A Novel Approach for Free, Affordable, and Sustainable Microsurgery Laboratory Training for Low- and Middle-Income Countries: University of Wisconsin-Madison Microneurosurgery Laboratory Experience.

BACKGROUND AND OBJECTIVES: In low- and middle-income countries (LMICs), approximately 5 million essential neurosurgical operations per year remain unaddressed. When compared with high-income countries, one of the reasons for this disparity is the lack of microsurgery training laboratories and neurosurgeons trained in microsurgical techniques. In 2020, we founded the Madison Microneurosurgery Initiative to provide no-cost, accessible, and sustainable microsurgery training opportunities to health care professionals from LMICs in their respective countries. METHODS: We initially focused on enhancing our expertise in microsurgery laboratory training requirements. Subsequently, we procured a wide range of stereo microscopes, light sources, and surgical instrument sets, aiming to develop affordable, high-quality, and long-lasting microsurgery training kits. We then donated those kits to neurosurgeons across LMICs. After successfully delivering the kits to designated locations in LMICs, we have planned to initiate microsurgery laboratory training in these centers by providing a combination of live-streamed, offline, and in-person training assistance in their institutions. RESULTS: We established basic microsurgery laboratory training centers in 28 institutions across 18 LMICs. This was made possible through donations of 57 microsurgery training kits, including 57 stereo microscopes, 2 surgical microscopes, and several advanced surgical instrument sets. Thereafter, we organized 10 live-streamed microanastomosis training sessions in 4 countries: Lebanon, Paraguay, Türkiye, and Bangladesh. Along with distributing the recordings from our live-streamed training sessions with these centers, we also granted them access to our microsurgery training resource library. We thus equipped these institutions with the necessary resources to enable continued learning and hands-on training. Moreover, we organized 7 in-person no-cost hands-on microanastomosis courses in different institutions across Türkiye, Georgia, Azerbaijan, and Paraguay. A total of 113 surgical specialists successfully completed these courses. CONCLUSION: Our novel approach of providing microsurgery training kits in combination with live-streamed, offline, and in-person training assistance enables sustainable microsurgery laboratory training in LMICs.

Microsurgical resection of a large petroclival meningioma via translabyrinthine approach combined with middle fossa craniotomy.

Petroclival meningiomas arise from the upper two-thirds of the clivus at the petroclival junction and are reached via various approaches. As petroclival meningiomas expand, they displace the brainstem and basilar artery toward the contralateral side. Because of their proximity to critical structures and deep skull base location, surgical treatment is challenging. Although several approaches have been introduced, their rationales vary. Herein, the authors demonstrate microsurgical resection of a large petroclival meningioma via a translabyrinthine approach combined with middle fossa craniotomy. For each approach, the pros and cons should be carefully evaluated based on the patient's presentation and lesion characteristics. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21253.

How I do it: management of M2 tear injury caused by drilling during intradural anterior clinoidectomy for microsurgical clipping of intracranial aneurysms.

BACKGROUND: High-speed drilling is associated with potential injury to neurovascular structures, particularly during intradural drilling of the anterior clinoid process. METHOD: During an anterior clinoidectomy, a cotton patty and middle cerebral artery branches became inadvertently wrapped around the bit, causing a tear on the inferior M2 trunk. Following temporary clipping of the internal carotid artery, the tear was identified. Temporary clips were placed proximally and distally. The tear was then repaired with interrupted microsutures. CONCLUSION: Extreme care should be exercised during clinoidectomy. Should small vascular injury occur, direct microsuturing can be a good alternative to sacrificing or implantation anastomosis repair.

Evaluation of the Association between Lumbar Spinal Stenosis and Lumbar Subcutaneous Fat Tissue Thickness by MRI: A Novel Perspective.

