Histopathologic and Spectrometric Evaluation of Bony Components of Synostotic Suture and Parietal Bone in Children with Sagittal Synostosis.

AIM: To understand the characterization of the ossification process both in the synostotic suture, and the adjacent parietal bone. MATERIAL AND METHODS: The surgical procedure for the 28 patients diagnosed with sagittal synostosis consisted of removing the synostotic bone as a whole, if possible, "Barrel-Stave" relaxation osteotomies, and strip osteotomies to the parietal and temporal bones perpendicular to the synostotic suture. The synostotic (group I) and parietal (group II) bone segments are obtained during osteotomies. Atomic absorption spectrometry was used to determine the amount of calcium in both groups, which is an indicator of ossification. Scanning electron microscopy and immunohistochemistry were employed to assess trabecular bone formation, osteoblastic density, and osteopontin, which is one of the in vivo indicators of new bone formation. RESULTS: Histopathologically, trabecular bone formation scores did not indicate any significant difference between the groups. However, the osteoblastic density and calcium accumulation in group I were higher than those in group II, and the difference was significant. Osteopontin staining scores in cells showing membranous and cytoplasmic staining with osteopontin antibodies significantly increased in group II. CONCLUSION: In this study, we found reduced differentiation of osteoblasts despite their increase in number. Moreover, the osteoblastic maturation rate was low in synostotic sutures, bone resorption becomes slower than new bone formation, and the remodeling rate is low in sagittal synostosis.

Angiographic Angular Adjustment: Matching Angiographic Views and Surgical Findings to Estimate the Actual Arterial Anatomy in Surgery for Intracranial Aneurysm - Technical Note.

AIM: To describe a simple technique of angular adjustment of cerebral angiographic views that makes them similar to the surgical field under the operation microscope. MATERIAL AND METHODS: The technique of angular adjustment consists of three steps: 1. Upside-down 180-degree rotation of the standard angiographic anterior-posterior view, 2. Adjustment of the course of the angiographic internal carotid artery according to the actual internal carotid artery seen in surgery under the operating microscope, and 3. A final and more accurate angular adjustment by rotating the angiographic view in its final position, as soon as parent arteries to aneurysm, such as the internal carotid, anterior cerebral, and middle cerebral arteries, are seen in surgery. RESULTS: The use of the technique provided a fair approximation of a rotated angiographic view and the actual surgical point of view. The technique is simple, and no sophisticated technology is needed. CONCLUSION: The angiographic data adjusted angularly to the surgeon?s point of view at surgery, very similar to the actual directions of arteries and the fundus of the aneurysm, is likely helpful to the microneurosurgeon for safely exploring aneurysms in conjunction with proximal and distal arteries.

Reattachment of the Temporalis Muscle After Frontoorbital Advancement in Craniosynostosis Surgery.

Craniosynostosis surgery may result in temporal hollowing occasionally. Overexpansion of the normal side and undergrowth of the affected side exacerbate the problem in unilateral cases (like unicoronal synostosis). Temporalis muscle lies in the temporal fossa, and it is usually severed or detached from its origin in order to reach the lateral aspect of the fronto-orbital bar. Reattachment of the temporalis muscle is challenging especially when the orbital bar is moved forward. In this technical note, exposure of the lateral cranial vault with zigzag incision of the temporalis muscle in 35 nonsyndromic anterior plagiocephaly patients has been described in detail, and the ease of reattachment is demonstrated afterward.

Successful Application of the Ventriculo-Gallbladder Shunt: A Salvage Procedure.

Ventriculo-gallblader shunt is very rarely used in the treatment of hydrocephalus. A 44-year-old male with ventriculoatrial shunt dysfunction was evaluated. His ventriculoatrial shunt was not working. His medical history revealed that his hydrocephalus was treated five times by venrtriculoperitoneal shunt, and four times by ventriculoatrial shunt. Another trial for ventriculoperitoneal or ventriculoatrial shunting was not considered feasible. A ventriculo-gallbladder shunt was placed to the patient as a potential salvage procedure. Remarkably, the patient benefited from the ventriculo-gallbladder shunt and was discharged from the hospital. We think that ventriculo-gallbladder shunting is a safe and effective treatment for hydrocephalus as the last resort in complicated cases of shunt dysfunction.

Spontaneous Intracystic Haemorrhage of an Arachnoid Cyst Associated with a Subacute Subdural Haematoma: A Case Report and Literature Review.

