Management of Incidental Carotid Cave Aneurysm.

BACKGROUND: Incidental diagnosis of saccular aneurysms is more common with the advent of imaging techniques. Because of the severe morbidity and mortality that they can cause, treatment is chased for them, either microsurgical treatment or endovascular, even when they are diagnosed incidentally. Carotid cave aneurysms are rare, and they seem to have a more benign course compared to other intracranial aneurysms, probably related to the physical enveloping effect of the surrounding structures. Yet, their microsurgical treatment is a serious challenge technically for the neurosurgeon, with its severe morbidity and mortality for the patient. Endovascular techniques have their risks, too. PURPOSE: In this paper, we analyzed and presented our series of incidentally diagnosed carotid cave aneurysms. MATERIALS AND METHODS: The age, gender of patients, the size, laterality, and MR angiographic follow-up of aneurysms were reported. Their clinical results were noted. RESULTS: Fifty-six patients who had incidentally been diagnosed with 59 carotid cave aneurysms were followed up. No patient was microsurgically treated, but 15 patients had endovascular treatment for 15 aneurysms. The mean size of 15 treated aneurysms was 4.6 ± 2.1 (range = 2-10) mm, and it was 3.0 ± 1.5 (range = 1.7-10) mm for the untreated aneurysms (n = 44). There was no significant difference between the follow-up times of the treated and untreated groups (P = 0.487). The median follow-up of 59 aneurysms in 56 patients was 52 (mean = 49.6 ± 27.9, range = 1-124) months, with a total follow-up of 244 aneurysm years. None of the patients had subarachnoid hemorrhage related to carotid cave aneurysms during follow-up, and none of the aneurysms had shown growth. Two patients who had endovascular treatment had ischemic complications with minor neurologic deficits. CONCLUSION: Follow-up can be a reasonable option for the incidental aneurysms that are located and confined to the carotid cave. Additionally, TOF might be a reliable method for follow-up imaging of carotid cave aneurysms.

The parietooccipital interhemispheric transtentorial approach for pineal tumors.

Access to the pineal region has always been a challenge for neurosurgeons. The parietooccipital interhemispheric transtentorial approach is a slight variation of the traditional occipital transtentorial approach that provides adequate exposure to the lesions of the pineal region without introducing additional risks. In this study, the modified parietooccipital interhemispheric transtentorial approach is discussed including step-by-step anatomical cadaveric dissections and operative images. 27 adult patients (age > 18) who were operated over a 30-year period (1992-2022) by the senior author (M.N.P.) at two clinics, Marmara University, Department of Neurosurgery, Istanbul, Turkey and Acibadem Mehmet Ali Aydinlar University, Department of Neurosurgery, Istanbul, Turkey were analyzed. Only pineal region tumors were included in the analysis. Falcotentorial meningiomas and vascular lesions including cavernomas were excluded. 5 cadaveric specimens were dissected step by step following the surgical approach. Each step was documented using a Canon EOS 5D Mark II camera with Canon 100 mm Macro Lens. Step by step images of the dissections were presented including comparison with surgical images. Additional illustrations were used to describe the surgical corridor. The surgical corridor is maintained anterior to the parietooccipital sulcus along the medial of the precuneus. No retraction to the calcarine sulcus resulted in no postoperative hemianopsia. The neurovascular structures along the surgical corridor along with the nuances of the tentorium incision and splenium resection are discussed. The parietooccipital interhemispheric transtentorial approach provides a wide and safe corridor for surgical resection of pineal tumors.

Impact of COVID-19 on interest in pediatric neurosurgery related symptoms, diseases, and treatments.

BACKGROUND: More and more often, patients use online resources to increase their knowledge/confidence in conventional medicine. Thus, the evaluation of the internet search trends may offer an insight into patients' perception of the healthcare system during the pandemic, especially for medical specialties with invasive interventions such as pediatric neurosurgery. METHODS: A total of 140 keywords representing a wide range of pediatric neurosurgery related symptoms/signs, diseases, and treatments were defined. Google Trends tool was queried for the predefined keywords within the United States from January 01, 2016, to November 17, 2020. Two periods in 2020, March 15 to July 4 and July 5 to October 31, were compared with similar periods over the preceding four years (2016-2019). We performed analyses in three sections: symptoms/signs, diseases, and treatments. RESULTS: Public interest has shifted from regular pediatric neurosurgery related symptoms/signs, diseases, and treatments to the ones related with neurological aspects of COVID-19 both in initial and short-term stages of the pandemic. CONCLUSIONS: Google Trends highlights that the link between neurosurgeon/pediatric patients/caregivers needs to be further empowered by growing educational efforts.

