Antiangiogenic Molecules Suppressed Meningioma-Induced Neovascularization: A Corneal Angiogenesis Study.

AIM: To investigate the angiogenic effects of bevacizumab and imatinib on different meningioma tissue grades. MATERIAL AND METHODS: In this study, in silico analysis of angiogenesis-related gene expression was carried out using previously reported datasets. Messenger ribonucleic acid expressions of VEGFA, VEGFB, PDGFRA, and PDGFRB genes were obtained from two different meningioma transcriptome datasets. The effect of antiangiogenic drugs, bevacizumab and imatinib, on meningiomainduced vascularization was assessed by using rat corneal angiogenesis assay (CAA). RESULTS: Bevacizumab and imatinib both significantly reduced meningioma-induced neovascularization in the CAA model. CONCLUSION: The angiogenic characteristics of meningiomas may be suppressed by using antiangiogenic drugs to prevent neovascularization, thus improving prognosis.

Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option.

BACKGROUND: Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option. MATERIALS AND METHODS: We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT. RESULTS: While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity. CONCLUSIONS: SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.

In vivo effect of pregnancy on angiogenesis potential of arteriovenous malformation tissue samples: an experimental study.

BACKGROUND: Increased angiogenic potential of cerebrovascular malformations during pregnancy may help to explain the complications of arteriovenous malformations (AVMs) in this group of patients. This experimental study investigated the effect of pregnancy on angiogenic activity of implanted AVM tissue samples. METHODS: A subject group of 10 pregnant rats and 10 non-pregnant rats as controls were used. Surgical AVM resection samples were implanted into the micropocket created in both eyes of each animal. Vascular development was assessed by vessel count throughout the study period. In addition, immunohistochemical studies were done for vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF), and their receptors (VEGFR, PDGFR). RESULTS: Statistically significant increase in the number of vessels was found in both groups (P<0.0001); however, the increase in the pregnant group was greater (P=0.0032). The difference between the two groups was evident at the 25th day of the experiment. Despite both groups showed increased level, there was no difference with the level of VEGF, VEGF receptor, PDGF, or PDGF receptor (P>0.05 for all comparisons). CONCLUSIONS: Findings of this study suggest that angiogenic activity of AVM tissues may increase during late pregnancy, hence physicians should inform pregnant patients with AVM of the potential risk.

A thoracic vertebral brown tumor presenting with paraparesis in a patient with end-stage renal disease.

Vertebral brown tumors are rare, non-neoplastic bone lesions that occur in the setting of hyperparathyroidism. There are differences in the management of them in the literature. Because brown tumors usually resolve after a parathyroidectomy. We present a case of a thoracic vertebral brown tumor with paraparesis.

Thalamic abscess caused by a rare pathogen: streptococcus constellatus.

Streptococcus constellatus is a microorganism that lives commensally in the oropharyngeal region, urogenital region, and intestinal tract. However, it can cause infection in patients with certain predisposing factors. Rarely, this microorganism can cause a brain abscess. Thalamic localization of brain abscesses is much rarer than abscesses in other locations of the brain. Brain abscess caused by streptococcus constellatus are very rarely been reported in the literature. We present a rare case of a left-sided thalamic abscess caused by streptococcus constellatus in a 25-year-old male patient who was injured by shrapnel pieces in the head and who was malnourished. The patient was successfully treated by stereotactic aspiration and antibiotherapy.

Surgical Exposure Gained in an Extended Retrosigmoid Approach to the Cerebellopontine Angle Compared to the Traditional Retrosigmoid Approach.

