Underwater versus Closed Drainage System for Surgical Treatment of Chronic Subdural Hematoma.

OBJECTIVES: Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage. METHODS: Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay. RESULTS: Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence. CONCLUSIONS: The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.

Examination of annulus fibrosus and nucleus pulposus in cervical and lumbar intervertebral disc herniation patients by scanning acoustic microscopy, scanning electron microscopy and energy dispersive spectroscopy.

Intervertebral disc herniation (IVDH) is observed in humans as a result of the alteration of annulus fibrous (AF) and nucleus pulposus (NP) tissue compositions in intervertebral discs. In this study, we studied the feasibility of scanning acoustic microscopy (SAM), scanning electron microscopy (SEM) and energy dispersive spectroscopy (EDS) in characterizing the herniated segments of AF and NP tissues from male and female patients. SAM determined the acoustic property variations in AF and NP tissues by calculating the acoustic impedance values of samples of 15 patients. SEM obtained higher resolution images and EDS made elemental analysis of the specimen. Consequently, we suggest that these techniques have the potential to be combined for the investigation and removal of the disrupted AF and NP tissues with micrometer resolution in clinics.

Surgical Anatomy of the Posterior Intermuscular Approach to the Brachial Plexus.

Background: First rib resection and scalenectomy is a well-established treatment option for thoracic outlet syndrome. The posterior approach is rarely used due to extensive muscle sacrifice resulting in significant procedural morbidity. In this paper, we report the surgical anatomy of modified and less-invasive muscle-sparing posterior approach. Methods: Eleven human cadavers were used in this study. With specific care to preserve muscles' integrity, the brachial plexus was exposed by dissecting through the posterior neck musculature. A muscular triangle was found under the trapezius muscle, which provided direct access to deeper structures. Four anatomical reference points were identified to denote a 3-dimensional space enclosing proximal brachial plexus. Results: A muscular triangle was found under the trapezius muscle in all cadavers. It was bordered infero-medially by rhomboid minor, supero-medially by splenius capitis, and laterally by levator scapula muscles. The inferomedial border (rhomboid) was 55 mm (48-80), superomedial border (splenius capitis) was 60.5 mm (42-89), and the lateral border (levator scapulae) was 99 mm (60-130). A consistent vein was present inside the triangle and could be used as an anatomical landmark. The 4 reference points were C5, T1 intervertebral foramina, transverse tubercle, and scalene tubercle of the first rib. Removal of the first rib could be performed without brachial plexus retraction. The latter was exposed from neural foramina to lateral border of the first rib. Conclusions: The posterior approach provides ample space to for exposure and manipulation with the first rib and proximal brachial plexus.

Risk of intervertebral disc joint puncture during lumbar puncture.

OBJECTIVE: Penetration of intervertebral disc joint during lumbar puncture might be unnoticed during procedure. However, accelerated degeneration of the disc joint is a long-term consequence of inadvertent penetration. In this paper, we aimed to demonstrate and evaluate the risk of disc puncture during standard lumbar puncture. PATIENTS AND METHODS: 50 human cadavers were used in this study. Disc puncture risk was assessed by using worst case scenario model. Lumbar puncture was performed in a standard fashion using midline route at L3-4, L4-5 and L5-S1 levels. The needle was advanced until it hit resistance from the bone. Lateral X-ray was used to visualize the needle position. Needle ended up in two possible locations - posterior vertebral body wall and intervertebral disc space. RESULTS: The probability of puncturing the joint was 20 % for L3-4, 38 % for L4-5, 16 % for L5-S1. Total probability of disc penetration was 25 %. Statistical analysis revealed significantly increased risk for performing LP at L4-5 level in comparison with L5-S1 (p = 0.023). CONCLUSION: Lumbar puncture carries significant risk of intervertebral disc penetration. This complication is not realized during the procedure and lead to accelerated joint degeneration.

Initial Results of Using Blood Beta 2 Transferrin as a Marker of the Functional Status of a Shunt.