Could gas-filled pseudocyst mimick extruded disc herniation?

There are case reports and small case series in the literature reporting gas-filled pseudocysts (GFP). However, a systematic review presenting overall view of the disease and its management is still lacking. In the present study, we aimed to make a systematic review of GFP cases, and present an exemplary case of ours. Our second aim was to discuss current theories for pathogenesis of GFP. A systematic review of GFP was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Two large-scaled data search engines were used. A total of 53 articles were retrieved from the literature and presented with an exemplary case of ours. Mean age of the historical cohort was 59.47 years. There were 66 male (54.1%) and 56 female (45.9%) patients. The most prevalent clinical presentation was radicular sign/symptom in lower limbs with (29.1%) or without low back pain (LBP) (67%). Gas-filled pseudocyst has most commonly been diagnosed at the lower lumbar spine (L4-L5, 45.3%; L5-S1, 37.7%). Surgery was the treatment of choice in most of the patients (80%). In the whole cohort, 79.1% of the patients had complete recovery. Gas-filled pseudocysts are rarely observed in daily practice. They present mostly in men at the age of 60s. Precise differential diagnosis determination using appropriate imaging would help clinicians treat the patients properly. Gas-filled pseudocysts should be treated similarly to other spinal pathologies causing nerve root compression.

Neurosurgical follow-up and treatment of a series of 26 WHO grade III meningiomas.

Meningiomas are the most common primary intracranial tumors. They have three pathologic grades. Surgical resection aiming Simpson I resection is the standard treatment for meningiomas. Radiotherapy and Gamma Knife radiosurgery are the main adjuvant and salvage treatments. Chemotherapy has limited use. Grade II, and III meningiomas have a higher recurrence rate, and adjuvant radiotherapy is usually the standard treatment for grade III meningiomas. In this paper, we analyzed our meningioma series of 1401 patients and presented the treatment and follow-up results of 26 grade III meningioma cases. Median follow-up of grade III meningiomas was 40.5 (range, 1-154) months. The mean age of patients was 51.7 ± 15.7 years; 12 of them were female and 14 were male (female/male ratio = 0.9). The median progression-free survival (PFS) of them was 22 months, and overall survival (OS) was 62 months. Meningiomas with gross total resection (GTR), non-skull base meningiomas, and primary grade III meningiomas had longer PFS, while meningiomas with GTR, non-skull base meningiomas, and primary meningiomas had longer OS with a statistical significance.

Treatment and follow-up results of WHO grade II meningiomas.

Meningiomas are the most common primary intracranial tumors. They have three pathologic grades. Surgical resection aiming Simpson I resection is the standard treatment for meningiomas. Radiotherapy and Gamma Knife radiosurgery are the main adjuvant and salvage treatments. Chemotherapy has limited use. Grade II, and III meningiomas have a higher recurrence rate, and adjuvant radiotherapy is usually the standard treatment for grade III meningiomas but there is not a consensus regarding grade II meningiomas. In this paper, we analyzed our meningioma series of 1401 patients and presented the treatment and follow-up results of 170 grade II meningioma cases. The median follow-up of grade II meningiomas was 61 (range = 1-231) months. The mean age of patients was 52.5 ± 15.0 years, 102 of them were female and 68 were male (female/male ratio = 1.5). The median progression-free survival (PFS) of them was 109 months, and the cumulative overall survival (OS) rate was 85% at 10 years. Meningiomas with gross total resection, non-skull base meningiomas, and primary grade II meningiomas had longer PFS with statistical significance, while non-skull base meningiomas, younger group of patients, and primary grade II meningiomas had longer OS with a statistical significance.

