Applications of enhanced recovery after surgery protocols for unruptured anterior circulation aneurysms in tertiary-level healthcare institutions: a national study.

OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols are standardized perioperative care that reduce patients' stress response during hospitalization and improve hospitalization time, complication rates, costs, and readmission rates. This study aimed to investigate the application rate of protocols for elective craniotomy in the surgery of unruptured anterior circulation aneurysms (AnCAs) at tertiary-level healthcare (TLH) institutions in Türkiye and its effect on the outcomes of the patients. METHODS: An electronic survey was sent to all Turkish TLH institutions (n = 127) between May and June 2023. The number of institutions participating in the survey was 38 (30%). The institutions were subdivided according to three main factors: institution type (university hospital [UH] vs training and research hospital [TRH]), annual case volume (low [≤ 20 aneurysms] vs high [> 20 aneurysms]), and institution accreditation status (accredited vs nonaccredited). RESULTS: Overall, 55.3% (n = 21) of the institutions participating in the study were UHs. The rates of those that were accredited and had a high case volume were 55.3% (n = 21) and 31.6% (n = 12), respectively. It was determined that the accredited clinics applied preoperative protocols at a higher rate (p = 0.050), and the length of stay in the postoperative period was shorter in the clinics that used the intraoperative protocols (p = 0.014). CONCLUSIONS: The length of stay in the postoperative period is lower in TLH institutions in Türkiye that highly implement intraoperative protocols. Furthermore, this is the first study in the literature evaluating protocols for elective craniotomy in unruptured AnCAs.

Flow diverter stent treatment for unruptured supraclinoid segment internal carotid artery aneurysms: a Turkish multicenter study.

OBJECTIVE: Despite the relatively high success of surgical clipping of supraclinoid segment aneurysms of the internal carotid artery (ICA), flow diverter (FD) stent therapy is becoming increasingly used for these aneurysms. This study aims to evaluate the characteristics of FD placement for unruptured ICA supraclinoid segment aneurysms at 6 different centers with different experience levels in Türkiye. METHODS: In this retrospective, multicenter study, the authors reviewed the demographic information, aneurysm shape/dimensions (neck, aspect ratio, dome/neck ratio, and maximum diameter), preoperative antiplatelet regimen, FD stent brand, perioperative complications, intervention time, clinical (modified Rankin Scale) and radiological (O'Kelly-Marotta [OKM] grading scale) outcomes, and follow-up time of 54 patients. RESULTS: A total of 55 interventions for 61 aneurysms (58 supraclinoid ICA aneurysms) were performed in the 54 patients included in the study. The female/male ratio in this population was 44/10, and the mean age was 53.5 ± 13.6 (range 21-82) years. The most common form and location of the aneurysms were saccular 91.4% (53/58) and ophthalmic segment 69% (40/58), respectively. The preferred antiplatelet regimen was acetylsalicylic acid plus ticagrelor 50% (27/54). The overall complication rate was 25.5% (14/55), and the mean follow-up time was 25.76 ± 17.88 months. The successful radiological outcome (OKM grade C or D) rate at the 6-month follow-up was 92.6%. No perioperative complications led to any permanent or transient neurological deficit. CONCLUSIONS: The results of this first multicenter study evaluating FD stent use for unruptured ICA supraclinoid segment aneurysms showed that FD stent treatment is a feasible method for replacing clipping and coil embolization with manageable complications and a high success rate.

Anterior spinal cord herniation after multilevel anterior cervical corpectomy: A case report.

Many complications related to the resection of an ossified posterior longitudinal ligament via the anterior approach have been reported. Postoperative neurological deterioration is one such complication that may appear due to massive anterior spinal cord herniation related to a dural defect following resection of the ossified posterior longitudinal ligament. Specifically, spinal cord herniations have been reported to be associated with posterior approaches, and a large number of theories regarding this association have been offered by various authors. However, anterior spinal cord herniation is extremely rare, and its pathophysiology has not yet been explained. In this case report, we report a male patient who experienced anterior spinal cord herniation following anterior surgery. Spinal cord herniation may develop following the removal of the anterior cervical corpectomy. Therefore, surgeons should be aware of this condition when planning treatments for cervical spondylotic myelopathy via the anterior approach.

Endoscopy-Assisted Craniosynostosis Surgery Versus Cranial Vault Remodeling for Non-Syndromic Craniosynostosis: Experience of a Single Center.

