Demonstration of Cosmetic Improvement After Cranioplasty Using a Personalized 3D-Printed Mold for Creating Polymethylmethacrylate Implants With a Simplified Process.

BACKGROUND: Although personalized polymethylmethacrylate (PMMA) implant production molds for cranioplasty are costly and time-consuming, they allow for better-quality implants. The researchers quantitatively tested the contribution of simplified, low-cost techniques to cosmetic improvement. METHODS: PMMA prosthesis was placed in a 25-year-old male patient due to osteolysis in the bone flap removed after decompression surgery. A single-sided mold was three-dimensional (3D) printed before the surgery, and the prosthesis was produced during the surgery. In addition, the change in cranial asymmetry was evaluated using a 3D surface scanner after surgery. RESULTS: The mold took half an hour to design and 5 hours to print. The mold cost about 2 dollars. The root means square (RMS) value measured to determine cranial asymmetry decreased from 5.4 mm to 2.8 mm postoperatively. The patient stated that he was pretty satisfied with the cosmetic result. CONCLUSIONS: Simple design techniques developed can offer low-cost, fast-design alternative solutions with satisfactory cosmetic results for low-income countries and patients.

Evaluation of clinical parameters of patients with aneurysmal subarachnoid hemorrhage during long-distance interhospital transport.

BACKGROUND: The objective of the study was to investigate the changes in Glasgow Coma Scale (GCS) score, Fisher's grade, and World Federation of Neurological Surgeons (WFNS) grade that occur during transport of patients with aneurysmal subarachnoid hemorrhage (aSAH) from secondary hospitals to a tertiary care center. METHODS: Seventy-five patients with aSAH who were transported through ground ambulance from secondary hospitals to our tertiary care centers between December 1, 2016, and December 1, 2019, were enrolled in this retrospective study. Data regarding GCS, Fisher's grade, and WFNS grade from both hospitals, patient demographics, and duration and distance of transport were analyzed. RESULTS: The female-to-male ratio was 46: 29 and median patient age was 55.0 years. Median transport time was 3.0 h and median distance traveled was 161.0 kilometers. GCS significantly decreased (p=0.004) and Fisher and WFNS grade significantly increased during transport (p=0.003 and p=0.003, respectively). The change in the WFNS grade during transport, but not GCS score or Fisher's grade, was significantly different between non-intubated patients and intubated patients (p=0.036). CONCLUSION: Significant changes in Fisher's grade, GCS, and WFNS grade occurred during ground transport of patients with aSAH from secondary hospitals to tertiary care centers. These changes in the parameters may affect and change patients future prognoses.

Surgical-Related and Hardware-Related Adverse Effects of Deep Brain Stimulation: A Retrospective Single-Center Analysis.

AIM: To review both the surgical-related, and hardware-related adverse effects of deep brain stimulation (DBS) in a single center over the last five years. MATERIAL AND METHODS: All patients who underwent DBS electrode implantation at the Akdeniz University Hospital during the last five years participated in this study. Demographic information (sex, age, diagnosis, the duration between diagnosis and surgery, comorbid disease) and the date of surgery were collected from an electronic medical database. The adverse effects of DBS were classified into two: surgery-related and hardware-related effects, which were further subdivided based on whether they occurred intraoperatively, in the early postoperative stage, or over a long period time. RESULTS: A database of 47 patients with 90 DBS electrode implants was analyzed in the study. The median age at the time of surgery of all patients was 54 years (range 11-75). Comorbid diseases were recorded in 16 (34%) patients. Out of the total, 33 patients (70.2%) had no adverse effects related to DBS. Surgical-related adverse effects were observed in five patients and of these, one haD an asymptomatic intracerebral hemorrhage (ICH), one had symptomatic ICH, one had both a seizure intraoperatively and an asymptomatic subdural hematoma whereas the other two had non-infectious peri-electrode edema. Hardware-related adverse effects were recorded in nine patients (19.1%). We recorded infections in six (12.7%) patients, erosion without infection in two (4.2%), and both lead fracture and lead malposition in one patient. All long-lasting adverse effects were hardware-related and recorded in eight (19%) patients. CONCLUSION: DBS has been a well-established treatment for movement disorders but is associated with an increased risk of some adverse events which have been analyzed in this study.

