Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients.

BACKGROUND: We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. MATERIALS AND METHODS: This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease. RESULTS: Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively. CONCLUSIONS: Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

Sodium fluorescein-guided brain tumor surgery under the YELLOW-560-nm surgical microscope filter in pediatric age group: feasibility and preliminary results.

OBJECTIVE: To evaluate the feasibility and safety of sodium fluorescein (Na-Fl)-guided surgery with the use of the PENTERO 900 surgical microscope (Carl Zeiss, Meditec, Oberkochen, Germany) equipped with the YELLOW-560-nm filter and low-dose Na-Fl (2 mg/kg) in pediatric brain tumor surgery. METHODS: The study included 23 pediatric patients with various intracranial pathologies, who underwent Na-Fl-guided surgery between April 2015 and February 2018. Clinical features, surgical observations, extent of resection, and tumor histopathology were retrospectively analyzed. The use of YELLOW-560-nm filter was found "helpful" if the discrimination of the pinkish brain tissue and bright yellow stained tumor tissue was clear. Otherwise, it was described as "not helpful." RESULTS: There were 11 female and 12 male patients with a mean age of 9.4 years. There were 7 brain stem/tectal plate gliomas, 6 supratentorial tumors, 4 intraventricular tumors, 2 pineal tumors, 2 infratentorial tumors, 1 clivus tumor, and 1 tumor with supra- and infratentorial extensions in the current series. Na-Fl was found helpful by means of the tumor demarcation in 20 instances (87%). In 11 of these 20 operations (55%), a total resection was achieved regardless of the tumor pathology. A subtotal resection was achieved in the remaining 9 patients (45%). No adverse events or side effects were encountered with regard to Na-Fl use. CONCLUSION: Na-Fl guidance with the use of the YELLOW-560 filter is safe and effective during brain tumor surgery in pediatric age group.

Life-threatening parkinsonism-hyperpyrexia syndrome following bilateral deep brain stimulation of the subthalamic nucleus.

Parkinsonism-hyperpyrexia syndrome (PHS), or neuroleptic malignant syndrome (NMS), is a neurophysiologic reaction to the acute withdrawal/decrease of central dopamine levels. It is a severe complication characterized by rigidity, change in consciousness level, fever, hypertension, and autonomic instability, that can be fatal. To the best of our knowledge, PHS following deep brain stimulation (DBS) of subthalamic nucleus (STN) surgery due to anti-Parkinson drug discontinuation has been previously reported only six times. Half of these cases resulted in fatalities. Herein, we report on an early diagnosed case of PHS following bilateral STN-DBS which was successfully treated with the administration of dopamine agonists, fluid replacement, and activation of DBS.

Intraventricular Shunt Catheter Placement of Adult Normal Pressure Hydrocephalus Using an AxiEMTM Electromagnetic Neuronavigation System: A Single-Center Experience.

AIM: To prove the superiority of the electromagnetic (EM) neuronavigation technique to increase the accuracy of intraventicular shunt catheter placement, and to reduce accompanying complications. MATERIAL AND METHODS: A total of 21 patients with hydrocephalus [age range (years): 53-84] were studied. All of them had undergone thin-slice, navigation-compatible, computed tomography (CT) preoperatively. Shunt surgery was performed under the guidance of EM neuronavigation technology. All patients underwent follow-up CT the next day to evaluate catheter tip placement and were followed up at 1, 3, 6, and 12 months. RESULTS: All catheter tips were placed properly in front of the foramen of Monro in the desired position, except in one case in which the tip migrated to the perimesencephalic cistern and underwent reoperation in the early postoperative period. No complications due to infection and obstruction were observed in the medium- and long-term follow-ups. The complication rate due to the incorrect catheter positioning was 4.76% of the total cases. CONCLUSION: The placement of the ventricular catheter under EM-guided navigation technology reduces the proximal-end failure caused by malpositioning, obstruction, and infection.

Effect of lumbar puncture in patients with aneurysmal subarachnoid hemorrhage treated microsurgically or endovascularly.