Arachnoid cysts (ACs) are congenital malformations that may develop anywhere in the subarachnoid space along the cerebrospinal axis, but are mostly observed in the temporal fossa and Sylvian fissure, predominantly on the left side. ACs account for 1% of all intracranial space-occupying lesions. ACs are potential risk factors for subdural haematoma in all age groups following a traumatic head injury. Although an intracystic haemorrhage of AC without evidence of a head trauma is very rare, it may particularly develop in children and young adults who spend much more time engaged in games and forced physical exercises. Here we present a rare case of spontaneous intracystic haemorrhage of AC with a subacute subdural haematoma and provide a review of the literature.

Spontaneous Resolution of a Sylvian Arachnoid Cyst in a Child: A Case Report.

We report the case of a 7-year-old boy with an incidentally diagnosed left sylvian arachnoid cyst. At a clinical follow-up of 2 years, cranial computed tomography scans found the cyst to be totally resolved. The mechanism of this rare spontaneous resolution of an arachnoid cyst is discussed.

Stepwise Removal of the Fused Midline Parietal Bone to Avoid Superior Sagittal Sinus Injury in Infants with Sagittal Synostosis.

This work describes a simple technique for the safe removal of the midline parietal bone with the synostotic sagittal suture in infants with sagittal synostosis to avoid dural tearing and bleeding from the superior sagittal sinus. The technique consists of stepwise removal of the midline parietal bone in three pieces instead of one piece, starting with the anterior one-third midline bone being safely freed from the underlying dural sinus and then transversely cut using a craniotome. The step is repeated twice for the middle and distal one-third of the bone respectively. Once the midline bone is bilaterally cut along its entire length, the stepwise elevation of the superior sagittal sinus dura using an elevator and removal of the midline bone in three pieces allows a safer, controlled procedure minimizing the risk of tearing the underlying dural sinus and preventing sinus bleeding in infants with sagittal synostosis.

Children with Metopic Ridge.

AIM: The premature closure of the metopic suture results in metopic synostosis, also known as trigonocephaly. However, there is a group of children who have only a frontal metopic ridge, obvious with inspection and fingertip palpation, without the clinical features of trigonocephaly. This study aims to report a group of children with metopic ridge with a special emphasis on the definition and the diagnostic features. MATERIAL AND METHODS: Thirty-eight children with a diagnosis of metopic ridge were followed up with clinical examinations and photographs in the pediatric neurosurgery outpatient clinic between January 2010 and November 2015. RESULTS: Children were between 3 and 30 (mean=14) months of age at diagnosis. Twenty-five (65.8%) of the children were boys and 13 (34.2%) were girls. A midline metopic ridge without fronto-orbital trigonocephalic deformity was the only diagnostic criterion. The parents" concern about the metopic deformity at initial diagnosis was a common feature in every case. Seven (18.4%) of the children had a sibling with either metopic ridge (n=4) or trigonocephaly (n=3). None of the children had worsened or had received surgery in the follow-up period. CONCLUSION: The metopic ridge is a pathology of the metopic suture and is a concern for parents in the context of craniosynostosis. Radiological investigation and craniosynostosis surgery are unnecessary in children with a metopic ridge.This clinical entity may be considered the mildest form of metopic synostosis.

Spontaneous Rhinorrhea mimicking sinusitis.

Spotaneous or non-traumatic cerebrospinal fluid rhinorrhea is an uncommon condition and may present a diagnostic challenge to clinicians. This condition is often being misdiagnosed for allergic rhintis or chronic sinusitis since the precipitating cause is not readily apperent in most patients. The mechanism of rhinorrhea is stil not completely clarified. We describe a case of this condition occuring in association with allergic rhinitis and sinusitis. A 52 year-old, obese female patient presented with two weeks history of bilateral clear nasal discharge and postural headache. Sample of nasal discharge tested for glucose and protein. The result was that the collection fluid was cerebrospinal fluid. The origin of cerebrospinal fluid fistula could not be identified despite the diagnostic tests.

Choroid plexus carcinoma in adults: an extremely rare case.

Choroid plexus tumors are rare intraventricular papillary neoplasms derived from choroid plexus epithelium, which account for approximately 2% to 4% of intracranial tumors in children and 0.5% in adults. Almost all choroid plexus carcinomas are seen in children and are extremely rare in adults. Headache, diplopia, and ataxia are the most common symptoms usually caused by mechanical obstruction of cerebrospinal fluid flow followed by hydrocephalus, regardless of tumor location. We present an illustrative case with 73 years old male patient who was consulted with headache to our neurosurgery department. In cranial computed tomography, there was a mass in 4(th) ventricle and we confirmed the mass with magnetic resonance imaging. After surgery had been performed, pathology specimen was diagnosed as choroid plexus carcinoma which was rarely seen in this age group.

