Intraoperative Fluorescein Sodium Videoangiography in Intracranial Aneurysm Surgery.

OBJECTIVE: Fluorescein sodium (FNa) videoangiography (VA) was performed to evaluate blood flow within vessels and exclusion of the aneurysm after surgical clipping of intracranial aneurysms. The aim of this study was to report results of FNa-VA in a case series, including benefits and limitations of the technique, and compare intraoperative findings with postoperative cerebral angiography to assess reliability of FNa-VA. METHODS: The study included 64 aneurysms in 50 consecutive patients. Following clip ligation of the aneurysm, 100 mg of FNa was administered intravenously. The microscope light was switched to the FL560 integrated fluorescence module. Aneurysm sac, parent arteries, and perforating arteries were observed. RESULTS: FNa-VA promoted real-time assessment of the surgical field in three-dimensional view through the binoculars with good image quality. In 79.68% of aneurysms, FNa-VA confirmed satisfactory clip application, as FNa did not penetrate into the aneurysm. In 14.06% of aneurysms, a homogeneous yellow-green color change occurred, which was accepted as a false-positive sign. In 6.25% of aneurysms, FNa seeped into the aneurysm emitting a heterogeneous green signal, which slowly dispersed throughout the sac. Postoperative angiography revealed satisfactory results. Small neck remnants were present in 5 patients, and mild parent artery stenosis was found in 3 patients. No ischemic event occurred secondary to parent artery or perforating artery occlusion. CONCLUSIONS: FNa-VA adds greatly to the safety of surgical treatment of intracranial aneurysms, particularly in lesions situated in deep locations, by enabling real-time inspection, which facilitates safer manipulation and evaluation of structures in question.

Transcranial superior orbitotomy for the treatment of intraorbital intraconal tumors: surgical technique and long-term results in single institute.

In this article, the authors are presenting their experience and the results with the surgical treatment of intraorbital intraconal tumors based on a review of 33 constitutive cases. Our data were evaluated in comparison to other major series, and possible factors that might influence surgical outcome and survival are discussed. Thirty-three patients diagnosed with intraorbital intraconal tumors between 1998 and 2009 were treated by transcranial approach. Of these patients, there were 14 males (42.4 %) and 19 females (57.8 %). The age ranged between 2 and 70 years (mean = 36 ± 16.6 years). The follow-up period ranged between 2 and 13 years (mean = 7.3 ± 3.2 years). The most common presenting symptoms were exophthalmus and decreased visual acuity, which was seen in 21 (63.6 %) and 19 patients (57.6 %), respectively. Total resection was achieved in 23 patients (69.7 %) while subtotal resection was done in ten patients (30.3 %). Cavernoma and optic nerve sheath meningioma were the most common histologic variants, which were found in 11 (33.3 %) and 10 (30.3 %) patients, respectively. In the long-term follow-up, 54.5 % of the patients showed total ophthalmologic improvement, 9.1 % showed partial improvement, 21.2 % demonstrated unchanged ophthalmologic status, and 15.2 % showed worse ophthalmologic outcome. Transcranial approach for the treatment of intraorbital intraconal tumors is an effective approach for the management of these pathologies. The effectiveness is clearly demonstrated by the clinical results and outcomes of these patients' groups.

Primary fourth ventricular meningioma: case report and review of the literature.

Primary fourth ventricle meningiomas are extremely rare, and they are defined as meningiomas arising from the choroid plexus and lying strictly within the fourth ventricle. In this report we present a 61-year-old man with progressive worsening vertigo and gait disturbance, and new onset of diplopia. Neurological examination revealed bilateral abducens nerve paralysis, horizontal nystagmus, and gait disturbance with truncal ataxia. Neuroimaging revealed a mass lesion in the fourth ventricle with brain stem compression, and obstructive hydrocephalus. The patient was operated in the prone position with suboccipital craniotomy and splitting the lower vermis. Total resection of the tumor was achieved with no intra- or post-operative complications. Histopathologic examination revealed fibroblastic type meningioma (WHO grade I).

Lateral sublabial endoscopic approach to foramen ovale: a novel endoscopic technique to access infratemporal fossa.