AIM: To evaluate and compare open cranial vault remodeling (OCVR) and endoscopy-assisted craniosynostosis surgery (EACS) in patients with non-syndromic craniosynostosis and to develop an algorithm to determine the most appropriate surgery for each patient. MATERIAL AND METHODS: Eighty-five children with craniosynostosis who underwent surgery between 2010 and 2022 were retrospectively analyzed. Demographic data, comorbidities, and peri-operative findings of the patients were recorded. Pre- and post-operative comparisons were made between predetermined measurement techniques for each deformation. In addition, measurements were obtained by computed tomography (CT) or 3D stereophotogrammetric (3DSPG) methods from eligible patients and compared with one another. RESULTS: In our study, 61 patients underwent EACS, whereas 24 underwent OCVR. The operating time of OCVR was approximately 54.4 minutes longer than that of EACS (p < 0.001). The intra-operative blood loss was around 139 ml higher in OCVR (p < 0.001). The length of hospital stay for patients who underwent EACS was shorter at 8.4 days on average (p < 0.001). Surprisingly, 5 complications were observed in OCVR compared with 7 in EACS. While the cosmetic outcome of EACS was superior in most of the pathologyspecific measurement techniques, the metopic index increased only in patients with metopic synostosis after both surgical operations. Still, this increase was lower in EACS than in OCVR. CONCLUSION: This study suggests that endoscopic craniosynostosis surgery has lower estimated blood loss and operation and hospitalization times, as well as comparable cosmetic results compared with open vault surgeries on long-term follow-up. CT and 3DSPG methods can help distinguish between different types of measurement techniques for synostoses. However, no significant differences were found in the comparisons since 3DSPG can also provide reliable measurements comparable to those on CT during follow-up.

Preserving the cerebellar hemispheric tentorial bridging veins through a novel tentorial cut technique for supracerebellar approaches.

OBJECTIVE: The objective of this study was to describe the distribution pattern of cerebellar hemispheric tentorial bridging (CHTB) veins on the tentorial surface in a case series of perimedian or paramedian supracerebellar approaches and to describe a novel technique to preserve these veins. METHODS: A series of 141 patients with various pathological processes in different locations was operated on via perimedian or paramedian supracerebellar approaches by the senior author from July 2006 through October 2022 and was retrospectively evaluated. During surgery, the number and locations of all CHTB veins were recorded to establish a distribution map on the tentorial surface, divided into nine zones. Patients were classified into four groups according to the surgical technique used to manage CHTB veins: 1) group 1 consisted of CHTB veins preserved without intervention during surgery or no CHTB veins found in the surgical route; 2) group 2 included CHTB veins coagulated during surgery; 3) group 3 included CHTB veins preserved with arachnoid and/or tentorial dissection from the cerebellar or tentorial surface, respectively; and 4) group 4 comprised CHTB veins preserved using a novel tentorial cut technique. RESULTS: Overall, 141 patients were included in the study. Of these 141 patients, 38 were in group 1 (27%), 32 in group 2 (22.7%), 47 in group 3 (33.3%), and 24 in group 4 (17%). The total number of CHTB veins encountered was 207 during surgeries on one side. According to the distribution zones of the tentorium, zone 5 had the highest density of CHTB veins, while zone 7 had the lowest. Of the patients in group 4, 6 underwent the perimedian supracerebellar approach and 18 had the paramedian supracerebellar approach. There were 39 CHTB veins on the surface of the 24 cerebellar hemispheres in group 4. The tentorial cut technique was performed for 27 of 39 CHTB veins. Twelve veins were not addressed because they did not present any obstacles during approaches. During surgery, no complications were observed due to the tentorial cut technique. CONCLUSIONS: Because there is no way to determine whether a CHTB vein can be sacrificed without complications, it is important to protect these veins in supracerebellar approaches. This new tentorial cut technique in perimedian or paramedian supracerebellar approaches makes it possible to preserve CHTB veins encountered during supracerebellar surgeries.

Endovascular occlusion of giant serpentine aneurysm: A case report and literature review.

Giant serpentine aneurysms (GSAs) are a rare subgroup of intracranial aneurysms. Separate inflow and outflow flow due to intraluminal thrombosis is the most distinguishing feature of GSAs. In treating these lesions, surgical clipping and ligation were the main treatments in the past, but bypass for revascularisation and endovascular therapies (EVTs) for deconstructive purposes are more prominent today. A 51-years-old male patient presented with headache and mild right hemiparesis. He had a GSA arising from the left fetal type posterior cerebral artery (fPCA) that was out of follow-up for six years. Radiological images revealed midline shifting and mesencephalon compression. We performed endovascular parent artery coil occlusion. The symptoms of the patient improved at the first-month follow-up. Even if there is a mass effect in GSAs, deconstructive EVT is a safe and feasible method for managing these lesions.

Is It Possible to Get Better Results in Bone Fusion in Laminoplasty Surgery for Lumbar Stenosis? A Novel Autologous Bone Graft Insertion Technique.