The effect of untethering on urologic symptoms and urodynamic parameters in children with primary tethered cord syndrome.

OBJECTIVE: To evaluate urinary system symptoms (USSs) and urodynamic parameters (UPs) before and after untethering in children with primary tethered cord syndrome (pTCS). METHODS: USSs and UPs of patients undergoing untethering for pTCS during the period January 2008-July 2012 were evaluated preoperatively and at the postoperative third and 12th months. For analysis, patients were separated into 4 groups according to the presence of USSs: group 1, USSs preoperative positive and postoperative negative; group 2, USSs preoperative positive and postoperative positive; group 3, USSs preoperative negative and postoperative positive; group 4, USSs preoperative negative and postoperative negative. Preoperative and postoperative USSs and UPs were compared. RESULTS: Forty patients (average age, 7.2 years, follow-up of 2.8 years) were included. There were 13 patients in group 1, 11 in group 2, 3 in group 3, and 13 in group 4. All patients showed improvement when preoperative and postoperative USSs and UPs were compared. There was no correlation between USSs and UPs, both preoperatively and postoperatively. USSs and UPs at the postoperative third and 12th months were similar. Patients with no USS showed the most significant improvement in UP after untethering. CONCLUSION: Our study has demonstrated that untethering in patients with pTCS improves urologic symptoms and UPs. However, there is no correlation between improvement in symptoms and urodynamic findings. Urodynamic changes are similar at the postoperative third and 12th months. As the most significant improvement was seen in patients without USSs, it is important that these patients undergo urodynamic studies preoperatively and postoperatively.

Microsurgical training model for residents to approach to the orbit and the optic nerve in fresh cadaveric sheep cranium.

BACKGROUND: Neurosurgery and ophthalmology residents need many years to improve microsurgical skills. Laboratory training models are very important for developing surgical skills before clinical application of microsurgery. A simple simulation model is needed for residents to learn how to handle microsurgical instruments and to perform safe dissection of intracranial or intraorbital nerves, vessels, and other structures. MATERIALS AND METHODS: The simulation material consists of a one-year-old fresh cadaveric sheep cranium. Two parts (Part 1 and Part 2) were designed to approach structures of the orbit. Part 1 consisted of a 2-step approach to dissect intraorbital structures, and Part 2 consisted of a 3-step approach to dissect the optic nerve intracranially. RESULTS: The model simulates standard microsurgical techniques using a variety of approaches to structures in and around the orbit and the optic nerve. CONCLUSIONS: This laboratory training model enables trainees to gain experience with an operating microscope, microsurgical instruments and orbital structures.

Laboratory training in the retrosigmoid approach using cadaveric silicone injected cow brain.

BACKGROUND: A neurosurgical laboratory training model is designed for trainees in microneurosurgery to learn to handle surgical microscopes and microneurosurgical instruments. The silicone injection of a fresh cadaveric cow cranium is an alternative to using a cadaveric human brain for becoming familiar with the cerebellopontine angle (CPA) via the retrosigmoid approach. To report an improved method for training in the CPA via the retrosigmoid approach, using a fresh cadaveric cow cranium injected with silicone. METHODS: The material consists of a cadaveric cow brain injected with silicone. Preparation consists of irrigation of the major vessels followed by injection of silicone, coloured either red or blue. RESULTS: A three-step approach was designed to simulate microneurosurgical dissection along with the cerebellopontine angle and to dissect cranial nerves emerging from the brain stem. CONCLUSION: This laboratory training model is useful in allowing trainees to gain experience with the use of an operating microscope and familiarity with the CPA via the retrosigmoid approach. The aim of this study was to develop a novel model and to adapt it to create a life-like neurosurgical training system.

A laboratory training model using fresh sheep spines for pedicular screw fixation.

BACKGROUND: Laboratory training models are essential for developing and refining surgical skills prior to clinical application of spinal surgery. A simple simulation model is needed for young residents to learn how to handle instruments and to perform safe posterior lumbar approaches. Our aim is to present a practical laboratory model using a fresh sheep lumbar spine that simulates the pedicular screw fixation in spine surgery. METHODS: The material consists of a fresh cadaveric spine from a 2-year-old sheep. A two-step approach was designed for posterior lumbar approaches including placement of lumbar pedicular screws. RESULTS: The model simulates standard posterior lumbar pedicular screw fixation of the human spine. CONCLUSIONS: The cadaveric sheep spine represents a useful method to accustom trainees of neurosurgery and spine surgery residents and simulates posterior lumbar pedicular screw fixation performed in the human spine.

Paediatric ganglioglioma of the conus medullaris.