Cranially migrated lumbar intervertebral disc herniations: A multicenter analysis with long-term outcome.

OBJECTIVE: Risk factors of cranial migration were investigated in patients with lumbar disc herniation (LDH) that migrated in the cranial direction and the long-term outcomes are discussed in this study. MATERIALS AND METHODS: Patients who underwent surgery for LDH at four different centers between 2012 and 2017 were studied. Extraligamentous discs were located in the lateral part of the posterior longitudinal ligament (PLL) within the spinal canal of the axial plane, and subligamentous discs were located under the PLL. The extent of cranial migration was calculated as a percentage of the height of the migrated corpus. Based on the extent of cranial migration, partial hemilaminectomy or hemilaminectomy was performed at different rates in each patient and the amount of laminectomy performed was recorded. During surgery, all free fragments were attempted to be removed. The appropriate technique was decided intraoperatively, and the surgery was performed on an individual patient basis. RESULTS: Of 1289 patients who underwent surgery for LDH, 654 (50.73%) had caudal migration, 576 (44.68%) had migration at the level of the disc, and 59 (4.57%) had cranial migration. Analysis of 59 patients with cranial migration according to the localization of the disc fragment revealed that 31 had extraligamentous and 28 had subligamentous fragments (P = 0.024). CONCLUSIONS: Extraligamentous intervertebral disc fragments migrate more cranially than subligamentous intervertebral fragments. The anatomy of the PLL that varies along the corpus is the main reason for the weakness of the resistance of the disc material to the dorsolateral region, direction of discrete force vectors, and orientation of the disc fragment due to torsional vertebral movements.

Evaluation of Cortical Brain Parenchyma by Diffusion and Perfusion MRI Before and After Chronic Subdural Hematoma Surgery.

AIM: To evaluate microcirculatory changes in neighboring parenchyma as a result of pressure due to chronic subdural hematoma (CSDH) in early and late periods after hematoma drainage. MATERIAL AND METHODS: The subject group consisted of 25 patients who underwent CSDH drainage. Brain diffusion and perfusion magnetic resonance images (MRIs) were obtained preoperatively, and at 48 hours (early period) and 2 months (late period) postoperatively. Measurements were performed on 1 cm2 regions of interest (ROI) in the neighboring parenchymal tissue. RESULTS: The early postoperative diffusion values showed improvement compared to the preoperative values. The late postoperative values showed improvement compared to the preoperative and early postoperative values. The early postoperative perfusion values showed slight decline compared to the preoperative values. However, the late postoperative values showed improvement compared to the preoperative and early postoperative values. CONCLUSION: The fact that there was an increase in diffusion values from early to late postoperative periods, compared with the preoperative period, indicates that the beneficial effects of surgery increase over time. Brain perfusion was found to be slightly decreased in early postoperative period. Following CSDH drainage, neurological deteriorations are observed in some patients in the early postoperative periods; a slight impairment in perfusion may account for this. However, during the late postoperative period, perfusion was seen to recover prominently.

Smartphones and Programmable Shunts: Are These Indispensable Phones Safe and Smart?