AIM: To define a novel autologous bone graft insertion technique, and to evaluate its effects on bone fusion in patients with lumbar stenosis who underwent laminoplasty. MATERIAL AND METHODS: Fifty-six patients and 142 vertebrae that underwent autologous bone graft insertion technique between 2009 and 2018 were analysed retrospectively. Demographic data, comorbidities, and perioperative findings of patients were recorded. The midline anteroposterior (AP) diameter was measured at the bone graft insertion levels, and fusion formation was evaluated with computed tomography (CT) and dynamic X-Ray images. Pain scores were assessed preoperatively with the visual analogue scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. Scores were re-evaluated on 1 < sup > st < /sup > day, at 3 < sup > rd < /sup > , and 12 < sup > th < /sup > months, postoperatively. RESULTS: Degenerative spinal stenosis was present in 56 patients who underwent autologous bone graft insertion technique. It was found that the diameter of the spinal canal increased by 37% in CT measurements. In postoperative radiological followups, fusion developed in 49 (87.5%) patients. There was a statistically significant decrease in both VAS and ODI scores in the postoperative period when compared to the preoperative evaluations. CONCLUSION: Bone graft insertion technique supports posterior fusion and protects against dural injuries during revision surgery by creating a barrier over the dura. The prevention of epidural fibrosis formation reduces the symptoms of the postlaminectomy syndrome. The fact that this technique does not require fixation material. Therefore, it reduces expenditure and eliminates the risk of complications related to synthetic materials.

The Effects of Rifampin, Povidone-Iodine and Hydrogen Peroxide on the Formation of Epidural Fibrosis in the Experimental Epidural Fibrosis Model.

The aim of the study was to determine the effect of direct application of rifampin, povidone-iodine, and hydrogen peroxide on the formation of epidural fibrosis in rats. Forty-eight adult male Wistar albino rats were equally and randomly divided into four groups (laminectomy, topical rifampin, topical povidone-iodine, and topical hydrogen peroxide). Laminectomy was performed at the T12 level in all rats. Four weeks later, the extent of epidural fibrosis was assessed both macroscopically and histopathologically. ANOVA test was used for the evaluation of dural thickness. Kruskal-Wallis test was used for the pathology and macroscopic evaluation. Chi-square test was used for evaluation of the arachnoid involvement. p value <0.05 was accepted as statistically significant. Our data revealed that topical application of both povidone-iodine and hydrogen peroxide were effective in reducing epidural fibrosis formation. The results of our study provide the experimental evidence of the preventive effects of topical application of povidone-iodine and hydrogen peroxide over epidural fibrosis.

Spontaneous recovery of post-traumatic cerebrospinal fluid rhinorrhea following meningitis: A case report.

The aim of the present report was to present the patient with an anterior cranial base fracture who developed post-traumatic cerebrospinal fluid rhinorrhea, which recovered after onset of meningitis complication. A 26-year-old male patient who had a traffic accident one week ago was sent to our clinic because of his rhinorrhea persisting for 4 days. On cranial computed tomography, fracture of the left frontal skull base and sinus walls, a fracture line on temporal bone, parenchymal bleeding in the vicinity of the frontal sinus, subarachnoidal bleeding and left temporal extradural hematoma were detected. Then he underwent sinus wall repair and extradural hematoma was drained through bifrontal craniotomy. However, rhinorrhea persisted which resulted a deterioration in consciousness and he entered into a deep somnolent state. When his symptoms of meningitis became apparent, rhinorrhea of the patient disappeared. The patient transferred in intensive care unit and re-connected to a lumbar drainage system. On cerebral magnetic resonance imaging, regression of contrast-enhanced lesions localized in the left anterotemporal and frontal and in the regions lateral to the right trigon and medial to the right thalamus and in the right posteroparietal regions was observed. Despite repair of the anterior cranial fracture and lumbar drainage, rhinorrhea may persist. Herein, development of meningitis caused disappearing of rhinorrhea symptoms without any need for surgical intervention.

Investigation of efficacy of mitomycin-C, sodium hyaluronate and human amniotic fluid in preventing epidural fibrosis and adhesion using a rat laminectomy model.

STUDY DESIGN: A retrospective study. PURPOSE: The aim of this study was to evalute the effects of mitomycin-C, sodium hyaluronate and human amniotic fluid on preventing spinal epidural fibrosis. OVERVIEW OF LITERATURE: The role of scar tissue in pain formation is not exactly known, but it is reported that scar tissue causes adhesions between anatomic structures. Intensive fibrotic tissue compresses on anatomic structures and increases the sensitivity of the nerve root for recurrent herniation and lateral spinal stenosis via limiting movements of the root. Also, neuronal atrophy and axonal degeneration occur under scar tissue. METHODS: The study design included 4 groups of rats: group 1 was the control group, groups 2, 3, and 4 receieved antifibrotic agents, mitomycin-C (group 2), sodium hyaluronate (group 3), and human amniotic fluid (group 4). Midline incision for all animals were done on L5 for total laminectomy. Four weeks after the surgery, the rats were sacrificed and specimens were stained with hematoxylin-eosin and photos of the slides were taken for quantitive assesment of the scar tissue. RESULTS: There was no significant scar tissue in the experimental animals of groups 2, 3, and 4. It was found that there was no significant difference between drug groups, but there was a statistically significant difference between the drug groups and the control group. CONCLUSIONS: This experimental study shows that implantation of mitomycin-C, sodium hyaluronate and human amniotic fluid reduces epidural fibrosis and adhesions after spinal laminectomy in rat models. Further studies in humans are needed to determine the complications of the agents researched.