OBJECTIVE: The aim of this study was to evaluate the effect of treatment modality (surgical clipping vs. endovascular coiling) and lumbar puncture (LP) in patients with aneurysmal subarachnoid hemorrhage (SAH) based on neurologic status on admission and clinical outcome. PATIENTS AND METHODS: One hundred forty-eight consecutive patients with ruptured intracranial aneurysms treated via endovascular or surgical methods were included in our study. Patients who refused further therapy or received only supportive therapy because of bad neurologic status were excluded. Severity of SAH was evaluated using the Fisher score. World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess (H&H) scores were used for evaluation of neurologic status. Glasgow Outcome Scale scores and modified Rankin scores were used for outcome evaluation. RESULTS: We found that modified Rankin scores were significantly lower in the surgical clipping group (1.1 ± 1.4) than in the endovascular coiling group (1.7 ± 1.8) (p: 0.04). The positive lumbar puncture [LP(+)] group had similar outcome scores as the negative lumbar puncture [LP(-)] group, although the LP(+) group had worse initial SAH evaluation scores (WFNS 1.64 ± 0.95-1.23 ± 0.61, p: 0.0004 and H&H 2.18 ± 1.07-1.65 ± 0.88, p: 0.001). CONCLUSION: Surgical clipping might improve clinical outcome better than endovascular coiling, although a more confident conclusion requires absolute randomization of patients for both treatments. LP could also improve clinical outcome in patients with high initial SAH evaluation scores.

Multiple atypical recurrent meningiomas 13 years after radiotherapy for unilateral retinoblastoma: case report and review of the literature.

Radiotherapy is an important treatment modality for intracranial malignancies. Improved survival rates were achieved via a combination of surgery, chemotherapy and radiotherapy. On the other hand, improved survival rates made long-term complications of radiotherapy more apparent. Secondary neoplasms due to cranial irradiation are encountered more commonly in neurosurgical practice. Radiation-induced meningiomas are recognized as a common late complication of radiotherapy. However, radiation-induced meningiomas after radiotherapy for retinoblastoma have been reported rarely. Herein we report a patient who harboured multiple meningiomas 13 years after radiotherapy for unilateral retinoblastoma, which were recurrent despite surgical removal and chemotherapy.

Contralateral vs. Ipsilateral Approach to Superior Hypophyseal Artery Aneurysms: An Anatomical Study and Morphometric Analysis.

Introduction: Surgical clipping of superior hypophyseal artery (SHA) aneurysms is a challenging task for neurosurgeons due to their close anatomical relationships. The development of endovascular techniques and the difficulty in surgery have led to a decrease in the number of surgical procedures and thus the experience of neurosurgeons in this region. In this study, we aimed to reveal the microsurgical anatomy of the ipsilateral and contralateral approaches to SHA aneurysms and define their limitations via morphometric analyses of radiological anatomy, three-dimensional (3D) modeling, and surgical illustrations. Method: Five fixed and injected cadaver heads underwent dissections. In order to make morphometric measurements, 75 cranial MRI scans were reviewed. Cranial scans were rendered with a module and used to produce 3D models of different anatomical structures. In addition, a medical illustration was drawn that shows different sizes of aneurysms and surgical clipping approaches. Results: For the contralateral approach, pterional craniotomy and sylvian dissection were performed. The contralateral SHA was reached from the prechiasmatic area. The dissected SHA was approached with an aneurysm clip, and maneuverability was evaluated. For the ipsilateral approach, pterional craniotomy and sylvian dissection were performed. The ipsilateral SHA was reached by mobilizing the left optic nerve with left optic nerve unroofing and left anterior clinoidectomy. MRI measurements showed that the area of the prechiasm was 90.4 ± 36.6 mm2 (prefixed: 46.9 ± 10.4 mm2, normofixed: 84.8 ± 15.7 mm2, postfixed: 137.2 ± 19.5 mm2, p < 0.001), the distance between the anterior aspect of the optic chiasm and the limbus sphenoidale was 10.0 ± 3.5 mm (prefixed: 5.7 ± 0.8 mm, normofixed: 9.6 ± 1.6 mm, postfixed:14.4 ± 1.6 mm, p < 0.001), and optic nerves' interneural angle was 65.2° ± 10.0° (prefixed: 77.1° ± 7.3, normofixed: 63.6° ± 7.7°, postfixed: 57.7° ± 5.7°, p: 0.010). Conclusion: Anatomic dissections along with 3D virtual model simulations and illustrations demonstrated that the contralateral approach would potentially allow for proximal control and neck control/clipping in smaller SHA aneurysm with relatively minimal retraction of the contralateral optic nerve in the setting of pre- or normofixed chiasm, and ipsilateral approach requires anterior clinodectomy and optic unroofing with considerable optic nerve mobilization to control proximal ICA and clip the aneurysm neck effectively.

