Direct Stimulation of Neural Placode and Nerve Roots in Open Myelomeningocele: The Efficacy of Neural Tube Reconstruction.

INTRODUCTION: Intraoperative electrophysiological studies are increasingly used in spinal surgery. However, its use in myelomeningocele (MMC) surgery is still not widespread. The aim of this study was to present our experience in neural placode (NP) and nerve root stimulations in newborns with open MMC. METHODS: Eight newborns underwent surgical treatment for thoracolumbar and lumbosacral MMCs. Intraoperative neuromonitoring including free-running electromyography and stimulation of NP, nerve roots, and spinal cord were performed in all cases. Stimulation sites and intensities and distal response's amplitudes and latencies were recorded. RESULTS: Five patients had thoracolumbar and 3 patients had lumbosacral MMC. Two patients had no movements at the lower extremities while the other had some movements. No response on the lower extremities was obtained in only 1 patient. Responses from the nerve root stimulations were more robust and significant than the placode stimulations. CONCLUSIONS: It is clear that the NP and nerve roots originating from the placode are mostly functional and should be preserved during the surgery. Intraoperative neuromonitoring and direct stimulation should be performed during the MMC repair in order to obtain a better neurological outcome.

Revision Cranioplasty with Three-dimensional Custom-made Titanium Implants in Patients with Failed Cranioplasty.

OBJECTIVE: Graft failure is a common complication of cranioplasty. Revision cranioplasty is required to overcome this complication. However, no previous studies have reported outcomes in revision cranioplasty with 3-dimensional (3D) custom-made titanium implants. We describe our experience with 3D titanium implants in patients with revision cranioplasty. METHODS: We evaluated 43 consecutive patients between January 2011 and December 2019 who underwent revision cranioplasty using 3D custom-made titanium implants. The 3D image of the patient's cranium and the plan to close the cranium defect were created in a virtual environment using software programs. Demographic and radiologic features were compared based on the materials used in the initial cranioplasty. RESULTS: Previous material was autologous graft (AG) in 27 patients and polymethyl methacrylate (PMMA) in 16 patients. The mean time without revision cranioplasty is longer in patients with PMMA implants than in patients with AG. There was no statistically significant difference in the length of hospital stay between patients with PMMA implants and patients with AG. There were no postoperative adverse events such as infection, wound dehiscence, convulsions, or epidural hematoma in 38 patients during hospitalization. Wound dehiscence developed in 5 patients and surgical repair was required in one. CONCLUSIONS: Initial cranioplasty with PMMA provides a longer time period than the AG before the revision. However, both of them have similar outcomes based on length of hospital stay and cranial defect area. Custom-made 3D titanium implant is a good option for revision cranioplasty to prevent implant failure and reduce patients' cosmetic concerns.

Pituitary apoplexy: An emergent and potential life-threatening complication of pituitary adenomas.

BACKGROUND: Pituitary apoplexy is an emergent and potential life-threatening complication of pituitary adenomas if not managed properly. The aim of our study is to present our series of pituitary adenomas and to focus on the clinical, radiological, and surgical characteristics of this rare complication. METHODS: In this study, a total of 143 patients with pituitary adenoma underwent surgical treatment between 2016 and 2018. All patients were operated using endoscopic endonasal transsphenoidal (EET) technique. The data of pituitary apoplexy cases were recorded. Resection rates, hormonal results, and visual outcomes of patients with pituitary apoplexy were evaluated. RESULTS: Of the 143 patients, 8 (5.59%) were presented with the symptoms and radiological findings of pituitary apoplexy. The mean age was 26.75 years, and 4 (50%) of them were male and 4 were female. Pre-operative mean Knosp grading score was 2.1 All of eight patients underwent emergent surgical intervention and total resection was achieved in 75% of patients with apoplexy. Hormone levels were significantly decreased after surgery (p<0.05), except prolactin (p>0.05). Cerebrospinal fluid leakage occurred in one pa-tient. None of the patient with pituitary apoplexy died in our series. CONCLUSION: Pituitary apoplexy is an important complication of pituitary adenomas. Early diagnosis and surgical intervention provide excellent ophthalmological and hormonal outcomes. Emergent EET approach is crucial for patients with ophthalmological findings and macroadenomas.

Surgical Management of Giant Intracranial Meningiomas.