The Carotid Endarterectomy Cadaveric Investigation for Cranial Nerve Injuries: Anatomical Study.

Cerebral stroke continues to be one of the leading causes of mortality and long-term morbidity; therefore, carotid endarterectomy (CEA) remains to be a popular treatment for both symptomatic and asymptomatic patients with carotid stenosis. Cranial nerve injuries remain one of the major contributor to the postoperative morbidities. Anatomical dissections were carried out on 44 sides of 22 cadaveric heads following the classical CEA procedure to investigate the variations of the local anatomy as a contributing factor to cranial nerve injuries. Concurrence of two variations was found to be important in hypoglossal nerve injury: the presence of a direct smaller vein in proximity of the carotid bifurcation, and the intersection of the hypoglossal nerve (HN) with this vein. Based on the sample investigated, this variation was observed significantly higher on the right side. Awareness of possible anatomical variations and early ligation of any small veins can significantly decrease iatrogenic injury risk.

Shunt Valve Rupture in Ventriculoperitoneal Shunt Failure.

BACKGROUND: Shunt complications are common despite advances in surgical techniques and shunting technology. Proximal and/or distal catheter malfunctions are detected in pediatric and adult patients. However, valve dysfunction is rare in such cases. CASE DESCRIPTION: A 24-year-old woman presented with a history of ventriculostomy and ventriculoperitoneal shunt (VPS) secondary to hydrocephalus concomitant with Dandy-Walker syndrome. She has had undulant headache and vision loss episodes in both eyes for 15 days. Her VPS valve was normal when manually checked, and the VPS was observed as intact on x-ray and computed tomography scan. She had high-grade papilledema in both eyes with an optical coherence tomography scan value of 55/99. Lumbar puncture was performed. Cerebrospinal fluid opening pressure was 560 mm H2O under sedation. VPS exploration surgery was performed. There was a tiny defect over the shunt valve from where clear cerebrospinal fluid was leaking. We revised the old VPS valve with a new valve of 1.5 regular pressure. Her vision improved shortly after the surgery. CONCLUSIONS: This case is a very rare example of shunt valve dysfunction that required further investigation and a new valve replacement even though the preoperative imaging was normal.

Location of Central Sulcus According to Coronal Suture.

BACKGROUND: It is essential to localize the central sulcus in patients with lesions within or nearby the sensorial and/or motor cortex. The coronal suture is a valuable bony landmark in neurosurgical practice; it could be used to localize the central sulcus. There are scarce amount of literature about normal values of the distance between the central sulcus and the coronal suture. In the present study, the authors aimed to learn normative values of the distance between the central sulcus and the coronal suture in a patient sample representing Turkish population. The authors also aimed to look for any difference in values according to sex and age. METHODS: The authors retrospectively reviewed a prospectively collected database. Patients were evaluated on cranial computed tomography (CT) reformatted in 3 planes (axial, coronal, and sagittal). Intracranial and extracranial pathologies were scanned. If there was no pathology, the reviewed CT scan was added up to the database. The coronal suture and the central sulcus were identified at the midline location on axial and sagittal view CT images. Vertical distance between coronal suture and central sulcus was measured. RESULTS: Mean distance of the central sulcus to the coronal suture was 47.5 ±â€Š7.6 mm (range = 26.2-67.3 mm). CONCLUSIONS: Identifying the central sulcus relative to the coronal suture is essential to preserve the primary motor and/or sensory cortices in neurosurgical procedures. The distance of the central sulcus to the coronal suture is approximately 4.7 cm in adult patients from Turkey, which did not differ according to age or sex.

Frontal Bone is Thicker in Women and Frontal Sinus is Larger in Men: A Morphometric Analysis.