OBJECTIVE: To evaluate whether lumbar subcutaneous fat tissue thickness (LSFTT) on midsagittal magnetic resonance imaging (MRI) is associated with lumbar spinal stenosis (LSS). STUDY DESIGN: Observational cross-sectional study. PLACE AND DURATION OF STUDY: Department of Radiology and Neurosurgery, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey between January 2018 and December 2020. METHODOLOGY: The study group included 79 patients, who had undergone surgery for lumbar spinal stenosis. The control group included MRI scans of 80 individuals without lumbar spinal stenosis. Association between LSFTT and LSS was analysed through a comparison of both the groups. RESULTS: The agreement between the two observers was found to be very good agreement with a two-way mixed intra-class correlation coefficient of 0.986 or higher (p <0.001). There was statistically significant differences between the LSS and non-LSS groups for both L5-S1 and L4-5 level measurements, p=0.001, and p=0.004, respectively. L5-S1 level measurements in the LSS group showed 29% increase in average with respect to the non-LSS group; and in L4-L5 level measurements, the increase was 40% in median. Females exhibited significantly higher values in both levels, (p <0.001 and p <0.001, respectively). CONCLUSIONS: Lumbar subcutaneous fat tissue thickness is significantly associated with lumbar spinal stenosis. Measuring LSFTT on mid-sagittal MRI is an easily applicable, reproducible alternative method for predicting LSS. Key Word: Lumbar, Spinal canal, Stenosis, Subcutaneous fat tissue, Magnetic resonance imaging.

The Association between the Timing of Shunt Placement and Shunt Infection in Hydrocephalus Associated with Myelomeningocele.

AIM: To determine whether the timing of shunt placement affects shunt infection rate in hydrocephalus associated with myelomeningocele (MMC). MATERIAL AND METHODS: The cases of 67 consecutive patients who underwent MMC repair and ventriculoperitoneal (VP) shunt placement between 2010 and 2017 were analyzed, retrospectively. Shunt infection rates were compared for three different approaches: simultaneous shunting (MMC repair and shunting in the same session; n=22), early shunting (shunting in the first week after MMC repair; n=21), and delayed shunting (shunting in the second week after MMC repair; n=24). RESULTS: Three patients in the simultaneous shunting group (13.6%) and two patients in the early shunting group (9.5%) developed shunt infection, whereas no such infections occurred in the delayed shunting group (p > 0.05). CONCLUSION: While the shunt infection rates for the simultaneous, early and delayed shunting groups were not significant, it is of interest that no shunt infections occurred in the delayed shunting group. Investigation with a larger number of patients is warranted to assess whether delayed shunting might reduce the risk of shunt infection.

Factors Affecting Prognosis in Patients With Spontaneous Supratentorial Intracerebral Hemorrhage Under Medical and Surgical Treatment.

Spontaneous intracerebral hemorrhage (ICH) is a vascular brain disease that causes very high rates of death and disability. Whether surgical or medical treatment is more appropriate is controversial.The purpose of the study was to examine the morbidity and mortality rates of surgical and medical therapy and their differences in order to determine which patients should be operated.In our study, the authors selected randomly and evaluated retrospectively 49 patients who were operated in Haydarpasa Numune Research and Education Hospital Neurosurgery Clinic and 51 patients who received medical therapy at Neurology Clinic for spontaneous supratentorial ICH between January 2007 and December 2011.The authors documented a detailed history of each patient featuring their neurological examination, Glasgow Coma Scale (GCS), Modified Rankin Disability Scale (MRDS), imaging, age, gender, and history of stroke, hypertension, diabetes mellitus, smoking and alcohol use, aspirin, or coumadin usage.As a result, the mortality rate found in our study was similar to previous studies (49%). Mortality of patients who underwent surgery (63%) found a higher rate of disability. This is because hematoma of the patients who were operated on larger volumes and diameters, GCS lower than and the higher MRDS scores, higher rates of herniation is connected. The authors concluded that very early operation does not create a difference in treatment between mortality rates. The authors observed that the most important factors for the prognosis of ICH patients whether operated or not are the GCS of patients at the time of arrival to the hospital and the nature of the hematoma.

Anterior third ventricular height and infundibulochiasmatic angle: two novel measurements to predict clinical success of endoscopic third ventriculostomy in the early postoperative period.