OBJECTIVE: Giant intracranial meningiomas are a challenge for neurosurgeons because of their size and location in the cranium. Difficult tumor dissection and encasement of important neurovascular structures make them a horrible nightmare. The aims of this study are to present our giant intracranial meningioma series and to compare our experience using advanced surgical technology with the current literature. MATERIALS AND METHODS: The data of patients with the diagnosis of giant intracranial meningioma between 2014 and 2020 who underwent surgical treatment were retrospectively reviewed. The demographic, radiological, and surgical characteristics of patients were documented. The size and location of tumors as well as surgical technique were analyzed in detail. RESULTS: A total of 61 patients with intracranial meningioma underwent surgical treatment over a 7-year period, and 10 (16.4%) tumors were larger than 5 cm in diameter, which were classified as giant meningioma. Seven patients were male and 3 were female, with a mean age of 64.9 years. Four tumors were located at the skull base. Histological diagnosis was meningioma World Health Organization grade I in 7 patients and grade II in 3 patients. Simpson grade 1 resection was achieved in 6 patients and grade 2 resection in 4 patients. No mortality was observed. CONCLUSION: Careful surgical planning should be made for giant intracranial meningiomas. Their location, adjacent neurovascular structures, and vascular supply affect the resection level of these giant tumors. Simpson grade 1 resection is seldom possible for skull base meningiomas.

Surgical treatment of peripheral nerve injuries: Better outcomes with intraoperative NAP recordings.

BACKGROUND: Peripheral nerve injuries are usually not lethal but may cause serious neurological deficits if not treated properly. The aim of this study is to present our patients who underwent surgical treatment for peripheral nerve trauma in the past 10 years and to discuss their results in light of the literature. METHODS: The clinical and electrophysiological results of 182 patients who underwent surgical treatment in our department between 2010 and 2019 were retrospectively analyzed. All surgeries were performed using intraoperative nerve action potentials (NAP) recordings. Demographic characteristics, etiologies, surgical timing, and results of surgical treatment were recorded. RESULTS: A total of 199 surgical interventions were performed in 182 patients with peripheral nerve trauma within 10 years. 162 patients were male, 20 were female and the mean age was 29.34 years for males and 30.2 years for females. The sciatic nerve trauma was the most common in men and peroneal nerve injury women. The most common cause of trauma was gunshot wounds in menand blunt/sharp traumas in women. External and internal neurolysis was the most common surgical technique, followed by epineural anastomosis and sural nerve grafting. 155 of 182 patients showed partial neurological improvement within 3 months after surgery, while 27 had no change in their neurological condition. CONCLUSION: Men are more frequently exposed to peripheral nerve trauma than women. Severe partial nerve lesions mostly benefit from surgical treatment, and neurolysis has become the most preferred method of surgical treatment. Intraoperative NAP recordings provide better clinical outcomes. Neurological improvement may not always be in correlation with electrophysiological improvement.

Radial nerve injuries and outcomes: Our surgical experience.

BACKGROUND: The aim of this study was to retrospectively evaluate patients who underwent surgery in our department for radial nerve lesions in terms of surgical outcomes. METHODS: Thirty-eight patients were admitted to our department with radial nerve lesion. Twenty-seven of the patients had entrapment neuropathy and 11 had radial nerve injury secondary to other traumas. Various factors such as surgical results, time to surgical intervention, injury mechanism, and reconstruction technique were analyzed. RESULTS: In all of 27 patients who were operated for radial nerve entrapment neuropathy, a complete improvement in wrist dorsal flexion was detected at postoperative 3rd month. Seven of the 11 patients who were operated for radial nerve lesion had different degrees of improvement in wrist dorsal flexion at the postoperative 3rd month. Two of the seven patients underwent anastomosis using a sural nerve graft. The recovery rate in our series was 89%. Three of the 4 patients who did not recover after the radial nerve injury were the patients who were operated within the 1st month after the trauma. CONCLUSION: Better functional results were obtained in the postoperative period in patients who were operated after the 1st month, underwent internal neurolysis and used a short nerve graft for anastomosis in the radial nerve lesions. In patients with entrapment neuropathy, the earliest surgery revealed satisfactory results in the postoperative period.

Resection of intra- and paraventricular malignant brain tumors using fluorescein sodium-guided neuroendoscopic transtubular approach.

BACKGROUND: The requirement of brain retraction and difficulty in distinguishing the tumor demarcation are challenging in conventional approaches to intra- and paraventricular malignant tumors (IV-PVMTs). Tubular retractors can minimize the retraction injury, and fluorescein-guided (FG) surgery may promote the resection of tumors. Our aim is to evaluate the feasibility, safety, and effectiveness of fluorescein-guided endoscopic transtubular surgery for the resection of IV-PVMTs. METHODS: Twenty patients with IV-PVMTs underwent FG endoscopic transtubular tumor resection. Fluorescein sodium was administered before the dural opening. The intraoperative fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was assessed using postoperative magnetic resonance imaging. Karnofsky Performance Status (KPS) score was used to evaluate the general physical condition of patients. RESULTS: There were 9 glioblastomas, 4 anaplastic astrocytomas and 7 metastatic tumors. "Helpful" fluorescence staining was observed in 16(80%) of 20 patients. Gross total resection was achieved in 16(80%) cases, near-total in 3(15%) cases, and subtotal in 1 (5%) case. No intra- or postoperative complications related to the fluorescein sodium occurred. The median preoperative KPS score was 83, and the median KPS score 3-month after surgery was 88. CONCLUSION: FG endoscopic transtubular surgery is a feasible technique for the resection of IV-PVMTs. It may be a safe and effective option for patients with these tumors. Future prospective randomized studies with larger samples are needed to confirm these preliminary data.