ABSTRACT: Cranial bone thickness and frontal sinus size are important parameters to be known before cranial procedures. Deep-learning systems have become popular for making bulk analyses to diagnose diseases/disorders and plan treatment algorithms in diverse fields of medicine. Deep-learning systems would be valuable assets also for cranial procedures. Deep-learning systems need normative values and variances of the population on which they are used. In the present study, the authors aimed to find out the normative values for skull bone thickness at 4 anatomical locations, and frontal sinus size. the authors also analyzed whether gender affected these values. Consecutive adult female and male patients that had presented to our outpatient and emergency clinics between December 2019 and April 2020 were evaluated. We included 174 patients (98 female and 76 male) into the final analysis. Skull bone thickness was measured in 4 anatomical compartments, and vertical dimension of the left and right frontal sinuses were measured. The mean thickness of frontal, parietal, temporal, and occipital bones was 7.9 mm, 9.7 mm, 6 mm, and 10.1 mm for men; 8.7 mm, 10.2 mm, 6.1 mm, and 10.1 mm for women, respectively. Women had significantly thicker frontal bone when compared to men (P = 0.009). Men had significantly larger frontal sinuses compared to women (16.1 mm versus 13.7 mm for right frontal sinus, P = 0.031; 16.4 mm versus 13.9 mm for left frontal sinus, P = 0.023). Women and men had thicker frontal bone, and larger frontal sinuses, respectively.

Gamma knife radiosurgery in patients with Cushing's disease: Comparison of aggressive pituitary corticotroph tumor versus corticotroph adenoma.

Aggressive pituitary corticotroph tumors causing Cushing's disease are rare, and there is limited data about their clinical management. Here, we aimed to report our long-term experience with gamma knife radiosurgery (GKRS) as adjuvant treatment in patients with residual or recurrent pituitary corticotroph tumors. This retrospective study included 45 adult patients (M/F, 7/38; mean age, 40.2 ±â€¯13.1 years) with residual tumor or recurrence after initially successful surgical resection. Single-session GKRS was performed in all patients. Tumors with a Ki-67 value higher than 3 % and radiologic invasion to surrounding tissues were classified as aggressive tumor group. Clinical, hormonal and radiological findings were compared between the aggressive (n = 10) and non-aggressive adenoma (n = 35) groups. Following GKRS, tumor volumes were significantly reduced in both groups. The mean time to hormonal remission in the non-aggressive group was significantly shorter than in the aggressive group (23.5 ±â€¯6.3 vs 33.0 ±â€¯5.0 month, respectively, p < 0.05). New-onset hypopituitarism was identified in only seven patients (15 %) after GKRS in the whole cohort. The present study introduces several essential findings about aggressive corticotroph tumors. First, aggressive behavior tends to occur more frequently in male subjects. Second, time to GKRS was significantly shorter in the aggressive group. Moreover, a tumor volume ≥2 cm3 may be associated with clinical aggressiveness in corticotroph tumors. In conclusion, we suggest that early adjuvant GKRS is an effective treatment option in aggressive pituitary corticotroph tumors.

Elderly Patients with Intracranial Meningioma: Surgical Considerations in 228 Patients with a Comprehensive Analysis of the Literature.

BACKGROUND: Improved life expectancy and advanced diagnostic tools including computed tomography and magnetic resonance imaging have increased the awareness and diagnosis of intracranial meningiomas in the elderly population. The risk/benefit ratio of surgery in elderly patients with intracranial meningioma has not been clearly defined because of the lack of objective measurement tools. We aimed to understand the risk factors associated with postsurgical outcomes and how these risk factors affected postsurgical outcomes in elderly patients with intracranial meningioma. METHODS: We retrospectively evaluated 1372 patients, who were operated on for intracranial meningioma, using our prospectively collected database. The same senior author operated on all patients at 2 different tertiary clinics. Patients' clinical charts, presurgical postcontrast T1-weighted magnetic resonance images, operative reports, and pathology reports were reviewed. The relevant literature was also reviewed. RESULTS: Higher age, higher American Society of Anesthesiologists class, presence of comorbidities, tumor location, larger initial tumor size, and presence of peritumoral edema were all associated with postsurgical complications in elderly patients with intracranial meningioma. Age ≥50 years was the strongest predictor of postsurgical systemic complications, whereas higher American Society of Anesthesiologists class was the strongest predictor of postsurgical neurologic complications. A literature review showed higher morbidity and mortality of elderly patients with intracranial meningioma. Initial tumor size and postsurgical MIB-1 labeling index were higher in the elderly patients, both of which were predictors of tumor growth. CONCLUSIONS: Even though elderly patients operated on for intracranial meningioma had higher morbidity and mortality compared with younger patients, surgery is still much more beneficial than wait-and-see strategy in elderly patients.