OBJECTIVE: This study aimed to determine whether smartphones affect programmable shunts. METHODS: iPhone 5S (Apple Inc., Cupertino, CA, USA) and Samsung Galaxy S5 (Samsung Electronics, Gumi, South Korea) smartphones were chosen for this study. For both phones, magnetic field mapping was performed with 3-dimensional magnetic scanning systems constructed with high-precision motorized stages, and a Hall effect sensor was used to measure the flux density on the smartphone surface. The distance (h) between the distal outlet of the reservoir and the rugby ball of the Strata valve (Medtronic Inc., Minneapolis, MN, USA) was measured using highly sensitive microanalysis optical method. During optical microanalysis, while keeping a 3-cm distance between the valve and the magnetic generator, the h value (µm) was recorded for different magnetic flux densities (MFDs). Then, direct x-ray radiography was performed for radiologic assessment after each process under different magnetic fields. For analysis of the Codman Certas valve (Codman Neuro, Raynham, MA, USA), the magnet orientation and the angle between the magnet with the tantalum ball were measured with the same optical analysis. RESULTS: Maximum MFDs found 62 G for iPhone 5S and 61 G for Samsung Galaxy S5. When the magnetic generator formed a current at 0, 30, 60, and 90 G, the h values of the Strata valve adjusted to 100 mm H2O opening pressure were 320, 280, 190, and 175 µm, respectively. When the magnetic generator was removed from the environment, the h value returned to 320 µm. In direct graphs taken after each optical analysis at different Gauss values, substitution was not observed at the indicator. The angle in the Codman Certas valve was 123.9°, 112.5°, and 103.6° at the magnetic flux densities of 0, 60, and 90 G, respectively. When the magnetic field was removed (0 G), the angle was still 103.6°, suggesting an irreversible effect in the shunt construct. CONCLUSIONS: Smartphones exert reversible effects on Strata programmable valves without producing remarkable radiologic findings and irreversible effects on Codman Certas valves.

Migration of fragments into the spinal canal after intervertebral polyethylene glycol implantation: an extremely rare adverse effect: Case report.

Percutaneous intervertebral hydrogel (polyethylene glycol) implantation is a current treatment procedure that aims to restore hydration of a degenerated disc. There have been a few studies that claim that polyethylene glycol is successful for pain relief as the intervertebral space restores its hydration and elasticity. This procedure is reported to be indicated for discogenic low-back pain and mild radicular pain as it contributes to disc restoration. In this report, the authors describe the case of a 43-year-old woman who was admitted with low-back and right leg pain. Muscle strength in dorsiflexion of the right ankle and right toe was 3/5. The patient had undergone hydrogel implantation for L4-5 intervertebral disc restoration 2 days prior to presentation. There was a significant increase in the patient's complaints after hydrogel implantation, and acute weakness in the right ankle and toe had developed. Magnetic resonance imaging of the lumbar vertebrae, which was performed before the hydrogel implantation, showed a significant narrowing of the L4-5 disc space height, and a disc herniation that extended to the right neural foramen and caused compression of the dural sac. The patient underwent surgery immediately. The sequestered disc fragment that caused a prominent stenosis in the spinal canal, as well as hydrogel fragments, was removed. There was an improvement in the patient's complaints and motor deficit postoperatively. In this paper, a very rare complication is reported. In patients who have increased pain after intervertebral hydrogel implantation and who develop a neurological deficit, the migration of the applied material into the spinal canal should be considered.

Sacrococcygeal sinus angle: as a new anatomic landmark for the posterior approach of presacral lesions.

PURPOSE: We have discussed the importance of sacrococcygeal sinus angle (SSA), which is a new anatomical landmark in the surgery of presacral lesions. Because of its anatomical structure, the sacrum limits the surgical exposure like a compact barrier for the posterior surgical approach. The main aim of this paper is to explain the anatomical description and clinical importance of SSA in the surgery of presacral lesions. METHODS: Three groups were designated, consisting of ten patients in each group, as early childhood (group 1), late childhood (group 2) and adulthood (group 3). Patients were selected randomly. The degree of SSA measurement was performed between the line tangent to the anterior margin of the first sacral vertebra and the line from the promontorium to the tip of the coccyx. The measurement of SSA was performed on patients' lumbosacral magnetic resonance images. When the SSA forms a triangle via a parallel line starting from the inferior tip of the sacrum and running parallel to the ground, the area of the triangle also covers the field of view of the presacral region. In addition, the sacral region needed to be resected for maximum exposure is also within this area. RESULTS: The mean SSA was measured to be 53.9 ± 11.4° in group 1, 77.8 ± 11.2° in group 2 and 74.5 ± 12.5° in group 3. Intergroup comparisons revealed a significant difference between group 1 and the other two groups statistically. It was found that the SSA was 20° less in group 1 as compared to the other age groups (p = 0.0005). The area of a triangle is calculated using the sine area formula, and according to this formula the area of a triangle increases when the degree of the angle increases, thus comprising larger part of the sacrum. This condition requires more and wide sacral resection to obtain maximum exposure in the presacral zone. CONCLUSIONS: We have observed that the SSA is significantly smaller during early childhood compared with the other age groups. This feature provides an anatomical superiority in this age group for the posterior approach in the surgical treatment of presacral masses.