Impact of a low-field intraoperative MRI on the surgical results for high-grade gliomas.

In this study the authors retrospectively evaluated the results of the operated intracranial high grade gliomas using low field intraoperative MRI system Polestar N 20+Stealth Station (Medtronic, Co, USA) at German Hospital, Istanbul. Between November 2006 and October 2008, 11 patients underwent microsurgical tumor resection with the use of intraoperative MRI for WHO Grade III and IV gliomas. There were six males and five females, mean age was 53 (range 30-73), and mean follow-up duration was 19 months (range 4-31). Ten total, one subtotal resection was achieved, whereas intraoperative MRI assessment demonstrated five residual tumors. Histopathological examination revealed that eight tumors were glioblastomas and three were anaplastic oligodendroglioma, anaplastic oligoastrocytoma and anaplastic ependymoma respectively. No complications directly related to the intraoperative scanning were observed and there was no mortality, but one patient with an insular tumor developed hemiparesis after the operation. Mean hospital stay was 4.8 day. Ten patients received additional radiotherapy and chemotherapy, one patient refused further therapy. Mean survival was 18.8 months for the entire group and 15.6 months for glioblastoma patients. In this small series of patients with high grade gliomas we found that the use of intraoperative MRI helps complete tumor removal and hence improves survival.

Dose-dependent ultrastructural and morphometric alterations after erythropoietin treatment in rat femoral artery vasospasm model.

PURPOSE: Cerebral vasospasm is the common cause of poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). Although many agents are experimentally and clinicaly used to protect or recover from vasospasm, an effective neurotherapeutic drug is still missing. Erythropoietin (EPO) is recently a promising candidate. The aim of this study is to investigate the dose-dependent effects of recombinant human EPO (rhEPO) on arterial wall in a rat femoral artery vasospasm model. METHODS: Thirty two animals were divided into four groups: vasospasm without any treatment (group A), vasospasm +250 IU/kg rhEPO group (group B), vasospasm +500 IU/kg rhEPO group (group C), and control group (group D). Rat femoral artery vasospasm model was used. For groups B and C, 7 days of 250 IU/kg and 500 IU/kg intraperitoneal rhEPO in 0.3 ml saline were administered respectively; and for groups A and D, 0.3 ml saline were administered intraperitoneally without any treatment. After 7 days, histological and morphometric analyses were carried out. RESULTS: Vasospasm alone group demonstrated the highest vessel wall thicknesses, comparing to other groups (p < 0.001). While for groups B and C, vessel wall thickness values were significantly higher than the control group (p < 0.001), between these two groups, there was no significant difference achieved (p > 0.05). CONCLUSION: In our study, there was no significant difference between the two rhEPO treatment groups, but rhEPO treatment was shown to be histologically and morphometrically effective in vasospasm. However, if dosage of EPO treatment is augmented, successful results may be achieved.

Lighting Up the Tumor-Fluorescein-Guided Resection of Gangliogliomas.