Ventricular Meningiomas: Surgical Strategies and a New Finding That Suggest an Origin From the Choroid Plexus Epithelium.

BACKGROUND: The aim of this study is to share our experiences on a series of 21 patients with intraventricular meningiomas (IVMs). Histopathologic examinations are reviewed in detail and the cell of origin of IVMs is discussed. METHODS: We retrospectively reviewed 1372 patients with intracranial meningioma who were surgically treated between September 1986 and July 2018. From this cohort, 21 patients with IVM were identified. The clinical, radiologic, surgical, and follow-up records were analyzed. The archival pathologic specimens were reviewed. Tissue microarray blocks were performed from the formalin-fixed, paraffin-embedded samples of all IVM cases, 2 choroid plexus tissue adjacent to the tumors, and 10 extraventricular fibrous meningioma cases selected as control randomly. Immunohistochemical staining with the antibodies S-100, SOX10, NGFR, and OTX2 was performed according to the protocols indicated by the manufacturers. RESULTS: Surgical complications included hemiparesis in 1 patient (5%), postoperative seizure in 1 patient (5%), sensorial aphasia in 1 patient (5%), and preexisting headache in 1 patient (5%). Seventeen (81%) of the IVMs had grade I pathology and 4 (19%) had grade II pathology. The immunoprofile of IVMs is identical to the immunoprofile of normal choroid plexus epithelium. CONCLUSIONS: Transcortical approaches using intraoperative ultrasonography and intraoperative monitoring with avoidance of eloquent cortical areas can achieve good outcomes. Resection of the choroidal attachments should be attempted. Our results indicate that IVMs do not show arachnoid cap cell phenotype and the findings support that IVMs originate from the choroid plexus epithelium or the progenitors of the choroid plexus epithelium.

Sphenoid Wing Meningiomas: Surgical Outcomes in a Series of 141 Cases and Proposal of a Scoring System Predicting Extent of Resection.

OBJECTIVE: Sphenoid wing meningiomas are the third most common group of intracranial meningiomas. Their management is a challenge because of their bone invasion potential and their proximity to neurovascular structures and the cavernous sinus. METHODS: A cohort of 141 patients with sphenoid wing meningioma who were operated on and followed up between 1986 and 2018 were retrospectively analyzed. Demographic data, clinical and radiologic features, surgical results, and follow-up data are presented. The effects of adjuvant treatments (radiosurgery, radiotherapy, and chemotherapy) are reviewed. The invasion pattern of tumors and other factors were noted to analyze the extent of resection. Recurrence/regrowth rates were also analyzed. RESULTS: There were 96 female and 45 male patients with a median age of 51 years (range, 17-87 years). The median follow-up was 62 months (range, 1-303 months). Tumors were grouped as spheno-orbital (31 patients), lateral (34 patients), middle (35 patients), and medial (41 patients). Gross total resection was achieved in 98 patients, and 43 tumors were resected subtotally. One hundred and twenty of these cases had World Health Organization grade I pathology, whereas the remainder had grade II. In the follow-up, there were 14 recurrences of totally resected tumors, and 24 regrowths were observed in the subtotally resected group. No invasion pattern was strongly predictive of extent of resection alone, and a scoring system was built up and proposed. CONCLUSIONS: Sphenoid wing meningioma is a large group with characteristics associated with skull base meningiomas and convexity meningiomas. The results of surgery and other adjuvant treatments are heterogeneous.

Chordoma: Immunohistochemical Analysis of Brachury.