OBJECTIVE: The authors sought to develop a set of parameters that reliably predict the clinical success of endoscopic third ventriculostomy (ETV) when assessed before and after the operation, and to establish a plan for MRI follow-up after this procedure. METHODS: This retrospective study involved 77 patients who had undergone 78 ETV procedures for obstructive hydrocephalus between 2010 and 2015. Constructive interference in steady-state (CISS) MRI evaluations before and after ETV were reviewed, and 4 parameters were measured. Two well-known standard parameters, fronto-occipital horn ratio (FOHR) and third ventricular index (TVI), and 2 newly defined parameters, infundibulochiasmatic (IC) angle and anterior third ventricular height (TVH), were measured in this study. Associations between preoperative measurements of and postoperative changes in the 4 variables and the clinical success of ETV were analyzed. RESULTS: Of the 78 ETV procedures, 70 (89.7%) were successful and 8 (10.3%) failed. On the preoperative MR images, the mean IC angle and anterior TVH were significantly larger in the successful procedures. On the 24-hour postoperative MR images of the successful procedures, the mean IC angle declined significantly from 114.2° to 94.6° (p < 0.05) and the mean anterior TVH declined significantly from 15 to 11.2 mm (p < 0.05). The mean percentage reduction of the IC angle was 17.1%, and that of the anterior TVH was 25.5% (both p < 0.05). On the 1-month MR images of the successful procedures, the mean IC angle declined significantly from 94.6° to 84.2° (p < 0.05) and the mean anterior TVH declined significantly from 11.2 to 9.3 mm (p < 0.05). The mean percentage reductions in IC angle (11%) and anterior TVH (16.9%) remained significant at this time point but were smaller than those observed at 24 hours. The 6-month and 1-year postoperative MR images of the successful group showed no significant changes in mean IC angle or mean anterior TVH. Regarding the unsuccessful procedures, there were no significant changes observed in IC angle or anterior TVH at any of the time points studied. Reduction of IC angle and reduction of anterior TVH on 24-hour postoperative MR images were significantly associated with successful ETV. However, no clinically significant association was found between FOHR, TVI, and ETV success. CONCLUSIONS: Assessing the IC angle and anterior TVH on preoperative and 24-hour postoperative MR images is useful for predicting the clinical success of ETV. These 2 measurements could also be valuable as radiological follow-up parameters.

Ventriculoperitoneal Shunting in Alobar Holoprosencephaly: Does it Work Even When Patient Has No Sign of Raised Intracranial Pressure?

Holoprosencephaly (HPE) is a developmental anomaly of forebrain characterized by a failure of division of the embryonic forebrain into hemispheres. It is associated with a set of facial anomalies at a rate of 80%. Survival rate, particularly in alobar HPE, is quite low. Alobar HPE is usually associated with a large dorsal cyst which might eventually lead to hydrocephalus and raised intracranial pressure. Placement of ventriculoperitoneal (VP) shunt has been reported to be beneficial in symptomatic hydrocephalus accompanying HPE. Here we report a preterm infant born with alobar HPE and undergoing VP shunt placement although there was no sign of raised intracranial pressure. She is 12 months old now having near-normal developmental progress. This case has revealed that the placement of VP shunt, particularly inserting the catheter tip into dorsal cyst of HPE, might be beneficial and contribute to the survival and further brain development even in the absence of the signs of raised intracranial pressure.

Pregabalin treatment for neuropathic pain may damage intervertebral disc tissue.

The aim of the present study was to determine whether pharmaceutical preparations with pregabalin (PGB) as an active ingredient, which are widely prescribed by clinicians, exert toxic effects on human primary nucleus pulposus (NP) and annulus fibrosis (AF). Primary human cell cultures were obtained from intact (n=6) and degenerated (n=6) tissues resected from the two groups of patients. Different doses of PGB were applied to these cultures and cells were subjected to molecular analyses at 0, 24 and 48 h. Cell vitality, toxicity and proliferation were assessed using a spectrophotometer. The expression of chondroadherin (CHAD), a (member of the NP-specific protein family), hypoxia-inducible factor-1α (HIF-1α) and type II collagen (COL2A1) was measured using reverse transcription-quantitative polymerase chain reaction. The results revealed that cell intensity increased in a time-dependent manner and cell vitality continued in the cultures without pharmaceuticals. Cell proliferation was suppressed in the PGB-treated cultures independent from the dose and duration of application. PGB was demonstrated to suppress the expression of CHAD and HIF-1α. In contrast, COL2A1 gene expression was not revealed in any experimental group. The present study utilized an in vitro model and the PGB active ingredient used herein may not be representative of clinical applications; however, the results demonstrated that PGB has a toxic effect on NP/AF cell cultures containing primary human intervertebral disc tissue. In summary, the use of pharmacological agents containing PGB may suppress the proliferation and differentiation of NP/AF cells and/or tissues, which should be considered when deciding on an appropriate treatment regime.

Is the Thoracolumbar Injury Classification and Severity Score (TLICS) Superior to the AO Thoracolumbar Injury Classification System for Guiding the Surgical Management of Unstable Thoracolumbar Burst Fractures without Neurological Deficit?