OBJECTIVE: Our aim was to define a novel endoscopic approach to selectively access the foramen ovale through the lateral sublabial route. METHODS: Lateral sublabial endoscopic approach to the foramen ovale was studied in 3 fresh cadavers. A 2.5-cm sublabial submucosal incision gained access to the foramen ovale through the corridor under the zygomatic process of maxilla and lateral to the pterygoid plate. To display the anatomic principles of the lateral sublabial endoscopic approach, the surgical anatomy of the endoscopic corridor and the neurovascular structures around the foramen ovale were studied and documented. RESULTS: Lateral sublabial endoscopic approach provided access to the foramen ovale and related neurovascular structures at the posterolateral part of the sphenoid bone without any bone resection. The branches of the pterygoid segment of the maxillary artery superficial to the lower and upper heads of the pterygoid muscles were exposed initially through the endoscopic corridor under the zygoma and lateral to the pterygoid plate. The buccal nerve, passing in between the 2 heads of the lateral pterygoid muscle and the lingual and inferior alveolar branches of the V3 segment of the trigeminal nerve, emerging from under the cover of the lower head of the lateral pterygoid muscle were exposed deep to the branches of the maxillary artery. Following the inferior alveolar nerve backward proximally under the lower head of the pterygoid muscle exposes the foramen ovale. CONCLUSIONS: Lateral sublabial endoscopic approach, a minimally invasive route to the foramen ovale, requires no bone removal and provides adequate exposure to a hard-to-reach area in the infratemporal fossa. With the advantage of visualizing the distal segment of the maxillary artery and the segments of the mandibular nerve, early in the procedure, the approach can provide a controlled endoscopic manipulation for accessing this region.

Extended endoscopic endonasal approach to the suprasellar parachiasmatic cisterns: anatomic study.

OBJECTIVE: The objective of this study is to recognize the available endoscopic routes during approaches to the suprasellar region and the surgical endoscopic anatomy of the related neurovascular structures. MATERIAL AND METHODS: Extended endoscopic endonasal approach to the suprasellar region (EEASR) through the planum sphenoidale was performed in five fresh adult cadavers. The anatomic characteristics of the suprasellar parachiasmatic cisterns were studied and documented following the resection of the planum sphenoidale and opening the dura to expose the anterior incisural space. RESULTS: Two separate surgical corridors could be used during EEASR: one above and the other below the chiasm. The suprachiasmatic route exposed the gyrus recti, interhemispheric fissure, anterior cerebral artery complex, the lamina terminalis, and through this structure the anterior recess of the third ventricle. The subchiasmatic route exposed the pituitary stalk, superior hypophyseal artery, supraclinoidal internal carotid artery, origin of the ophthalmic artery, anterior choroidal artery, posterior communicating artery, uncus, optic tract, basilar artery and its bifurcation, pons, posterior cerebral artery, superior cerebellar artery, and oculomotor nerve. CONCLUSION: The EEASR, a minimally invasive route to suprasellar parachiasmatic area, provided wide exposure of the basal cisterns. The surgical areas that were accessed through the subchiasmatic corridor could be divided into a medial part that included the interpeduncular and prepontine cisterns and a lateral part that contained carotid and sylvian cisterns superiorly and the crural and ambient cisterns inferiorly.

Endoscopic endonasal anatomy and approaches to the anterior skull base: a neurosurgeon's viewpoint.

OBJECTIVES: The objective of this study was to review the endoscopic anatomy of the anterior skull base, defining the pitfalls of endoscopic endonasal approaches to this region. Recently, these approaches are gaining popularity among neurosurgeons, and the details of the endoscopic anatomy and approaches are highlighted from the neurosurgeons' point of view, correlated with demonstrative cases. MATERIALS AND METHODS: Twelve fresh adult cadavers were studied (n = 12). We used Karl Storz 0 and 30 degrees, 4 mm, 18- and 30-cm rod lens rigid endoscope in our dissections. After preparation of the cadaveric specimens, we approached the anterior skull base by the extended endoscopic endonasal approach. RESULTS: After resection of the superior portion of the nasal septum, bilateral middle and superior turbinates, and bilateral anterior and posterior ethmoidal cells, we could obtain full exposure of the anterior skull base. The distance between optic canal and the posterior ethmoidal artery ranged from 8 to 16 mm (mean, 11.08 mm), and the distance between posterior ethmoidal artery and the anterior ethmoidal artery ranged from 10 to 17 mm (mean, 13 mm). After resecting the anterior skull base bony structure and the dura between the 2 medial orbital walls, we could visualize the olfactory nerves, interhemispheric sulcus, and gyri recti. With dissecting the interhemispheric sulcus, we could expose the first (A1) and second (A2) segments of the anterior cerebral artery, anterior communicating artery, and Heubner arteries. CONCLUSIONS: This study showed that extended endoscopic endonasal approaches are sufficient in providing wide exposure of the bony structures, and the extradural and intradural components of the anterior skull base and the neighboring structures providing more controlled manipulation of pathologic lesions. These approaches need specific skill and learning curve to achieve more minimally invasive interventions and less postoperative complications.