(1) Background: Gangliogliomas comprise a small number of brain tumors. They usually present as World Health Organization (WHO) grade I, and they delineate on gadolinium-enhanced MRI; the surgical goal is wide radical resection, and the course thereafter is usually benign. Fluorescein sodium (FL) tends to accumulate in areas with altered blood-brain barrier (BBB). Thus far, the results provided by prospective and retrospective studies show that the utilization of this fluorophore may be associated with better visualization and improvement of resection for several tumors of the central nervous system. In this study, we retrospectively studied the effect of fluorescein sodium on visualization and resection of gangliogliomas. (2) Methods: Surgical databases in three neurosurgical departments (Regensburg University Hospital; Besta Institute, Milano, Italy; and Liv Hospital, Istanbul, Turkey), with approval by the local ethics committee, were retrospectively reviewed to find gangliogliomas surgically removed by a fluorescein-guided technique by the aid of a dedicated filter on the surgical microscope from April 2014 to February 2020. Eighteen patients (13 women, 5 men; mean age 22.9 years, range 3 to 78 years) underwent surgical treatment for gangliogliomas during 19 operations. Fluorescein was intravenously injected (5 mg/kg) after general anesthesia induction. Tumors were removed using a microsurgical technique with the YELLOW 560 Filter (YE560) (KINEVO/PENTERO 900, Carl Zeiss Meditec, Oberkochen, Germany). (3) Results: No side effects related to fluorescein occurred. In all tumors, contrast enhancement on preoperative MRI correlated with bright yellow fluorescence during the surgical procedure (17 gangliogliomas WHO grade I, 1 ganglioglioma WHO grade II). Fluorescein was considered helpful by the operating surgeon in distinguishing tumors from viable tissue in all cases (100%). Biopsy was intended in two operations, and subtotal resection was intended in one operation. In all other operations considered preoperatively eligible, gross total resection (GTR) was achieved in 12 out of 16 (75%) instances. (4) Conclusions: The use of FL and YE560 is a readily available method for safe fluorescence-guided tumor resection, possibly visualizing tumor margins intraoperatively similar to contrast enhancement in T1-weighted MRI. Our data suggested a positive effect of fluorescein-guided surgery on intraoperative visualization and extent of resection during resection of gangliogliomas.

Cerebral vasospasm following subarachnoid hemorrhage: time for a new world of thought.

OBJECTIVE: Delayed cerebral vasospasm has long been recognized as an important cause of poor outcome after an otherwise successful treatment of a ruptured intracranial aneurysm, but it remains a pathophysiological enigma despite intensive research for more than half a century. METHOD: Summarized in this review are highlights of research from North America, Europe and Asia reflecting recent advances in the understanding of delayed ischemic deficit. RESULT: It will focus on current accepted mechanisms and on new frontiers in vasospasm research. CONCLUSION: A key issue is the recognition of events other than arterial narrowing such as early brain injury and cortical spreading depression and of their contribution to overall mortality and morbidity.

Effects of arterial and venous wall homogenates, arterial and venous blood, and different combinations to the cerebral vasospasm in an experimental model.

BACKGROUND: Risks related to rebleeding of a ruptured intracranial aneurysm have decreased. However, ischemic neurologic deficits related to vasospasm are still the leading causes of mortality and morbidity. It is well known that vasospasm is a dynamic process affected by various factors. The severity of vasospasm in animal models and clinical observations differ from each other. This variability has not been completely explained by blood and blood degradation products. Therefore, metabolites released from the damaged vessel wall during the bleeding are thought to play an important role in vasospasm. METHOD: To test this hypothesis, we used 46 male Wistar rats that were divided into 7 groups and administered one of the following to cisterna magna: venous blood, arterial blood, arterial wall homogenate, venous wall homogenate, combined mixture of arterial blood and artery wall homogenate, or combined mixture of venous blood and venous wall homogenate. Brainstems of the rats were excised, and the basilar arteries were harvested for morphometric measurements. RESULT: There were significant differences between the degree of vasospasm caused by arterial and venous blood (P < .0001). The intraluminal area of the basilar artery was significantly narrower after application of arterial blood, artery wall homogenate, or their combination (49% +/- 1%) than after venous groups (30% +/- 1.9%) (P < .0001). CONCLUSION: The results of this experiment demonstrated that metabolites from vessel walls play as important roles in the pathophysiology of vasospasm as blood and blood degradation products. Further investigation of these metabolites will improve our understanding of vasospasm, pathophysiology, and its treatment.

Carotid endarterectomy with regional anesthesia: an audit of 71 cases.