AIM: To determine whether the Thoracolumbar Injury Classification and Severity Score (TLICS) and the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine Thoracolumbar Injury Classification System have any superiority to each other regarding the reliability of their recommendations in the surgical management of unstable thoracolumbar burst fractures. MATERIAL AND METHODS: Fifty-five consecutive patients with thoracolumbar burst fractures undergoing instrumentation between 2010 and 2015 were analyzed retrospectively. TLICS and AO systems were compared based on patients" American Spinal Injury Association (ASIA) scores and they were analyzed for their safety and reliability. RESULTS: A total of 55 patients were studied. Neurological deficits were detected in 18 patients and the remaining 37 patients had normal neurological functions. All the patients with neurological deficits received > 4 points according to TLICS. There were 14 patients with incomplete spinal cord injury and all of them received > 4 points according to TLICS (p < 0.01). On the other hand; 8 of these 14 patients received 4 points according to the AO system. None of the 37 patients without neurological deficit received < 4 points of TLICS whereas 18 of these 37 patients received 3 AO points, to whom AO recommends conservative treatment despite the fact that they had unstable burst fractures (p < 0.01). CONCLUSION: Recommendations of TLICS might be more reliable than those of AO particularly for guiding the surgical management of unstable thoracolumbar burst fractures without neurological deficit. However, this conclusion needs to be verified with further multicenter prospective studies.

Remote Cerebellar Haemorrhage Occurring after Transcranial Pituitary Surgery.

Post supratentorial and spinal surgeries, in rare cases, Remote Cerebellar Haemorrhage (RCH) develops as a complication. Although the exact aetiology of RCH remains uncertain, excessive drainage of the Cerebrospinal Fluid (CSF) is accepted as the most possible cause. It has been suggested that overdrainage of CSF leads to stretching and resultantly tearing of the cerebellar veins. Early diagnosis and appropriate management decrease mortality and morbidity significantly. In this report, we present a case of RCH encountered on the third postoperative day of transcranial pituitary surgery and discuss the possible causative factors. Excessive loss of CSF is considered to be the major cause of RCH. To our knowledge this is the first case of RCH seen after transcranial macroadenoma surgery reported in the literature so far.

Unilateral Vision Loss without Ophthalmoplegia as a Rare Complication of Spinal Surgery.

Postoperative visual loss is an extremely rare complication of nonocular surgery. The most common causes are ischemic optic neuropathy, central retinal artery occlusion, and cerebral ischemia. Acute visual loss after spinal surgery is even rarer. The most important risk factors are long-lasting operations, massive bleedings, fluid overload, hypotension, hypothermia, coagulation disorders, direct trauma, embolism, long-term external ocular pressure, and anemia. Here, we present a case of a 54-year-old male who developed acute visual loss in his left eye after a lumbar instrumentation surgery and was diagnosed with retinal artery occlusion.

Might Trauma Be a Triggering Factor for Craniofacial Fibrous Dysplasia?

Fibrous dysplasia (FD) is a rare, benign disease of unclear etiology where normal bone is replaced with abnormal fibrous and weak osseous tissue. Any bone of the skeleton might be involved but skull is one of the most commonly affected sites. Fibrous dysplasia is known to be caused by a genetic mutation leading to inappropriate proliferation and differentiation of osteoblastic cells. However; it is not known whether any triggering factor exists which might contribute to this genetic mutation. The authors postulated that trauma might be a triggering factor for this disease. Trauma, as a triggering factor, has not been reported to be clearly linked to FD in the literature so far. Through this perspective; the authors report a patient of fronto-orbital fibrous dysplasia developing 6 years after a fronto-orbital skull fracture, at the same localization of the fracture line.

Lipomatous meningioma: A rare subtype of benign metaplastic meningiomas.

Lipomatous meningiomas are extremely rare subtypes of benign meningiomas and are classified as metaplastic meningioma in the World Health Organization classification. We present a 77-year-old man presented with the history of a gradually intensifying headache for the last 3 months. A right frontoparietal mass was detected on his cranial magnetic resonance imaging. The patient was operated on via a right frontoparietal craniotomy, and histopathological diagnosis was lipomatous meningioma. Distinctive characteristics of lipomatous meningiomas were discussed with special emphasis to importance of immunohistochemical examinations, particularly for its differentiation from the tumors showing similar histology though having more aggressive character.