OBJECTIVE: Ventriculoperitoneal shunt is the most common cerebrospinal fluid diversion procedure to treat hydrocephalus. With the change of physiologic cerebrospinal fluid absorption site from arachnoid granulations to the peritoneum, beta 2 transferrin enters the systemic circulation. Therefore, the detection of beta 2 transferrin in the blood can possibly be used as a noninvasive method to assess the functional status of the shunt. The objective of this study was to study the presence of beta 2 transferrin in patients with functional shunts and in shunts suspected of being malfunctional. METHODS: Blood samples were obtained from a group of 20 patients with functional ventriculoperitoneal shunts, from a control group of 10 age-matched healthy volunteers, and from 8 patients with suspected shunt malfunction (6 ventriculoperitoneal, 2 lumboperitoneal). Blood serum beta 2 transferrin levels were measured by enzyme-linked immunosorbent assay with specific anti-beta 2 transferrin antibodies. RESULTS: The mean age in the ventriculoperitoneal shunt group was 36.5 years (range, 24-50 years). The mean age in the control group was 39.5 years (range, 32-48). There was no statistical difference in age between the groups. Beta 2 transferrin levels were 1.99 ± 1.02 ng/mL in the ventriculoperitoneal shunt group and 0.05 ± 0.02 ng/mL in the control group; the statistical difference was strongly significant (P < 0.001). Patients presenting with suspected shunt malfunction had preoperative low beta 2 transferrin levels (0.10 ± 0.12). Postoperatively, their beta 2 transferrin levels increased to 1.75 ± 0.46 ng/mL, and the difference was statistically significant (P = 0.012). CONCLUSION: Blood beta 2 transferrin can be used as a noninvasive test to assess the functional status of a shunt.

U-shaped Dural Flap: A Simple Method for Transcranial Skull Base Defect Repair-Technical Report.

Accidental anterior skull base defects associated with surgery are difficult to treat. There are several methods for the repair, yet postoperative rhinorrhea can occur despite the closure. A 56-year-old female patient was admitted for the treatment of a paraclinoid internal carotid artery aneurysm. The surgery included removal of the anterior clinoid process, unroofing the optic canal, decompressing the optic nerve, and clipping the aneurysm. During the surgery, the planum sphenoidale was accidentally drilled and the nasal cavity exposed. The dural defect was repaired using a U-flap technique. No postoperative cerebrospinal fluid (CSF) rhinorrhea occurred in the patient, and she was discharged on postoperative day 3. On follow-up examination the patient did not have evidence of CSF leakage.

Cranial and spinal injuries in motorcycle accidents: A hospital-based study.

BACKGROUND: Injuries caused by motorcycle accidents have been reported in several studies with an examination from a general trauma point of view. However, to our knowledge, there is no detailed study specific to central nervous system injuries. This research was focused on central nervous system injuries associated with motorcycle accidents. METHODS: The medical records of 540 patients who were admitted to the emergency department between 2008 and 2016 as the result of a motorcycle accident were retrospectively evaluated. Data were collected from electronic medical records, follow-up forms, and radiological images. Information on patient age, gender, type and site of injury, helmet use, alcohol level, Glasgow Coma Scale score on admission, length of stay in the intensive care unit and hospital, neurological status on discharge, and follow-up was collected and analyzed. RESULTS: A total of 486 of 540 patients (90%) were male, 54 (10%) were female, and the mean age was 31+-18 years (range: 2-85 years, median: 25 years). Cranial injuries were detected in 320 cases (59%). The distribution of cranial injuries was: epidural hemorrhage (12.6%), subdural hemorrhage (15.2%), depressed fracture (10.4%), linear fracture (23%), skull base fracture (5.5%), diffuse axonal injury (9.3%), subarachnoid hemorrhage (25.2%), intracerebral hemorrhage (13.5%), and contusion (26.3%). Spinal fractures were detected in 52 cases (9.6%). Twenty-two (4.07%) of the spinal fractures were observed in the cervical region, 10 (1.85%) in the thoracic region, and 20 (3.7%) in the lumbar region. The mean length of stay in the hospital was 8.2+-4 days and 7 days in the intensive care unit. Sixty-eight patients (12.6%) died. Traumatic cranial entities other than linear fracture were associated with an elevated level of mortality. A Glasgow Coma Scale score of 6 or less was associated with significant mortality (68%). CONCLUSION: A detailed report of motorcycle accident-associated central nervous system injuries is provided. The use of protective equipment, such as helmets, significantly reduced the rate of cerebral injury and death.

Shunt Tapping Versus Lumbar Puncture for Evaluating Cerebrospinal Fluid Infections in a Pediatric Population.