AIM: The aim of carotid endarterectomy (CEA) is the successful removal of the atherosclerotic plaque and meticulous anatomical and physiological reconstruction of the carotid artery without any perioperative complications. Endarterectomy can also be carried out with regional anesthesia, which allows monitoring of the neurological status. This study reviews patients who underwent CEA with regional anesthesia. MATERIAL AND METHODS: A total of 71 consecutive patients were planned to undergo carotid endarterectomy under regional anesthesia between 2000 and 2006. All of these patients, assessed by our neurovascular team, were recruited prospectively and the data was analyzed retrospectively. RESULTS: The study group consisted of 23 women and 48 men with a mean age of 62 (range 37-79). 67 patients (94,4%) had symptomatic, and 4 (5,6%) had asymptomatic (5.6%) carotid stenosis. Six patients (8.45%) were intolerant to carotid clamping (8,45%). The stroke morbidity rate was 1.4% and the mortality rate was 1.4%. The mean hospitalization time was 2.07 (range 1-10) days. CONCLUSION: Carotid endarterectomy performed under regional anesthesia can be a safe method which may lead to better neurological outcome. This method offers several advantages including monitorization of the cerebral ischemia during surgery, usage of selective shunting, decreased need for intensive care and shorter hospitalization time.

Intracranial cystic meningiomas: A series of six patients.

OBJECTIVE: Although meningiomas are the most common primary non-glial intracranial tumors, cystic meningiomas are quite rare. This study presents six cases in order to discuss the radiological and pathological features of cystic meningiomas. PATIENTS AND METHODS: Six patients with cystic meningiomas were included in the study. All patients underwent a cranial computed tomography scan and magnetic resonance imaging (MRI) evaluation, pre- and postoperatively. RESULTS: All patients presented with long standing headache dating back at least two years. There was no gender predominance in our series. Radiological evaluation revealed two parasagittal and two convexity meningiomas located at the frontal region. Two lesions were located at the tuberculum sellae and the foramen magnum. All of the tumors were totally excised (Simpson Grade I or II). Pathology results included meningothelial meningioma in three patients, angiomatous meningioma in two patients, and metaplastic meningioma in one patient. In two patients, the cystic meningiomas were resected with the use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter. Na-Fl was found to be very useful in demonstrating the brain-tumor interface, and it was especially effective in resecting the cyst wall of the peritumoural cystic meningiomas. None of the patients had any complications, and no recurrences were noted in any of the patients within the mean follow-up period of 51 months (range: 16-102 months). CONCLUSION: It is important to note MRI changes specific to cystic meningioma and include meningiomas in the differential diagnosis of intracranial cystic lesions. The use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter is a useful tool to differentiate the brain-tumor interface, as well as to identify the cyst wall in order to fully resect the tumor with the cystic component to avoid recurrence and achieve better clinical results.

Fluorescein Sodium in the Surgical Treatment of Recurrent Glioblastoma Multiforme.

BACKGROUND: Glioblastoma multiforme (GBM) is the most common primary brain tumor and has a high recurrence rate. Maximizing the extent of resection (EOR) in recurrent GBM has proved to be the cornerstone of neurosurgical retreatment. The development of surgical microscopes fitted with fluorescein-specific filters has facilitated fluorescein-guided microsurgery and the identification of tumor tissue. Use of fluorescein sodium (FL) in primary high-grade glioma resection has shown promising results. Here, we present our experience with FL and the dedicated surgical microscope filter YELLOW 560 nm in 106 patients with recurrent GBM. METHODS: A total of 106 patients with recurrent GBM were included (53 women, 53 men; mean age, 53 years). A total of 5 mg/kg bodyweight of FL was intravenously injected approximately 45 minutes before craniotomy. A YELLOW 560 nm filter (PENTERO 900 [Carl Zeiss Meditec, Oberkochen Germany]) was used for microsurgical tumor resection and resection control. Surgical reports were reviewed regarding the degree of fluorescent staining. Postoperative magnetic resonance images were examined within 48 hours after surgery regarding the EOR and postoperative course regarding neurologic outcome, complications, and any adverse events. RESULTS: Bright fluorescent staining was present in all patients, which markedly enhanced tumor visibility and was deemed helpful for tumor resection. Seventeen patients (16%) showed residual tumor tissue on postoperative magnetic resonance imaging (MRI). Therefore, gross total resection was achieved in 89 patients (84%). No adverse events were registered postoperatively. CONCLUSIONS: FL and YELLOW 560 nm are readily available methods for fluorescence-guided tumor resection, similar to contrast enhancement in T1-weighted MRI. FL may improve resection in recurrent GBM with minimal risk, and tumor margins are clearly visualized. FL and the YELLOW 560 nm filter are safe and feasible tools for safe maximal resection of recurrent glioblastoma.