Endoscopic anatomy and approaches of the cavernous sinus: cadaver study.

OBJECTIVE: The objectives of this study were to recognize the endoscopic anatomy of the cavernous sinus and to understand the standard, purely endoscopic endonasal approaches to this anatomic structure. This basic information will facilitate our surgical procedures and decrease the rate of surgical complications. MATERIALS AND METHODS: Seven fresh adult cadavers were studied bilaterally (n = 14). We used Karl Storz 0 and 30 degrees , 4 mm, 18 cm and 30 cm rod lens rigid endoscope in our dissections. After cadaver preparation, extended endoscopic endonasal approaches were performed to access the cavernous sinus. RESULTS: In the seven cadavers, the cavernous sinus and superior orbital fissure, on both sides, were widely exposed with extended endoscopic endonasal approach. The antero-inferior portion of the cavernous sinus was exposed by removing the superior and the middle turbinates and the posterior ethmoidal cells (extended endoscopic endonasal transsphenoidal approach); the whole lateral wall of the cavernous sinus was exposed by removing the anterior and the posterior ethmoidal cells (endonasal ethmoido-pterygo-sphenoidal approach: far lateral); and the medial wall of the cavernous sinus was exposed by introducing the 30 degrees endoscope from the contralateral nostril (contralateral endoscopic endonasal transsphenoidal approach). According to the neurovascular architecture, the lateral wall of the cavernous sinus is divided into the superior triangular area, the superior quadrangular area and the inferior quadrangular area. This division can facilitate understanding of the anatomic relations of the cavernous sinus from the endoscopic view. CONCLUSION: Knowledge of the anatomy of the cavernous sinus obtained with an endoscopic view of cadaver dissections is an essential step in the learning curve of endoscopic skull base surgery, and is important for endoscopic treatment of various pathologies in this region. In this anatomic study, we reviewed the approaches to the cavernous sinus with an endoscopic view and identified the neurovascular relations. This approach will help in performing safer and minimally invasive surgery.

Pneumatization degree of the anterior clinoid process: a new classification.

The objective of this study is to determine the incidence and degree of anterior clinoid process pneumatization, in addition highlighting to their clinical significance. Multidetector-row CT scans of the skull base were reviewed in 648 subjects between 2007 and 2008. The presence of pneumatized anterior clinoid process and its degree were studied and documented. These data were statistically analyzed. Pneumatization of the ACP was found in 62 of 648 patients (9.6%) including 32 (51.6%) men and 30 (48.4%) women. The age of these patients ranged from 21 to 82 years (mean, 41 +/- 15.7 years). Pneumatization of the ACP occurred only on the left side in 14 cases (22.6%), only on the right side in 11 cases (17.7%), and bilaterally in 37 patients (59.7%). ACP pneumatization Type I, in which less than 50% of the ACP is pneumatized, was found in 47 of 124 sides (38%), Type II, in which more than 50% but not totally pneumatized ACP, was found in 28 of 124 sides (22.6%), and Type III, in which the ACP is totally pneumatized, was found in 22 of 124 sides (17.7%). The incidence of Type I in the general population was 6.6%, Type II was 3.5%, and Type III was 2.5%. Radiologically recognizing the degree of ACP pneumatization is important in decreasing the incidence of surgical complications during anterior clinoidectomy. Proper intraoperative management can be undertaken with special attention to the new classification.

Extended endoscopic endonasal approach to the clival region.