AIM: To compare the results of lumbar puncture (LP) and shunt tapping in pediatric patients with suspected ventriculoperitoneal shunt infection. MATERIAL AND METHODS: Medical records of pediatric patients with suspected shunt infections were retrospectively analyzed. All patients had cerebrospinal fluid samples obtained either via shunt tapping, LP or both. The diagnosis of infection was made when at least one cerebrospinal fluid had positive culture results. The patients with negative cerebrospinal fluid culture results were followed up for at least 6 months to monitor the occurrence of central nervous system infection. RESULTS: There were 20 patients in the study (12 males, 8 females). Cerebrospinal fluid was obtained by shunt tapping in 11, by lumbar puncture in 9 and by both methods in one patient. Thirteen patients [ Shunt tapping: 5/11 (45%), LP: 7/9 (78%), Both: 1) ] were diagnosed with shunt infection on the basis of cerebrospinal fluid culture. Seven patients with negative cerebrospinal fluid culture were found to have infections unrelated to shunts and did not show evidence of cerebrospinal fluid infection during the follow-up period. Although the percentage of detecting the infection was higher in LP group, both groups showed negative predictive value of 100%. CONCLUSION: Both shunt tapping and LP are effective in establishing the diagnosis of shunt infection in suspected patients.

Neuroprotective effects of adalimumab on rats with experimental peripheral nerve injury: An electron microscopic and biochemical study.

BACKGROUND: Adalimumab, a new-generation anti-inflammatory agent, exerts its effect through tumor necrosis factor α (TNF-α), secreted from immune response cells such as macrophages and lymphocytes. TNF-α has been shown to play an important role in the processes of apoptosis and demyelination, and blockage of its activity may improve neural healing. Investigated in the present study is the probable neuroprotective influence of adalimumab in rats using a peripheral nerve injury model with biochemical and electron microscopic methods. METHODS: Forty adult Wistar albino rats were randomly divided into control, sciatic nerve trauma, low-dose adalimumab, and high-dose adalimumab groups. Six rats from each group were assigned biochemical microscopy, and 4 were assigned electron microscopy. Neural injury was induced with clip compression following dissection of sciatic nerves. Adalimumab was simultaneously injected. The rats were sacrificed after 2 weeks of adalimumab treatment. RESULTS: Nerve tissue lipid peroxidation values were found to be significantly decreased in both the low- and high-dose adalimumab treatment groups, compared to the group subjected only to sciatic nerve trauma. CONCLUSION: Results demonstrate that adalimumab is an effective neuroprotective agent for neural healing, particularly in the early phase.

Use of Spongostan™ for Prevention of Cranial Subdural Adhesions Following Craniotomy in an Experimental Rabbit Model.

AIM: Spongostan™ is a sterile, water-insoluble, porcine gelatin absorbable sponge, which is widely used as a hemostatic material. The aim of this study is to test the anti-fibrotic capacity of Spongostan™, using a craniotomy model in an experimental rabbit model. MATERIAL AND METHODS: Eighteen rabbits were divided into two groups: Each group consisted of 9 rabbits, duratomy plus Spongostan™ (group 1), and duratomy without Spongostan™ (group 2). Right parietal bone was removed via trephine and low speed drill and dura was opened. On the group 1 rabbits, an appropriate piece of Spongostan™ was meticulously placed under dural layer. On group 2 rabbits, same procedures were repeated without Spongostan™. Histological sections were taken from each group and evaluated for degree of fibrosis and collagen fibers. RESULTS: There was marked increase in number of fibroblasts and collagen fibers in group 2 rabbits, however most of the rabbits in Spongostan™ group demonstrate scarce histopathological findings for fibrosis. CONCLUSION: We conclude that an appropriately placed subdural Spongostan™ over cerebral tissue may prevent postoperative surgical adhesions after neurosurgical operations.

Distinctive Characteristic Features of Intramedullary Hemangiopericytomas.

STUDY DESIGN: The retrospective analysis of intramedullary hemangiopericytomas (HPCs) was performed, and the entity was discussed in accordance with the literature findings. PURPOSE: This study aimed at defining distinctive characteristic features of intramedullary HPC with respect to surgical approach and prognosis. OVERVIEW OF LITERATURE: Intramedullary HPCs are extremely rare tumors. They originate from capillary pericytes, supposedly follow the vessels over the spinal cord, and infiltrate deep into the spinal cord without a distinct plane. Their treatments and prognosis are not well-defined in the literature. METHODS: Our database was retrospectively reviewed for the cases of HPCs. Later on, a literature search was performed to reveal all reported cases of intramedullary HPCs. The following key words were searched in PubMed databases: "hemangiopericytoma and intramedullary," "hemangiopericytoma and spine (spinal) and intradural," and "hemangiopericytoma and spinal cord." The articles were reviewed for patients' demographics features, imaging characteristics, tumor-specific factors (surgical technique, pathological descriptions, and world health organization grades), and postoperative course and prognosis (adjuvant therapies, recurrences, complications, and mortalities). RESULTS: A total of seven patients (three male and four female) was reached, with their ages ranging from 15 to 80 years (mean, 32.5 years). The tumors were located majorly in thoracic region (5/7, 71.4%), and only two cases were in the cervical region (2/7, 28.6%). All tumors were completely removed, and only two cases received radiotherapy. No recurrence was reported. CONCLUSIONS: Complete resection of the intramedullary HPCs seems to be the best management strategy for long-term and recurrence-free survival and in alleviating further need for radiotherapy.