AIM: Retrosigmoid approach to the posterior fossa has been a popular and dependable approach for accessing the cerebellopontine angle (CPA) and petroclival region. Although this approach is commonly used, it requires cerebellar retraction and has limitations when the lesion is located ventral to the brainstem. The aim was to quantify the angle of view provided by extended retrosigmoid approach in comparison to the traditional approach. A secondary objective was to identify a strategic initial burr hole site for craniotomy. MATERIAL AND METHODS: Ten adult human cadaver heads (20 sides) were used. First, traditional retrosigmoid approach was performed and the angle of exposure was measured on cranial computerized tomography (CT). Following, extended retrosigmoid approach was performed with mastoid bone drilling and reflection of venous sinuses. Angle of exposure was measured on CT. Two measurements of both approaches were compared. RESULTS: Mean angle of view for the traditional retrosigmoid approach (31.4° ± 4.1°) was significantly smaller than that of the extended approach (46.0° ± 4.7°) (p < 0.001). Site of strategic burr hole was 5 mm below and 15 mm lateral to the asterion was defined. CONCLUSION: Extended retrosigmoid approach offers neurosurgeons approximately 50% larger angle of view and shorter working distance than the traditional approach provides. This modification permits better access to the CPA and ventral brain stem without cerebellar retraction.

Primary Dural Spinal Lymphoma Presentation of a Rare Spinal Tumor Case.

Background. Primary spinal dural lymphomas (PSDL) are tumors with characteristic histopathology of a lymphoma, which are completely in the spinal epidural space without any other systemic involvement. Extranodal primary lymphoma involving nervous system prefers thalamus/basal ganglia, periventricular region, cerebellum, eyes, meninges/dura, and cranial nerves or spinal cord. Rare spinal localization with acute spinal cord compression is worth attention. Case Presentation. A 48-year-old male presented with a several-month-long history of upper back pain. Lately, he had numbness and weakness at both lower extremities and was unable to walk for one week. A spinal MRI showed a thoracic lesion with cord compression at T2-T4 levels. The patient underwent surgical decompression, with his final histopathology showing diffuse large B-cell lymphoma. Systemic work-up was negative for nodal disease. Following surgery, he received radiotherapy combined with chemotherapy. He experienced a good outcome after four years. Conclusion. The upper thoracic cord is a rare location for primary spinal lesions/metastases, both of which prefer the lower thoracic and upper lumbar regions. In cases of progressive paraparesis, there should be immediate surgical intervention in the case of denovo disease, followed by combined radiotherapy and chemotherapy procedures.

Intraoperative antepulsion of a posterior lumbar interbody fusion cage: three case reports.

Spinal fusion surgery techniques develop together with technologic advancements. New complications are seen as the result of new techniques and these may be very severe due to spinal cord and vascular structures in the lumbar region. The posterior lumbar interbody fusion cage (PLIFC) was shown to enhance spinal fusion and to prevent pseudoarthrosis due to its basic dynamic characteristics. PLIFC migrations are usually observed during the postoperative period, just after the mobilization of the patient and usually toward spinal canal. Migration to the retroperitoneal region is a extremely rare condition in the literature. In this article we discussed three cases of PLIFC antepulsion into the retroperitoneal region during the intraoperative period.

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 Supraorbital Keyhole Approach.

AIM: The major aim of the present anatomical study was to demonstrate the anatomical structures that can be visualized using the supraorbital keyhole approach, both endoscopically and microscopically, from an eyebrow incision to intracranial structures. Furthermore, it defines an optimal craniotomy for surgery. METHODS: Fine dissection was performed on each side of 5 formalin-fixed adult cadavers according to the surgical procedures of the supraorbital keyhole approach, and each step was documented both endoscopically and microscopically. Furthermore, the distance between the superior temporal line and the supraorbital notch/foramen was measured from the 10 total sides of the 5 cadavers and from the 118 sides of the 59 autopsies. RESULTS: Tumors and aneurysms of the anterior cranial fossa can be visualized during the supraorbital keyhole approach. The average distance between the superior temporal line and the supraorbital notch/foramen was measured. The distance obtained from the autopsies on the 25 females was 31.56 ±â€Š4.03  mm on the right side and 31.04 ±â€Š5.40  mm on the left side. The average distance obtained from the autopsies on the 34 males was 34.00 ±â€Š4.59  mm on the right side and 33.59 ±â€Š5.41  mm on the left side. There was no statistically significant difference between right and left in the female and male autopsies or between sexes. CONCLUSIONS: This anatomical study showed that structures in the anterior and middle cranial fossa can be reached via the supraorbital keyhole craniotomy approach with minimal brain retraction and adequate exposure and with minimal craniotomy size.

Intradural communication between dorsal rootlets of spinal nerves: their clinical significance.