AIM: Chordomas are rare, slow growing but locally aggressive malignancies of the axial skeleton. Skull base chordomas, due to their intricate anatomical localization, pose significant challenges to managing physicians. In classical and chondroid chordomas, the disease course cannot be reliably determined using only morphological criteria. Brachyury (T Gene) was shown to play a central role in chordoma pathogenesis and several studies also showed that this gene also carries potential as a prognostic biomarker. This study aims to correlate Brachyury expression with the clinical course in surgically treated skull base chordomas. MATERIAL AND METHODS: Chordoma tumor samples from 14 patients with skull base chordomas, diagnosed using histopathological and immunohistochemistry criteria (epithelial membrane antigen (EMA), S100, pan cytokeratin (panCK)) were retrospectively analyzed for Brachyury expression using immunohistochemistry. Brachyury expression was graded using a 4 point semi-quantitative scoring system. Focal (grade II) and diffuse staining (grade III) were considered as overexpression. Patient recurrence-free survival and total survival were compared between Brachyury overexpressing and non-overexpressing groups using Kaplan-Meier survival analysis. RESULTS: Among the stained tumor samples, 85.7% were positive for brachyury expression. In both groups, there was one sample that was negative. We did not observe any significant difference among the groups for staining, grade and percentage of brachyury positive cells. CONCLUSION: Brachyury expression in tumor samples is not a sensitive indicator of prognosis in chordomas.

Pterional and Unifrontal Approaches for the Microsurgical Resection of Olfactory Groove Meningiomas: Experience with 61 Consecutive Patients.

AIM: Olfactory groove meningiomas make up 4 to 13% of meningiomas. The first line treatment of meningiomas is surgery, but the extent and types of approaches advised for olfactory groove meningiomas are diverse, from aggressive skull base approaches to standard or minimally invasive craniotomies and endoscopic approaches. We retrospectively reviewed our series of olfactory groove meningiomas that were operated microsurgically by standard pterional or unifrontal approaches. MATERIAL AND METHODS: Our series of 61 olfactory groove meningioma patients operated through pterional or unifrontal approaches between March 1987 and September 2015 was reviewed and the clinical data, radiological findings, surgical treatment and clinical outcomes of the patients were retrospectively analyzed. RESULTS: Sixty-three craniotomies were performed in total. Pterional and unifrontal approaches were used in 38 (60.3%) and 25 (39.7%) surgical procedures, respectively. Overall, gross total tumor resection was achieved in 59 (93.7%) cases. Complications were seen in 8 cases, and 2 of these patients underwent reoperation. Three of the 4 patients where only subtotal resection could be achieved underwent gamma knife radiosurgery. CONCLUSION: Pterional and unifrontal approaches, which are familiar and standard for neurosurgeons, can accomplish high rates of total resection with acceptable complication and recurrence rates for the treatment of olfactory groove meningiomas.

Pituitary Colloid Cyst.

Colloid cysts appear most commonly in the third ventricle, their occurrence in the sellar region is uncommon. The authors report a female patient with a pituitary colloid cyst. She was diagnosed incidentally with a sellar lesion by a routine paranasal computed tomography examination performed for planning of a dental implant surgery. Radiologic examinations revealed a pituitary lesion that was removed by transnasal transsphenoidal route. Her pathologic examination revealed that the lesion was a colloid cyst. Although rare, colloid cysts should be considered in the differential diagnosis of pituitary lesions.

Concomitant Double Tumors of Myxopapillary Ependymoma Presented at Cauda Equina-Filum Terminale in Adult Patient.

A 32-year-old man presented with gradually increasing bilateral buttock pain. He had intermittent claudication. Multiple, homogenously enhanced intradural extramedullary lesions at L2-L3 and L5-S1 levels were observed on magnetic resonance imaging. The tumors were debulked and were removed in piecemeal pattern until they had completely been resected. Histopathological examination of the surgical specimens confirmed that both tumors were myxopapillary ependymomas (MPE). MPE presenting as concomitant double tumor at conus-cauda-filum level are very rare. This kind of presentation could not be directly considered as dissemination, since both tumors were in the site of classical origin of MPE. Ten cases of double spinal MPEs have been reported to date. Including the present case, analysis of the 11 patients revealed some facts. There is a male predominance, which is opposite to the ependymomas that are commonly observed in females. Median age at presentation is 15 years. Most pronounced symptom is low back pain that sometimes radiates to lower extremities. Surgical approach was aimed in all tumors, which could be succeeded in all tumors except one. Adjuvant radiation therapy was applied in 5 patients. No recurrences have been reported after surgery or surgery + radiotherapy regimens.