OBJECTIVE: The objective of this study was to recognize the endoscopic anatomy of the clival region of the skull base and its neurovascular relations, which will make us able to perform safer and minimal invasive endoscopic approaches to this region with lower rate of complications. MATERIALS AND METHODS: Six fresh cadavers were studied (n = 5). We approached the clivus by performing binostril extended endoscopic endonasal approach. After locating the sphenoid sinus as a key point, the vomer was totally removed to expose the clival region located inferiorly to the sphenoid sinus. Mucosal incision is done vertically from the sphenoidal portion the clivus caudally to the inferior portion of nasal cavity just medially to vidian nerve. The mucosal flap is then dissected and retracted. The clivus was resected until the foramen magnum inferiorly. The lateral limit of the resection is the paraclival portion of the internal carotid artery (ICA).The dura and the meningohypophyseal artery is exposed. A vertical dural incision was done and retracted laterally to expose the intradural structures. The prepontine cistern and basilar artery were visualized. RESULTS: The clivus was best localized by orienting the endoscope +15 degrees rostrally. After resecting the inferior wall of the sphenoid sinus and vomer and the overlying mucosa is retracted laterally until the vidian nerve, we obtained sufficient exposure of the clivus. The safe lateral limit of the surgical corridor was the vidian nerve. The clivus is resected until the foramen magnum inferiorly. The safe lateral limit of the resection in this step was the proximal cavernous and the distal petrosal portions of the ICA. This resection provided us with a wide exposure of the clival dura. The basilar plexus, the abducens nerve (sixth cranial nerve) passing through the basilar plexus, and the paraclival portion of the ICA can be injured when careful dissection is not performed. After dural incision, the prepontine cistern and the basilar artery were able to be exposed widely. CONCLUSION: Binostril extended endoscopic endonasal approach is an appropriate approach to the clival region of the skull base. With good knowledge of the endoscopic anatomic features of this region and its neurovascular relations, surgical procedures can be performed safely with more minimal invasiveness.

Endoscopic anatomy of the oculomotor nerve: defining the blind spot during endoscopic skull base surgery.

OBJECTIVE: The objective of this study is to define the endoscopic anatomy of the oculomotor nerve (CN III) and its neurovascular relations in order to facilitate surgical procedures and avoid injury to this nerve during endoscopic endonasal approach to the skull base. MATERIALS AND METHODS: Endoscopic anatomy of the cavernous sinus was studied in seven fresh adult cadavers bilaterally and the basal cisterns in five fresh adult cadavers. Extended endoscopic endonasal suprasellar approach was performed to expose the oculomotor nerve in the interpeduncular cistern and the endoscopic endonasal transethmoidopterygoidosphenoidal approach to expose the oculomotor nerve within the cavernous sinus. RESULTS: The extraorbital part of the oculomotor nerve can be divided into three segments in regard to the cisterns and venous spaces that are being transected: the interpeduncular segment, the cisternal segment, and the intercavernous segment. Of these segments, only the cisternal segment could not be exposed since this segment was located at the initial part of the roof of the cavernous sinus, anterolateral to the posterior clinoid, and posteroinferior to the anterior clinoid processes. Thus, cisternal segment of the oculomotor nerve was considered a blind spot during endoscopic approaches to the skull base. CONCLUSION: We defined the endoscopic anatomy of the CN III and the related neurovascular structures and proposed a new segmental classification of extraorbital oculomotor nerve. Awareness of the endoscopic anatomy and the new segmental classification of the CN III may prove helpful in avoiding the risk of nerve injury during endoscopic endonasal surgery for skull base pathologies.

Endoscopic endonasal approach to the orbital apex and medial orbital wall: anatomic study and clinical applications.

OBJECTIVE: The objective of this study was to recognize the endoscopic anatomy of the orbital apex and medial orbital wall to understand the pure endoscopic endonasal approaches to this region and their clinical applications. These basic information will facilitate our surgical procedures and decrease the rate of surgical complications. MATERIAL AND METHODS: Five fresh adult cadavers were studied bilaterally (N = 10). We used Karl Storz 0- and 30-degree 4-mm, 18-cm, and 30-cm rod-lens rigid endoscopes in our dissections. After cadaver specimen preparation, we approached each orbital apex and medial orbital wall through each nostril. After resection of medial orbital wall, an endoscopic intraorbital approach was performed. RESULTS: The orbita could be exposed by using 0- and 30-degree endoscopes. We preferred to start the approach from the sphenoid sinus instead of transethmoidal approaches that are less familiar to the neurosurgeons. The posterior and anterior ethmoidal arteries are in close relation to the supralateral wall of ethmoid sinus, thus care must be taken not to injure these arteries during dissection. In this way, we can safely expose the whole medial wall of the orbita. Optic canal decompression can be safely done by bone resection starting from the optic nerve toward the optic canal. We continued bone resection from the posterior to the anterior of the medial orbital wall, thus we can perform medial orbitotomy. The intraorbital approach can be done medially by introducing the endoscope between the medial and inferior rectus muscles. CONCLUSIONS: Our anatomic study offered the facility to learn the endoscopic anatomy of the orbital apex and the medial wall of the orbita and understand the appropriate approaches (such as medial orbitotomy and optic canal decompression) to some pathologic lesions of this region. With skilled and experienced hands, it can superimpose many traditional orbital approaches with minimal invasiveness and less postoperative complications.