Spinal cavernous malformations: a report of 5 cases.

BACKGROUND: This is a report of 5 patients treated surgically for SCMs. METHODS: During the period from 1998 to 2003, 5 patients (4 male and 1 female) harboring SCMs were treated surgically (all of them underwent complete surgical removal). Patients' ages ranged between 22 and 57 years (mean age, 46 years). Median duration of symptoms was 31 months (1-120 months). Diagnosis was made by MRI scan showing lesions in length of 1 to 6 cm in diameter (mean length, 2.9 cm). Three lesions were found in the cervical, one in the upper dorsal, and one in the lower dorsal cord. One of them was located extradurally, one of them intradural extramedullary, and 3 of them intramedullary. RESULTS: An MRI examination showing total removal was performed postoperatively in each patient (the postoperative MRI examinations revealed total removal in all cases). The follow-up period ranged from 1 to 4 years (mean, 27 months). All patients showed clinical improvement, with 3 of them worsening early in the postoperative period but doing better in long-term follow-up (although 3 of 5 patients had worse neurological examinations in the early postoperative period, all recovered in long-term follow-up and clinically improved relative to preoperative status). CONCLUSION: Neurological status of the patients can worsen in the early postoperative period, causing intramedullary operation; but it usually improves relative to preoperative status. Surgical removal seems to be a safe and a promising way of treatment of symptomatic SCMs.

Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine.

The sympathetic trunk is sometimes damaged during the anterior and anterolateral approach to the cervical spine, resulting in Horner's syndrome. No quantitative regional anatomy in fresh human cadavers describing the course and location of the cervical sympathetic trunk (CST) and its relation to the longus colli muscle (LCM) is available in the literature. The aims of this study are to clearly delineate the surgical anatomy and the anatomical variations of CST with respect to the structures around it and to develop a safer surgical method that will diminish the potential risk of CST injury. In this study, 30 cadavers from the Department of Forensic Medicine were dissected to observe the surgical anatomy of the CST. The cadavers used in this study were fresh cadavers chosen at 12-24 h postmortem. The levels of superior and intermediate ganglions of cervical sympathetic chain were determined. The distance of the sympathetic trunk from the medial border of LCM at C6, the diameter of the CST at C6 and the length and width of the superior and intermediate (middle) cervical ganglion were measured. Cervical sympathetic chain is located posteromedial to carotid sheath and just anterior to the longus muscles. It extends longitudinally from the longus capitis to the longus colli over the muscles and under the prevertebral fascia. The average distance between the CST and medial border of the LCM at C6 is 11.6 +/- 1.6 mm. The average diameter of the CST at C6 is 3.3 +/- 0.6 mm. Superior ganglion of CSC in all dissections was located at the level of C4 vertebra. The length and width of the superior cervical ganglion were 12.5 +/- 1.5 and 5.3 +/- 0.6 mm, respectively. The location of the intermediate (middle) ganglion of CST showed some variations. The length and width of the middle cervical ganglion were 10.5 +/- 1.3 and 6.3 +/- 0.6 mm, respectively. The CST's are at high risk when the LC muscle is cut transversely, or when dissection of the prevertebral fascia is performed. Awareness of the CST's regional anatomy may help the surgeon to identify and preserve it during anterior cervical surgeries.

[Craniocerebral civilian gunshot wounds: one hospital's experience]. / Kranyoserebral atesli silah yaralanmalari: bir hastanenin deneyimi.