Anterior Herniation of Partially Calcified and Degenerated Cervical Disc Causing Dysphagia.

We report a rare case of anterior cervical disc herniation associated with dysphagia. A 32-year-old man presented with complaints of dysphagia and concomitant pain in the right arm resistant to conservative therapy. On physical examination with respect to the muscle strength, the right shoulder abduction and flexion of the forearm were 3/5. Lateral X-ray revealed calcified osteophytes at the anterior C4-5 level. Magnetic resonance imaging showed soft disc herniation involving the right C6 root at the C5-6 level and anterior herniation of the C4-5 cervical disc. Anterior discectomies for C4-5 and C5-6 levels stabilized and ameliorated the dysphagia and pain. Cervical disc herniation usually presents with radicular findings. However, dysphagia may be an uncommon presentation. Anterior cervical disc herniation should be considered in a patient presenting with dysphagia.

Comparison of the Toxicities of Ethylene Vinyl Alcohol Copolymer (EVOH) Preparations, Dimethyl Sulphoxide and N-Butyl 2-Cyanoacrylate on Cerebral Parenchyma in an Experimental Rabbit Model.

AIM: Ethylene vinyl alcohol copolymer (EVOH), its organic solvent dimethyl sulfoxide (DMSO), and N-Butyl 2-Cyanoacrylate (NBCA) are widely used in neurovascular embolization procedures and yet with potential risk of cytotoxicity. The aim of this study was to evaluate the toxic effect of EVOH-DMSO, its solvent DMSO and NBCA on cerebral parenchyma in a rabbit model. MATERIAL AND METHODS: Forty-eight albino male rabbits were divided into 6 groups based on the substance injected into the parenchyma; normal saline, DMSO, NBCA, 6% EVOH-DMSO and 20% EVOH-DMSO and control group. At 72 hours the subjects were sacrificed and brain samples were harvested for histopathological examination and lipid peroxidase measurements. RESULTS: Neuronal degeneration and inflammatory reaction in the brain parenchyma was prominent especially in DMSO group and EVOHDMSO groups. Furthermore, the extent of degeneration and inflammatory reaction was related to the concentration of the embolic agent in the EVOH group. Lipid peroxidase activity was significantly increased in the NBCA group as compared to all but to 20 % EVOH-DMSO group. CONCLUSION: EVOH and its solvent DMSO cause degeneration and inflammatory reaction in brain parenchyma and for EVOH this reaction was appeared to be dose dependent.

Unusual posttraumatic delayed cerebrospinal fluid rhinorrhea due to gunshot wound.

Delayed posttraumatic cerebrospinal fluid rhinorrhea (CSFr) without meningitis is considered to be relatively rare. However, even years after trauma, recurrence or delayed onset of CSFr and meningitis due to CSFr are possible. In this article, a case of delayed CSFr from the sphenoid sinus without meningitis three years after the transfacial gunshot wound is reported. Plain high-resolution computed tomography sections through the sphenoid sinus showed a bone defect at the roof with CSF-density fluid extending into the sphenoid sinus. Arachnoid membrane herniation into the sphenoid sinus was found and site of CSF fistula confirmed during the surgery. Skull base defect was reconstructed through an endoscopic approach without any complications and the patient was followed up for 12 months without recurrence. The cause, timing, clinical course and location of CSFr make this an apparently unique case. Patients with a skull base defect without CSFr should be closely followed up and may need further evaluation or management due to the possibility of CSFr development. The positive diagnosis of a CSFr raises the matter of choosing the adequate surgical approach for its repair. Endoscopic closure of CSFr is both safe and effective.

Using an autologous fibrin sealant in the preventing of cerebrospinal fluid leak with large skull base defect following endoscopic endonasal transsphenoidal surgery.