Endoscopic endonasal transsphenoidal approach to the sellar region: results of endoscopic dissection on 30 cadavers.

AIM: To recognize the endoscopic anatomy of the surgical corridor along the nasal cavity, sphenoidal sinus and the sellar area to delineate the pure endoscopic endonasal transsphenoidal approach (EETSA) to the region of the pituitary gland. MATERIAL AND METHODS: The endoscopic anatomy of the nasal cavity, sphenoid sinus and the sellar region was studied in 30 fresh cadavers (mean age 42.1 / range 18-66) and dissections were performed in a stepwise manner to simulate EETSA to the sellar region. RESULTS: The sphenoid ostium, located 14.9 mm superior to the choana, was identified at the midpoint between the nasal septum and the superior turbinate in 23 specimens. The shape of the sphenoid ostium was linear (35%), fusiform (30%), oval(22%) or circular (13%). The mean width of the pituitary gland was 14.3 mm and the average minimum distance between the internal carotid arteries on both sides ranged between 13 to 22 mm. Following total hypophysectomy in 12 specimens, the width and length of diaphragma sellae was measured 10.83 and 5.83 mms respectively. CONCLUSION: This study documents that variations are common in nasal, sphenoidal and sellar phases of the trans-sphenoidal approach. Detailed knowledge of the basic anatomical relationships through the view of the endoscope and performing endoscopic dissections in large number of specimens will facilitate the endoscopic surgical procedures and decrease the rate of surgical complications.

Extended endoscopic endonasal approach to the anterior cranio-vertebral junction: anatomic study.

OBJECTIVE: Our aim in this study was to identify the endoscopic anatomy of the anterior cranio-vertebral junction to be able to perform minimal invasive endoscopic surgical procedures to this region (such as dens resection) safely with better postoperative performance of the patients. MATERIAL AND METHODS: Five fresh adult cadavers were studied (n=5). We used Karl Storz 0 and 30 degree, 4mm, 18 cm and 30 cm rod lens rigid endoscope in our dissections. After cadaveric specimen preparation, we approached the anterior cranio-vertebral junction by binostril extended endoscopic endonasal approach. RESULTS: The cranio-vertebral junction was located by orientating the endoscope between -10 to +10 degrees. The rhinopharynx was widely exposable after resection of the vomer. The safe lateral limit of this approach was the occipital condyles and foramen lacerum. We could perform odontoid process resection with a pure endoscopic endonasal approach. CONCLUSION: Our anatomic study offered the facility to learn the endoscopic anatomy of the anterior cranio-vertebral junction and understand the appropriate approaches to this region. Our approach is appropriate for treatment of some pathologies of this region, with less invasiveness compared to the traditional transoral approach.

Middle fossa approach: microsurgical anatomy and surgical technique from the neurosurgical perspective.

BACKGROUND: The purpose of this study was to call attention to the subtemporal approach directed through the petrous apex to the IAM. We studied the microsurgical anatomy of the middle floor to delineate a reliable angle between the GSPN and the IAM to precisely localize and expose the IAM from above. A new technique for the elevation of middle fossa floor in an anterior-to-posterior direction has also been examined in cadaveric dissections and performed in surgery. METHODS: The microsurgical anatomy of the middle fossa floor was studied in 10 adult cadaveric heads (20 sides) after meatal drilling on the middle fossa. Five latex-injected specimens were dissected in a stepwise manner to further define the microsurgical anatomy of the middle fossa approach. The middle fossa approach is illustrated in a patient for the decompression of the facial nerve to demonstrate the surgical technique and limitations of bone removal. RESULTS: Elevation of middle fossa dura in an anterior-to-posterior direction leads to early identification of the GSPN, where the nerve passes under V3. The most reliable and easily appreciated angle to be used in localizing the IAM is between the IAM and the long axis of the GSPN, which is approximately 61 degrees . Beginning drilling the meatus medially at the petrous ridge is safer than beginning laterally, where the facial and vestibulocochlear nerves become more superficial. The cochlea anteromedially, vestibule posterolaterally, and superior semicircular canal posteriorly significantly limit the bone removal at the lateral part of the IAM. CONCLUSIONS: The surgical technique for the middle fossa approach which includes an anterior-to-posterior elevation of middle fossa dura starting from the foramen ovale and uses the angle between the IAM and the long axis of the GSPN to localize the meatus from above may be an alternative to previously proposed surgical methods.