BACKGROUND: Anatomical and surgical textbooks give almost no attention to the intradural communications between dorsal rootlets of adjacent spinal nerves. These communications can be of significance in various neurosurgical procedures and clinical conditions of the region. METHODS: The spinal cord of six formaldehyde-fixed cadavers was dissected from C1-S5. The dorsal rootlets of the spinal nerves were exposed via a posterior approach and communications between adjacent spinal nerves were documented. RESULTS: The frequency of communication between adjacent dorsal rootlets of the spinal nerves showed variations among spinal levels. Thirty-eight dorsal rootlet communications were observed in six cadavers (12 sides) and 20 (52.6%) were at cervical levels, 14 (36.8%) at thoracic levels, and four (10.5%) at lumbar levels. The majority of communications were observed on the left side (65.8%). Communications were most frequently observed at cervical (C4-C5, C5-C6) and upper thoracic (T1-T2) levels and seen least frequently at lower thoracic and lumbar levels. No communications were observed at sacral levels. Five types of communication were observed: I. oblique ascending, II. oblique descending III. short Y, IV. long Y and V shaped. None of the communication extended beyond one segment at any spinal level. The occurrence of such dorsal rootlet communications ranged from 3 to 7 for each cadaver and the mean was 4.8 ± 1.3. Histological sections from various levels of the dorsal rootlet communications showed that all consisted of myelinated fibers of varying diameters. CONCLUSIONS: Such communications may lead to misinterpretation of the pathology on the basis of clinical signs and symptoms and also should be considered in rhizotomy.

Anatomy of the spinal dorsal root entry zone: its clinical significance.

BACKGROUND: The posterolateral sulcus (PLS) is an important surgical landmark, especially for DREZ (dorsal root entry zone) operations. METHODS: The present study aimed to show the variations of the PLS using human spinal cord histological sections and report the variability in the number of dorsal rootlets of the spinal nerves in each the spinal cord segment. Further, measure the height and width of the dorsal horn on histological sections for cervical, thoracic, and lumbar levels. RESULTS: The results of the present study showed various patterns of PLS 1.clearly present PLS, 2. short PLS, 3. absent PLS or 4. irregular PLS. Height and width measurements of the dorsal horn showed that the average width was greatest at lower cervical (0.48 ± 0.04 mm) and least at lower thoracic levels (0.41 ± 0.04 mm), whereas the average height was greatest at upper cervical (3.0 ± 0.06 mm) and smallest at lower lumbar levels (1.8 ± 0.08 mm). The average number of rootlets varied considerably, at cervical level it was 7.6 ± 1.4 mm, at thoracic 6.6 ± 0.8 mm and at lumbar 6.1 ± 0.4 mm. CONCLUSIONS: The detailed anatomy of the variations of the PLS and the average number of rootlets at each spinal level can increase the success of regional surgery. Further, fine measurements on histological sections can give detailed knowledge on the size necessary for lesioning in DREZ operations.

Short term effects of classic massage compared to connective tissue massage on pressure pain threshold and muscle relaxation response in women with chronic neck pain: a preliminary study.

OBJECTIVE: The purpose of this study was to evaluate the short-term effects of classic massage (CM) and connective tissue massage (CTM) on pressure pain threshold and muscle relaxation response in women with chronic neck pain. METHODS: Participants included 45 female volunteers (ages between 25 and 45 years) presenting to the Köroglu State Hospital Neurosurgery Polyclinic who had experienced neck pain for 3 to 6 months. The volunteers were randomly assigned to 2 groups (CM or CTM to the thoracic spine and the neck). Each treatment was carried out for 1 session. Outcome measures were obtained before and after treatment, which included pressure pain threshold that was measured with an algometer and muscle relaxation response that was evaluated with electromyography biofeedback (EMG-BF). RESULTS: Pressure pain threshold of the sternocleidomastoid muscle was significantly different for the CM (P < .05) group. The EMG-BF values were significantly different for the CTM group (P < .05). Comparing the results of CM and CTM, EMG-BF averages favored the CTM group (P < .05). CONCLUSION: For the group of women with chronic neck pain that were included in this study, 1 treatment of CTM demonstrated relaxation responses and 1 treatment of CM demonstrated pain reduction.