AIM: Postoperative cerebrospinal fluid (CSF) leak following endoscopic endonasal transsphenoidal surgery (EETS) is associated with increased morbidity and mortality. This prospective study is the first evaluation of using autologous fibrin sealant for preventing postoperative CSF leak and related complications. MATERIAL AND METHODS: 200 endoscopic endonasal transsphenoidal approaches were included in the study and reviewed retrospectively from September 2010 to June 2012. A total of 55 patients who have large skull base and diafragma sella defects, connected with basal cisterns or ventricles, were chosen for the study. The patients were operated via extended or classical endoscopic endonasal transsphenoidal approach. The skull base has been repaired using AFS combined with multilayer reconstruction in all cases. The incidence of CSF leak as a complication of EETS was analyzed. RESULTS: The ages of the patients ranged from 20 to 83 years (mean 49.3 years). There were 25 (46%) male patients and 30 (54%) females. All patients had tumors with suprasellar or parasellar extension. Postoperative CSF leak was determined in 2 patients (3.6%). There were no complications and allergic reactions associated with the use of AFS. CONCLUSION: Using of AFS combined with multilayer reconstruction technique is a safe and effective method to prevent CSF leak in large defects following EETS.

The neuroprotective effects of rituximab in rat spinal cord injury model: an immunohistochemical study.

AIM: In the present study, we investigate the neuroprotective effects of rituximab, a monoclonal antibody directed towards B cell mediated humoral immunity, on a rat spinal cord injury (SCI) model with immunohistochemical methods. MATERIAL AND METHODS: Twenty-four rats were used for the study. Rats were divided as control, SCI, and rituximab-treated SCI groups. Intraperitoneal rituximab administration was performed on days 0, 3 and 5 in the third group. Rats were sacrificed 7 days after trauma. Antibodies against IL-1ß, IL-6, TNF-α and CD20 were studied with the ELISA method together with electron microscopic analysis. RESULTS: It was found that rituximab suppressed oligodendrocytes at the phagocytic stage but was still inefficient for the regenerative phase. TNF-α expression was markedly increased in rats subjected to SCI and suppressed after rituximab treatment. Decreased CD20 expression was another prominent finding in rats under rituximab therapy. However, expressions of IL-1ß and IL-6 were both increased in glial cells without significant change after rituximab administration. CONCLUSION: TNF-α expression was augmented at the level of SCI both in neuronal and glial cells, particularly in oligodendrocytes. All were suppressed after rituximab administration and rituximab reduced CD20 expression both in neuronal and supportive glial cells which may be related to neural healing.

The effects of levetiracetam on neural tube development in the early stage of chick embryos.

AIM: This study aimed to investigate the effects of a new generation antiepileptic agent, levetiracetam, on the neural tube development in a chick embryo model that corresponds to the first month of vertebral development in mammals. MATERIAL AND METHODS: Forty-five Atabey® breed fertilized chicken eggs with no specific pathogens were randomly divided into 5 groups. All of the eggs were incubated at 37.8±2°C and 60±5 % relative humidity in an incubator. Group A was control group. The other eggs were applied physiological saline and drugs at a volume of 10 µL by the in ovo method at the 28th hour of the incubation period. Group B was given distilled water; Group C, physiological saline; Group D, Levetiracetam (L8668) at a dose equivalent to the treatment dose for humans (10 mg/ kg), and Group E, Levetiracetam (L8668) at a dose of 10 times the treatment dose. The embryos in all of the groups were removed from the shells at the 48th hour and morphologically and histologically evaluated. RESULTS: Of the 45 embryos incubated, neural tubes of 41 were closed and the embryos displayed normal development. CONCLUSION: Levetiracetam, at a dose equivalent to human treatment dose and 10 times the treatment dose, was shown not to cause neural tube defects in chick embryos.

Alveolar hydatid cyst mimicking cerebellar metastatic tumor.

BACKGROUND: Echinococcus multilocularis is a rare infestation in the world with a particularly increased incidence mainly in South America, Central Europe and Asia. Progression of alveolar Echinococcosis is more aggressive that can metastasize to lungs, brain and bones however brain involvement is usually rare with an incidence about 1%. CASE DESCRIPTION: We report a 23-year-old man with a cerebellar Echinococcosis multilocularis mimicking a metastatic cerebellar tumor. Suboccipital craniotomy was performed for gross total removal of the tumor. Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis. CONCLUSION: Radical surgical excision should be recommended for single Echinococcosis multilocularis lesions particularly at infratentorial localization.

Huge intradiploic epidermoid cyst.

A 60-year-old man presented with an occipital mass under the scalp and complained of headache, nausea, and dizziness. Magnetic resonance imaging showed a well-defined mass in the occipital scalp extending from the scalp through the cranium and several centimetres into the posterior fossa. There were well-defined margins in the deep portion and the mass was totally removed. Histological examination showed that the cystic structure was lined by squamous epithelium containing laminated keratin material. The pathological findings were consistent with the diagnosis of an epidermoid cyst. The patient was discharged free of symptoms.