BACKGROUND: In this study we have discussed the factors that affect our surgical results according to our experience on patients who were admitted to our hospital's Emergency Surgery Department for civilian craniocerebral gunshot wounds between 1997 and 2006. METHODS: The clinical and radiological findings of 82 patients (74 males, 8 females) who were treated for civilian craniocerebral gunshot wounds were retrospectively recorded. Neurological and physical examination, cranial computerized tomography (CCT) findings, trauma types, treatment modalities, prognosis, complications, morbidity and mortality rates were analyzed. RESULTS: Seventy-four (90%) of the patients were male, the mean age was 29.2 year. The Glasgow Coma Scores (GCS) during admission were as following respectively: 3-5 in 35 patients, 6-8 in 9 patients, 9-12 in 19 patients and 13-15 in 19 patients. According to their radiological findings, most commonly subdural hematoma, intracerebral hematoma, multiple contusion, depressed fracture and subarachnoidal hematoma were encountered. Operation or debridement was performed in 51 patients totally. Forty-one patients died and the mortality rate of 82 patients was calculated as 50%. CONCLUSION: The mortality rate of craniocerebral gunshot wound is high. The patients with GCS higher than 8 and with unihemispheric lesions during admission have better prognosis. We concluded that all patients must undergo debridement and the patients that have mass effect must be operated as soon as possible.

Anterolateral approach to the cervical spine: major anatomical structures and landmarks. Technical note.

OBJECT: The authors undertook a study to explore the topographic anatomical features seen during the anterolateral approach to cervical spine, anatomical variations, and certain landmarks related to the surgical procedure. METHODS: The study was conducted in 30 fresh cadavers. RESULTS: The common carotid artery bifurcation was mostly found at the level of C-4 (78%). The inferior belly of the omohyoid muscle was seen to cross the sternocleidomastoid muscle at the C5-6 disc level along the entire C-6 vertebral body. To reach the lower cervical region, the sacrifice of this muscle makes the procedure easier. The facial vein drained into the internal jugular vein mostly at the level of C3-4 (54%). The superior ganglion of the cervical sympathetic chain was located at the C-4 vertebra, but the location of the intermediate ganglion exhibited some variation. The vertebral artery entered the transverse foramen of C-6 in 27 cadavers (90%), the transverse foramen of C-7 in two cadavers (7%), and the transverse foramen of C-4 in one cadaver (3%). Because the inferior thyroid artery crossed the C6-7 interspace obliquely, the course of the inferior thyroid artery may complicate the procedure. The C-5 uncinate process was shortest and narrowest and had the greatest distance from the medial edge of the process to the anterior tubercle (p < 0.001). CONCLUSIONS: Understanding the qualitative anatomy of this region not only improves the safety of anterior and anterolateral cervical spine surgery but also allows adequate decompression of neural elements and resolution of the other pathological processes of this region. In this fresh cadaveric study, our goal was to improve the approach and decrease the incidence of complications.

Chronic subdural hematoma after endoscopic third ventriculostomy: case report.

Endoscopic third ventriculostomy (ETV) is an effective and rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. It has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although it is a safe procedure, several complications related to this procedure have been reported in the literature. We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. A 42-year-old female patient presented with acute symptoms of obstructive hydrocephalus, headaches and blurring of consciousness. A computerized tomogram (CT) of the patient's brain revealed marked triventricular supratentorial hydrocephalus and an external ventricular drainage (EVD) was performed first. After this procedure, magnetic resonance imaging (MRI) demonstrated hydrocephalus secondary to aqueductal stenosis. ETV was performed and the EVD removed uneventfully. The patient was discharged home after a few days without any complications. She then presented with headaches 4 weeks following ETV. A CT demonstrated chronic subdural hematoma on the contralateral side. This was treated with burr-hole evacuation. Postoperatively, her headaches improved. During the follow-up period, she remains symptom-free and has radiographic evidence of a patent ventriculostomy. This case confirms chronic subdural hematoma formation is a possible complication following endoscopic third ventriculostomy.