A sine-wave-shaped skin incision for inserting deep-brain stimulators.

BACKGROUND: The sine-wave-shaped skin incision is a technique that minimizes skin-related complications near burr hole caps after electrode placement for deep-brain stimulation (DBS). METHODS: Between 2011 and 2013, 54 DBS electrodes were implanted in 27 consecutive patients with Parkinson's disease (PD), essential tremor, or dystonia. The sine-wave incision was used in 26 patients and conventional bilateral linear scalp incisions were used in one patient. RESULTS: None of the patients whose operations involved sine-wave-shaped incisions developed hardware-linked complications such as skin infection or skin erosion. The one patient who underwent conventional bilateral linear scalp incisions developed a skin infection. CONCLUSION: By preserving the vascular anatomy of the scalp and reducing skin tension at the wound site, the sine-wave-shaped incision promotes wound healing.

Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients.

BACKGROUND CONTEXT: We retrospectively analyzed a total of 1,218 pedicle screws for accuracy, with postoperative computed tomography (CT), in 198 patients who were operated on between March 2004 and September 2012. PURPOSE: To determine the incidence of screw misplacement in patients who received a transpedicular screw fixation, with intraoperative fluoroscopy in the lateral and lateral with anteroposterior (AP) positions. The results are compared between the two groups. STUDY DESIGN: Retrospective comparative study of accuracy of pedicle screw placement in thoracic and lumbar spine. PATIENT SAMPLE: The sample consists of 198 consecutive patients who underwent transpedicular screw fixation. OUTCOME MEASURES: Accuracy of screw placement was evaluated by postoperative CT scan. Misplacement was defined in cases where more than 25% of the screw size was residing outside the pedicle. METHODS: The indications for hardware placement, radiologic studies, patient demographics, and reoperation rates were recorded. Five hundred twenty-eight screws (Group A, n=81) were inserted into the vertebral body with the assistance of lateral fluoroscopy only, whereas 690 screws (Group B, n=117) were inserted with the assistance of lateral fluoroscopy, and the final positions of the screws were checked with AP fluoroscopy. RESULTS: A total of 1,218 screws were analyzed, with 962 screws placed at the lumbosacral region and 256 screws at the thoracic region. According to the postoperative CT scan, 27 screws (2.2%) were identified as breaching the pedicle. Nineteen of them (3.6%) were in Group A, whereas 8 (1.16%) were in Group B. The rate of pedicle breaches was significantly different between Group A and B (p=.0052). In Group A, the lateral violation of the pedicle was seen in 10 screws (1.9%), whereas medial violation was seen in 9 screws (1.7%). In Group B, the lateral violation of the pedicle was seen in six screws (0.87%), whereas medial violation was seen in two screws (0.29%). The medial and lateral penetration of screws were significantly different between Groups A and B (p<.05). A pedicle breach occurred in 21 patients, and 15 of them underwent a revision surgery to correct the misplaced screw. Of these patients, 11 (13.6%) were in Group A, and 4 (3.4%) were in Group B (p=.0335). CONCLUSIONS: In this study, we evaluated and clarified the diagnostic value of intraoperative fluoroscopy in both the lateral and AP imaging that have not yet been evaluated in any comparative study. We concluded that the intraoperative use of fluoroscopy, especially in the AP position, significantly decreases the risk of screw misplacement and the results are comparable with other advanced techniques.

Determining the morphometry and variations of the confluens sinuum and related structures via a silicone painting technique on autopsy patients.