The effects of systemic and intratumoral interleukin-12 treatment in C6 rat glioma model.

OBJECTIVE: Cytokine based immunotherapy has long been an exciting field for many investigators aiming to provide an effective alternative treatment modality for glioma management. Among these cytokines, interleukin-12 (IL-72) plays a crucial role in mediating inflammatory and antitumoral activity on the host defence. We have investigated the therapeutic role of systemic and local delivery of IL-12 in C6 rat glioma model and compared these two modalities. METHODS: The donor C6 glioma cells were injected stereotactically to 32 Wistar rats and right frontal tumor formation was established in all subjects. The rats were evenly divided into four groups as intratumoral (i.t.) control group (Group IA), intraperitoneal (i.p.) control group (Group IB), i.t. treatment group (Group II) and i.p. treatment group (Group III). Magnetic resonance imaging were performed to 72 rats (three from each group) on the seventh post-inoculation day. Recombinant mouse IL-12 (rmIL-12) was administered via i.t. (0.1 microg 5 microl/day/rat) and i.p. (0.1 microg 20 microl/day/rat) routes to treatment groups between days 9 and 11 following tumor inoculation, for 3 consecutive days. The rats which were unresponsive to the external stimuli, unable to feed themselves or having severe neurological impairment were decapitated and the specimens were histopathologically examined. RESULTS: The subjects of Group ILL (i.p.) showed a statistically significant prolongation in survival time (mean = 39 days) when compared to the control group (mean = 31.7 days) (p = 0.035) and Group II (i.t.) (mean = 24.5 days) (p = 0.005). Histopathologic examination of Group III revealed markedly increased intratumoral and peritumoral lymphocyte infiltration compared with the other groups. CONCLUSION: This study demonstrated that systemic administration of IL- 12 in C6 glioma model in rats prolongs the survival, probably by stimulating the cellular immunity leading to lymphocytic infiltration.

Cervical intradural ventral arachnoid cyst resected via anterior corpectomy with reconstruction: a case report.

UNLABELLED: Intradural arachnoid cysts are rare lesions that frequently arise posterior to the spinal cord in the thoracic spine region. Those located at the cervical spine level, anterior to the spinal cord are even rarer. The usual treatment of symptomatic intradural spinal cysts involves surgical removal through a posterior approach using a laminectomy or laminotomy. However, ventrally located intradural cysts are frequently not amenable to complete resection without undue manipulation of the cord and aggressive removal through a posterior approach may result in spinal cord injury. The authors present a 29-year-old male harbouring an intradural ventral cervical arachnoid cyst which was successfully resected via an anterior approach with corpectomy and reconstruction. CONCLUSION: For purely ventral cervical intradural arachnoid cysts, which compress the spinal cord dorsally, an anterior approach can allow access to the lesion without any need for intraoperative manipulation of the spinal cord. For such cases, the anterior approach prevents the consequent risk of neurological injury due to posterior approaches.

Neuronal nitric oxide synthase expression in glial tumors: correlation with malignancy and tumor proliferation.