Chemoresistance in Malignant Intracranial Tumors: Longer Survival with Negative MDR1 Expression.

AIM: To analyze the Glutathione S-transferase (GST)-P, GST-M, cytochrome p450 (CYP)1-A1, CYP1-B1, and multidrug resistance (MDR)-1 expressions in malignant intracranial tumor (ICT)s, and to elicit their role on patient survival. MATERIAL AND METHODS: GST-P, GST-M, CYP1-A1, CYP1-B1, and MDR-1 expressions were analyzed using immunostaining in 149 samples from 141 patients with preoperative ICT diagnosis. The case characteristics were reviewed, and the enzyme expressions were equated based on the age, gender, and tumor type. Then, 77 of 141 patients with malignant ICT and complete medical records postoperative were also investigated in detail for the relationship between the diagnosis, enzyme expression, and overall survival. RESULTS: The average age was 49.44 years, with 83 (58.45%) male patients. Among the 77 malignant ICTs, 38 (49.3%) and 29 were glial tumors and metastases, respectively, with a 13.35-month overall survival. Patients with metastatic tumor have approximately threefold higher GSTP level than those with glial tumors. MDR-1 expression was approximately twofold higher in > 60-year-old patients. No statistically significant association was found between patients? smoking behaviors, alcohol consumption, and overall survival. Only MDR-1 expression was correlated with overall survival. Better overall survival was observed in patients with a negative MDR-1 expression than those with a positive one. CONCLUSION: MDR-1 is an important indicator of survival in malignant intracranial tumor patients. Longer survival is associated with negative MDR-1 expression.

The efficacy of continuous lumbar drainage in post-traumatic cerebrospinal fluid fistulas.

BACKGROUND: This study aims to investigate the clinical outcomes of patients who underwent closed continuous lumbar drainage (CLD) for post-traumatic cerebrospinal fluid (CSF) fistula and to compare with those of non-traumatic patients. METHODS: The data of patients who were treated in the department of neurosurgery between January 2018 and December 2019 and underwent CLD were analyzed. The diagnosis, demographic characteristics, CSF results and clinical outcomes of these patients were evaluated. The outcomes of the patients with dura defect and CSF fistula due to trauma were compared with patients who underwent CLD for other diagnoses. RESULTS: In this study, 45 patients underwent CLD for 51 times. The mean age was 38.84 years, and 27 (60%) of the patients were male. Seven (15.55%) patients underwent CLD due to post-traumatic CSF fistula and 38 patients after tumor or malformation surgery. While five patients developed CSF fistula due to dura defect after gunshot injury, two patients developed CSF fistula secondary to motor vehicle accident. Staphylococcus Epidermidis was isolated in one patient among post-traumatic CSF fistula patients while Serratia Marcescens was isolated in patients with CSF fistula secondary to posterior fossa tumor surgery. While none of the seven patients died during the follow-up period in post-traumatic group, one of the 38 patients with CLD secondary to tumor surgery was lost due to sepsis in the follow-up period. CONCLUSION: CLD in post-traumatic CSF fistulas is a safe and effective treatment method. Especially in patients with gunshot wounds, CLD should be performed before revision surgery in the treatment of CSF fistula. Studies with different parameters are needed in larger trauma populations.

Older patients with intraventricular hemorrhage are prone to infection after external ventricular drainage.

BACKGROUND: External ventricular drainage (EVD) is a life-saving and emergent procedure in neurosurgery. However, infection is the main problem in patients with EVD. The present study aims to analyze the infection rate of patients with EVD and to investigate the factors that contribute to infection and mortality rates. METHODS: The data of patients who underwent emergent EVD procedure between 2018 and 2019 were retrospectively analyzed in this study. The demographic features of the patients were recorded. The correlation between age, gender, indication and duration of EVD, and the infection and mortality rate were investigated. RESULTS: In this study, 47 patients underwent emergent EVD in two years. Thirty (63.83%) patients were male, and 17 were female with a mean age of 28.02 years. The mean duration of drainage was 6.2 days. Fifty-eight cerebrospinal fluid (CSF) samples were analyzed during the drainage period and CSF culture was positive in 14 (24.14%) samples. The most common microorganism was Staphylococcus epidermidis. The infection rate was high in older and male patients with duration longer than six days. Nine (19.15%) patients died during the treatment period and six of them had IVH. CONCLUSION: The duration of EVD should be shorter in patients older than 65 years with the diagnosis of intraventricular hemorrhage, which is mostly related to dea.