In this study, we aimed to investigate the morphometric and morphologic structures of the confluens sinuum (CS) and related structures with a silicone painting technique. We studied 30 cadavers. Twelve of them were washed with alcohol and filled with a silicone painting technique via the vena jugularis interna, internal carotid artery, and vertebral artery. The other 18 were autopsied postmortem. The CS and related structures were dissected under microscope. Their anatomy was investigated, and variations were noted. The diameters of the sinus sagittalis superior (SSS), CS, occipital sinus (OS), sinus rectus (SR), and bilateral transverse sinus (TS), and the angle between SSS and SR were measured. The mean diameters were 11.7 mm for SSS, 22.3 mm for CS, 5.25 mm for OS, 7.5 mm for SR, and 9.7 (right) and 9.1 mm (left) for TS. The angle between the SR and SSS was 58°. There was no difference in the bilateral venous structures that drained to the SSS and TS. There was an extra drainage to the CS from the left side in 4 cases. The right TS was located superiorly in 7 cases compared with the left TS, and this process was correlated with the type of CS. A septum in the SSS was detected in 2 cases. In addition, we encountered an OS in 80% of the cases. We conclude that the septum inside the CS affects the dominancy of the TS, the angle between the SSS and SR, and the other venous variations.

A practical laboratory study simulating the lumbar microdiscectomy: training model in fresh cadaveric sheep spine.

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 lumbar approaches. Our aim is to present a practical laboratory model using a fresh sheep lumbar spine that allows to simulate lumbar microdiscectomy in humans. The material consists of a fresh cadaveric spine from a 2-year-old sheep. The surgical steps for lumbar microdiscectomy were conducted under the magnification of the operating microscope. The cadaveric sheep spine represents a useful model to train posterior lumbar microdiscectomy.

Symptomatic pneumorrhachis.

Pneumorrhachis (PR) is the presence of air within the spinal canal, whether localized in the epidural or in the subarachnoid space. Evidence of intraspinal air, especially in the subarachnoid space, had been thought to be merely a radiological artifact of serious underlying pathology until it was proven that PRs can be related to neurologic symptoms ranging from radicular pain to serious neurologic deficits. The etiologies, pathomechanisms, and natural courses show differences from case to case, with the result that no consistent treatment strategies exist in the literature. Although the conservative treatment modalities seem to be more appropriate in nonsymptomatic cases, treatment strategies in symptomatic cases remain the subject of discussion. In this study, we present two symptomatic cases of PR arising from different causes and review the literature, focusing especially on the symptomatic cases and strategies for treating them.

Falcine venous plexus within the falx cerebri: anatomical and scanning electron microscopic findings and clinical significance.

BACKGROUND: Only limited attention has been paid to the anatomy and clinical importance of the falcine venous plexus. The aim of this study was to evaluate the falcine venous plexus anatomically using scanning electron microscopy (SEM), and to provide guidance for neurosurgical approaches. METHODS: Latex or ink was injected into the superior and inferior sagittal sinus. The falcine venous plexus lying within the connective tissue of the falx cerebri was observed by dividing the falx into thirds (anterior, middle and posterior). Further, the SEM appearance of the falcine venous plexus was evaluated. RESULTS: The anterior third of the falx cerebri consisted of small diameter falcine venous vessels. These vessels were localized close to either the superior or inferior sagittal sinus, and none extended as far as mid-falx cerebri levels in any of the 16 cases. They communicated with either superior or inferior sagittal sinuses, but not with both of these sinuses. In the middle third of the falx cerebri, the majority of the vessels of the falcine venous plexus had larger diameter compared to those of the anterior third. These vessels extended the length of the falx cerebri levels. They communicated with both superior and inferior sagittal sinuses. In the posterior third of the falx cerebri, the vessels of the falcine venous plexuses had the largest diameter and were located at the junction of the inferior sagittal sinus and the straight sinus. They were localized at the lower two-thirds of the falx cerebri. In all cases, the dense venous networks communicated with the inferior sagittal sinus but not with the superior sagittal sinus. The falcine venous plexus observed in the posterior third of the falx cerebri was denser than in the anterior and middle portions. The SEM revealed small vessels whose diameter ranged between 42 and 138 µm. The vessels of the falcine venous plexus in the anterior third had a mean diameter of 0.42 ± 0.1 mm, in the middle third a mean diameter of 0.87 ± 0.17 mm, and in the posterior third, 1.38 ± 0.21 mm. CONCLUSION: The falcine venous plexus is a network of venous channels that exists within the connective tissue of the falx; the sizes and patterns of communication of these structures showed regional differences. Neurosurgeons should be aware of the regional differences when making an incision or puncturing the falx during a surgical approach.