Gangliogliomas of the conus medullaris are very rare, with only 12 patients reported so far. We report a 6-year-old male who presented with a painless numbness of the left lower limb and with bladder dysfunction. MRI revealed an intramedullary lesion at the T11-T12 vertebral levels. The tumour was subtotally removed. Histopathological examination demonstrated ganglioglioma.

Primary cerebellopontine angle craniopharyngioma in a patient with Gardner syndrome.

Craniopharyngiomas usually involve the sella and suprasellar space. Ectopic craniopharyngiomas have rarely been reported at the cerebellopontine angle (CPA). We report a rare primary craniopharyngioma of the CPA without extension into the sellar region. The lesion was initially detected by MRI during investigation of multiple scalp fibromas. Multiple osteomas of the skull and face were detected 2years later, and colonic adenomatous polyposis was detected 4years later; typical features of Gardner syndrome. This is the third report of a primary CPA craniopharyngioma in a patient with Gardner syndrome.

One-stage surgery through posterior approach-for L5-S1 spondyloptosis.

Grade 5 spondylolisthesis or spondyloptosis is a rare condition. Generally, the surgical management of spondyloptosis includes multi-staged procedures instead of one-staged procedures. One-stage treatment for spondyloptosis is very rare. A 15-year-old girl with L5-S1 spondyloptosis was admitted with severe low back pain. There was no history of trauma. The patient underwent L5 laminectomy, L5-S1 discectomy, resection of sacral dome, reduction, L3-L4-L5-S1 pedicular screw fixation, and interbody-posterolateral fusion through the posterior approach. The reduction was maintained with bilateral L5-S1 discectomy, resection of the sacral dome, and transpedicular instrumentation from L3 to S1. In this particular case, one-staged approach was adequate for the treatment of L5-S1 spondyloptosis. One-staged surgery using the posterior approach may be adequate for the treatment of L5-S1 spondyloptosis while avoiding the risks inherent in anterior approaches.

Validity of serum tau protein levels in pediatric patients with minor head trauma.

BACKGROUND: The aim of this study was to investigate the relationship between intracranial injury and serum tau protein levels in pediatric patients with minor head trauma (MHT). METHODS: We included 60 pediatric patients with MHT (Glasgow Coma Scale [GCS], 14-15) and 28 control patients. The patients were divided into 3 groups as follows: those without (group 1) and with (group 2) intracranial lesions shown on cranial computed tomography (CCT) and the control group (group 3). RESULTS: The mean serum tau protein level was 96.06 +/- 70.36 pg/mL in group 1, whereas it was 112.04 +/- 52.66 pg/mL in group 2, with no statistically significant difference between the groups (p = .160). The mean serum tau protein levels between the study groups (group 1 and group 2) and control (38.52 +/- 29.01) were statistically significant (P < .001 and P < .001, respectively). The GCS score and pathologic condition in CCT were only influential variables on tau protein levels. CONCLUSIONS: We found that serum tau protein increased after MHT but did not distinguish between those with and those without intracranial lesions demonstrable on CCT.

Indications for brain computed tomography and hospital admission in pediatric patients with minor head injury: how much can we rely upon clinical findings?

OBJECTIVES: The aim of this study was to describe the characteristics of patients with a minor head injury (MHI) who were admitted to a pediatric emergency unit and to identify the clinical signs and symptoms that most reliably predict the need for cranial computed tomography (CCT) and hospital admission following MHI. METHODS: All patients were retrospectively evaluated according to age, gender, details of injury, presenting symptoms, physical examination findings, radiological investigations ordered and results, length of stay, outcome of the injury and hospitalization rates. RESULTS: The factors affecting indications for computed tomography and hospitalization were retrospectively analyzed in 916 patients--585 males and 331 females, aged between 1 month and 15 years (mean: 5.01 +/- 3.58 years), with MHI. A multivariate analysis revealed significant correlations between CCT abnormalities and Glasgow Coma Scale scores of 13 or 14, headache, posttraumatic amnesia, blurred vision, cephalohematomas, periorbital ecchymoses, otorrhea and abnormal neurological findings. CCT abnormalities were identified in 67 (19.8%) of the 338 CCT scans. Twenty of the 67 patients (29.9%) with CCT scan abnormality had no clinical signs. Of all cases, 125 (13.6%) were hospitalized, 617 (67.4%) were treated as outpatients, and 174 (19.0%) left the emergency department based on a personal decision. CONCLUSION: Some clinical risk factors can be used as predictors of abnormalities in CCT scans following MHI, but the absence of such clinical findings does not exclude the possibility of intracranial injuries.