INTRODUCTION: Increased vascular permeability, vasodilatation, neovascularization and free radical injury in malignant tumors and adjacent normal tissues are believed to be mediated by nitric oxide (NO). High levels of neuronal nitric oxide synthase (nNOS) have been demonstrated in cultured and intracerebral cells. Our aim was to investigate nNOS expression in human glial tumors and to assess its correlation with the histologic grade and proliferative potential. METHODS: Tissue specimens were obtained from 29 patients with supratentorial astrocytomas [15 glioblastoma multiforme (GBM), six anaplastic astrocytomas (AA) and eight low grade astrocytomas (LGA)] diagnosed and classified according to the current WHO classification of nervous system tumors. Immunohistochemical staining was performed in paraffin embedded specimens with polyclonal anti-nNOS antibody, and the levels of nNOS expression was evaluated as slight, moderate or dense on the basis of intensity and the extent of distribution of nNOS immunoreactivity. Proliferative potential was evaluated with immunostaining for Ki-67. RESULTS: There was a significant positive correlation between the histologic grade and nNOS expression in terms of intensity and the extent of distribution of nNOS immunoreactivity (p<0.05). Greater values of Ki-67 indices were demonstrated in tumors with higher nNOS expression, indicating a positive correlation between proliferative potentials and expression of nNOS immunoreactivity. CONCLUSION: Our study suggests that nNOS expression is increased in glial tumors, which was significantly correlated with histologic grade and proliferative potential. NO overproduction due to overexpression of nNOS activity, seems to have significant correlation with malignancy in glial tumors, and may provide another target for anti-proliferative therapy in the future.

Cervical intradural lipoma with associated hemivertebra formation at C6 level: a case report.

UNLABELLED: INTRODUCTION AND CASE DESCRIPTION: Intramedullary lipomas are rare tumours of the spinal cord and account for about 1% of all spinal neoplasms. These lesions can occur anywhere along the length of spinal cord, but are frequently localized to the lower thoracic and lumbosacral levels. The authors present a 18-year-old female with intractable shoulder and neck pain and progressive weakness in the upper extremities, harbouring a cervical intradural lipoma with intramedullary extension, along with concomitant scoliosis. CONCLUSION: Despite its benign nature, surgical treatment of these lesions in symptomatic patients generally provides satisfactory relief of symptoms. Radical removal of spinal intradural lipomas is not recommended since attempts at complete excision carry an unacceptable risk of postoperative morbidity and sufficient decompression with or without duraplasty generally provides a successful clinical outcome.

Late decompression in patients with acute facial nerve paralysis after temporal bone fracture.

OBJECTIVE: The aim of this paper was to address the management of acute facial nerve paralysis after temporal bone fracture and the outcomes of late decompression. METHODS: The study design was a retrospective review of eight patients who underwent late decompression of acute facial nerve paralysis due to temporal bone fracture involving the geniculate region. Pre-operative electrophysiological testing showed total degeneration of the facial nerve in all patients. The mean operation period was 70.1 +/- 54.8 days after the trauma. A pure middle fossa approach and combined approach included middle cranial fossa and transmastoid approaches and were used in six and two patients, respectively. Evaluation of the facial nerve function was graded according to the House-Brackmann grading scale. RESULTS: The mean follow up period was 5.7 +/- 3.2 years, ranging from 3 months to 10 years. Six patients showed 3 score of House-Brackmann recovery of facial nerve function in long-term follow-up and the last 2 patients still need time for their final House-Brackmann evaluation. CONCLUSIONS: Surgery should be performed if serial electroneurography and electromyography demonstrate more than 90% degeneration and total denervation potentials, respectively, of nerve fibers. Based on the outcomes observed, late facial nerve decompression may have still beneficial effects in patients who could not be operated on early.

Bypass to the intracranial giant or large internal carotid artery aneurysms: superficial temporal artery to middle cerebral artery bypass re-visited.

OBJECTIVE: Hunterian ligation of the internal carotid artery is an acceptable treatment modality for inoperable intracranial carotid aneurysms. Despite the risk of thrombo-embolic complications, ligation together with superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is vital in some patients. Our aim is to present our experience in five patients in whom STA-MCA bypass and balloon occlusion were performed due to inoperable intracranial carotid artery aneurysms. METHODS: During the last five years, five patients with inoperable internal carotid artery (ICA) aneurysms were treated by STA-MCA bypass surgery followed by permanent endovascular ICA occlusion. Patients were selected for bypass surgery on the basis of failing balloon test occlusion. Patients were managed in the intensive care unit after surgical and endovascular procedures. RESULTS: Clinical improvement was noted in all patients and no major complication during the follow-up was seen. Aneurysmal thrombosis was confirmed in all patients. CONCLUSION: Hunterian ligation associated with bypass surgery is an effective treatment method in selected patients. The following points should be considered for a good outcome: (1) experienced surgeon for bypass surgery, (2) experienced neuroradiologist for endovascular occlusion of the parent vessel as close to the aneurysm neck as possible, and (3) judicious postoperative management by means of anticoagulation, fluid replacement, and pressure control.