances. Neurosurgeons should fully explain the risks and benefits of surgery for tethered cord to the patient and family. A much larger and prospective randomized series is needed to determine the effects of operative vs nonoperative management of tethered cord syndrome in adulthood.

Tumors of the lateral ventricle: the factors that affected the preference of the surgical approach in 46 patiens.

AIM: Optimal surgical pathway for lateral ventricle tumors is still controversial. The purpose of this study is to discuss the factors that affected the preference of the surgical techniques for removing lateral ventricle tumors. MATERIAL AND METHODS: 46 consecutive patients underwent operation for lateral ventricle tumors. The mean age was 36 years. Preoperative magnetic resonance imaging (MRI) images were examined to determine the location, expansion and size of each tumor. The transcallosal approach was used in 25 patients, and the transcortical approach was used in 21 patients. We performed MRI to determine the tumor size and recurrence or increased size of the residual tumor. RESULTS: Total resection was performed in 31 patients. Only one patient, with glioblastoma, died due to hepatic encephalopathy and intraventricular hemorrhage after the operation. Additional neurological deficits were seen 4 patients, and postoperative seizure occurred in one patient. The mean duration of follow-up was 38,37 months. CONCLUSION: Lateral ventricle tumors can be treated best by careful selection of the surgical approach according to localization of the tumor within the ventricle, the expansion side of the tumor, the size of the tumor, the origin of the vascular feeding branches, the venous drainage, and the relationship of the structures, and the histopathological features.

Iliocaval arteriovenous fistula following lumbar disc surgery: endovascular treatment with a Stent-graft.

Arteriovenous (AV) fistulae, pseudoaneurysms, and lacerations may occur during disc surgery. AV fistula after lumbar disc surgery is rare. Early diagnosis and treatment of vascular complications associated with disc surgery is essential due to their high mortality and morbidity rates. We report a case report who was presented with fistulous shunt between right common iliac artery and inferior vena cava fifteen days after operation for herniated discs at L4-L5 and L5-S1 levels. Treatment was transcatheter covered stent placement at the fistulous site of right common iliac artery using a self expandable stent-graft. We suggest use of minimally invasive interventional techniques in the management of suitable vascular injuries following lumbar disc surgery.

The effect of moderate hypothermia in acute ischemic stroke on pericyte migration: an ultrastructural study.

Pericytes are essential components of the blood-brain barrier together with endothelial cells and astrocytes. Any disturbance of brain perfusion may result in blood-brain barrier dysfunction due to pericyte migration from the microvascular wall. The neuroprotective influence of hypothermia on ischemic brain injury has been clearly shown in models of both global and focal ischemia. Leakage of plasma proteins contributes to the extension of neuronal injury and hypothermia has a neuroprotective influence during the ischemic insult. This line of thinking impelled us to investigate the possible role of the pericytes in the occurrence of hypothermic protection during cerebral ischemia. In this study, we examined at the ultrastructural level the effect of moderate hypothermia on microvascular pericyte responses using a rat model of permanent middle cerebral artery occlusion. Twenty rats were divided into four groups. Middle cerebral artery occlusion was performed in all rats except the control group (first group), which was used to determine the pericyte morphology under normal conditions. In the second group, pericyte response to irreversible ischemia under normothermic conditions was examined at the end of the first hour. In the third group, pericyte response to hypoxia was examined under normothermic conditions three hours after ischemia. In the fourth group, temporalis muscle temperature was maintained at 27-29 degrees C for 1h after middle cerebral artery occlusion and pericyte response was then examined at the ultrastructural level. In ischemic normothermic conditions at the end of the first hour (Group 2), a separation was observed between pericytes and the basement membrane and this was interpreted as pericyte migration from the microvascular wall. In ischemic normothermic conditions at the end of the third hour (Group 3), basement membrane disorganization and increased space between the basement membranes were seen in addition to the differentiation of second group. In ischemic hypothermic conditions at the end of the first hour (Group 4), pericyte separation or migration from basement membrane were not seen and the blood-brain barrier remained firm. These findings were interpreted by the authors as a possible relationship between pericyte behavior and neural protection during hypothermia. We suggest that hypothermia may delay the pericyte response but not necessarily attenuate it, and should be associated with hypothermic protection.

The investigation of the role of the facet joint angle in the development of L5-S1 spondylolysis in young men.

OBJECTIVES: This study aims to evaluate facet tropism in younger patients with lumbar spondylolysis and to investigate the role of facet tropism in the development of spondylolysis. PATIENTS AND METHODS: Between February 2013 and December 2015, a total of 102 male patients with bilateral L5 pars defect including 53 with spondylolysis and 49 control subjects were included in this case-control study. The facet joint angles were measured bilaterally and axially at the level of L3-4, L4-5, L5-S1 using computed tomography (CT). The classification was made as follows: A difference between two reciprocal facet joint angles of <6° indicated no tropism, 6°-12° indicated moderate tropism, and >12° indicated severe tropism. RESULTS: A total of 612 angles including 318 facet joint angles from 53 patients with spondylolysis and 294 facet joint angles from 49 control subjects were measured. L3-4 measurements in the control group showed no tropism in 87.8% (n=43), moderate tropism in 12.2% (n=6), and severe tropism in 0% (n=0). L4-5 measurements in control group showed no tropism in 79.6% (n=39), moderate tropism in 20.4% (n=10), and severe tropism in 0% (n=0). L5-S1 measurements in the control group showed no tropism in 69.4% (n=34), moderate tropism in 28.6% (n=14), and severe tropism in 2.0% (n=1). The mean facet joint angles in the spondylosis group were 32.9±5.1°, 37.5±5.4°, and 41.2±7.8° at the levels of L3-4, L4-5, and L5-S1, respectively. The mean facet joint angles of the control group were 33.2±5.7°, 39.7±4.9°, and 42.2±4.9° at the levels of L3-4, L4-5, and L5-S1, respectively, indicating no significant difference between the right and left mean facet joint angles between the groups (p>0.05). The frequency of facet tropism and the difference between right and left facet joint angles for all three levels were significantly higher in the spondylolysis group (p<0.05). Facet tropism at the level of L5-S1 was significantly more frequent than facet tropism at L3-4 level (p<0.05). CONCLUSION: Our study results show that the rate of facet joint tropism is higher in the patients with spondylolysis, suggesting that facet tropism seems to play a role in the etiology of spondylolysis as a predisposing factor.

Penetrating orbitocranial gunshot injuries.

BACKGROUND: The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries. METHODS: Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured. RESULTS: The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect-negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect-positive injuries. CONCLUSION: The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.