Spontaneous Rupture of Intracranial Dermoid Cyst Mimicking a Primary Psychiatric Disorder.

We discussed the case of a 14-year-old patient with acute onset of psychiatric symptoms for two months who had been examined and different antipsychotic drugs had been prescribed by several psychiatrists without any neuroradiological imaging. Because of unresponsiveness to the antipsychotic drugs, computed tomography and magnetic resonance imaging were performed which revealed a ruptured intracranial dermoid cyst. The patient underwent surgery and antipsychotic medications were withdrawn in short time. The emphasis of this case is that intracranial lesions can present with neuropsychiatric symptoms and findings only without any neurological deficit or signs.

Free floating ventricular shunt catheter between lateral ventricles: a case report of an unusual ventriculoperitoneal shunt complication.

Ventriculoperitoneal (VP) shunt proximal tip disconnection is rarely seen as a shunt complication. Shunt dysfunction and hydrocephaly can develop due to this disconnection. Presented here is a case of a disconnection of the ventricular catheter from the shunt valve, which passed between both lateral ventricles by free floating in the brain CT. The patient was operated on for hydrocephaly. The dysfunctional shunt valve and peritoneal catheter were removed and a new VP shunt system was implemented. Although some publications report that the ventricular catheter can be disconnected from the shunt valve, can adhere to the intraventricular structures, and can be a source of infection, no studies similar to the current case were found in the literature reporting a free floating ventricular catheter between the lateral ventricles.

How innocent is corpus callosum dysgenesis?

BACKGROUND/AIMS: We aimed to investigate the relationship between corpus callosum dysgenesis (CCD) and associated asymptomatic closed spinal dysraphisms (CSDs). METHODS: 2,840 pediatric patients who were referred to our outpatient clinic between the years 2005 and 2013 with the diagnosis of microcephaly, macrocephaly, congenital hydrocephaly, epilepsy, mental-motor retardation and suspicion of intracranial mass were evaluated. Eighty-five patients were identified with a CCD by cranial magnetic resonance imaging (MRI). The 85 patients with CCD were evaluated by whole spinal vertebral MRI for possible CSD and the results were evaluated. RESULTS: 31/85 (36.4%) patients (20 males, 11 females) were detected to have radiological findings of CSD. The most common radiological finding was a low-lying conus medullaris, either alone, or as part of a multiple pathology in 26 of the 31 patients, followed by diastematomyelia in 16 of 31 cases and spinal lipoma in 4 of the 31 cases. CONCLUSION: When the neuroaxis emerges as a whole, the structures of embryological ectodermal origin and cranial and spinal structures are not independent regions from each other and thus, asymptomatic CSDs have been demonstrated to accompany CCD. In diseases of neural origin in which early diagnosis is of the utmost importance, each case with dysgenesis, diagnosed incidentally or during differential diagnosis, should be evaluated for possible CSD and should be treated with a multidisciplinary approach before any neurological deficit appears.

Is the elapsed time following the placement of a ventriculoperitoneal shunt catheter an individual risk factor for shunt fractures?

In this study, we examined whether the resistance of peritoneal catheters against the retraction force changed over time following shunt placement, and the role of this resistance in shunt fracture is discussed. We investigated peritoneal catheters removed from patients treated with a ventriculoperitoneal shunt because of hydrocephalus; previously, patients underwent shunt revision. The maximum tension, maximum elongation and elongation percentages of the peritoneal catheters were measured. The mean and maximum tension values of the revised peritoneal catheters were increased compared to the unused catheters. The maximum elongation and elongation rates were significantly decreased. The changes in the maximum elongation, elongation rate and tension values were unrelated to the time elapsed after catheter insertion. This finding indicates that the time elapsed following peritoneal catheter placement was not an individual factor based on the strength of the response of the organism to the foreign body and the mechanical trauma exposed in shunt fractures.