Forestier syndrome presenting with dysphagia: case report of a rare presentation.

Diffuse idiopathic skeletal hyperostosis (DISH) (Forestier syndrome) is a rheumatologic disease, the etiology of which is not exactly known. It is characterized by spinal osteophyte formations resulting from the ossification of the paravertebral ligaments and muscles. Anterior longitudinal ligament is the usual site of involvement and the frequency of the disease increases after the 5th decade. Lower cervical segments are the most frequently involved regions whereas the upper cervical involvement leading to dysphagia is very rare. In this report, a 77-year-old patient with Forestier syndrome in upper cervical region presenting with dysphagia was presented. Anterior cervical osteophyte resection was performed with no need for discectomy, fusion or stabilization. The patient showed a significant improvement in his all preoperative symptoms, and no recurrence was detected at 1-year follow-up.

Spontaneous Subdural Haematoma Developing Secondary to Arachnoid Cyst Rupture.

Arachnoid cysts are congenital, benign, non-neoplastic, extra-axial intra-arachnoidal lesions. Arachnoid cysts rarely become symptomatic, with bleeding. Intracranial haemorrhage as a complication of arachnoid cyst is a very rare condition. It is well-known that mid-cranial fossa cysts might cause intracerebral haemorrhage or subdural haematoma secondary to traumas. However, the occurrence of spontaneous subdural haematoma secondary to arachnoid cysts, developing without any trauma, is even rarer. A 17-year-old boy presenting with diplopia and headache, with no history of trauma, was diagnosed with left temporal lobe arachnoid cyst and left fronto-parietal subdural haematoma. He was operated on, solely for his haematoma, with no intervention performed for the arachnoid cyst. Authors suggest that it is sufficient to perform an operation for the haematoma only -without arachnoid cyst resection- if there is no clinical presentation specific to the arachnoid cyst itself.

Remote Cerebellar Haemorrhage after Burr Hole Drainage of Chronic Subdural Haematoma: A Case Report.

Remote cerebellar haemorrhage (RCH) is an unusual complication of supratentorial neurosurgical procedures. Even the rarer is cerebellar haemorrhage occurring after supratentorial burr hole drainage of Chronic Subdural Haematoma (CSDH). The exact mechanism is still unclear despite some possible causative factors such as rapid evacuation of haematoma and overdrainage of CSF (Cerebrospinal Fluid). We report a 80-year-old male patient who developed cerebellar haemorrhage after burr hole drainage of left frontoparietal chronic subdural haematoma and discuss the possible aetiological mechanisms through the review of the current literature.

The Effect of Matrix Metalloproteinase-3 on the Prognosis and Biological Behaviour of Meningiomas.

AIM: To analyse the effect of MMP-3 (Matrix Metalloproteinase Enzyme-3)-one of the extracellular matrix proteins- on the prognosis and biological behaviour of meningiomas. MATERIAL AND METHODS: 79 cases of meningioma that were operated in our clinic between 2005 and 2010 were retrospectively analysed. Age, sex, preoperative peritumoral edema, histological subtype, grade, Ki-67 expression, MMP-3 staining pattern and recurrence rate were analysed. Pathological preparations were graded according to the WHO (World Health Organisation) 2007 grading system. RESULTS: Of the MMP-III positive cases; 24 cases (60%) were grade I, 16 cases were grade II. The MMP-3 staining pattern was significantly positive (80%) in grade II meningioma. 14 of the MMP-3 positive cases were atypical meningiomas. Of the 20 cases with high Ki-67 proliferation index (PI), 12 cases (60%) were MMP-3 positive and 8 cases (40%) were MMP-3 negative. Rates of recurrence and preoperative peritumoral edema were high in cases with MMP-3 positivity. CONCLUSION: In this study it was determined that MMP-3 positivity has a strong relationship with meningiomas having an aggressive character. MMP-3 may be used as a proliferation marker for biological behaviour, recurrence rate and prognosis of meningiomas.

The Association between Sagittal Index, Canal Compromise, Loss of Vertebral Body Height, and Severity of Spinal Cord Injury in Thoracolumbar Burst Fractures.

AIM: Our aim was to determine whether a combination of sagittal index (SI), canal compromise (CC), and loss of vertebral body height (LVBH) is associated with the severity of neurological injury in patients with thoracolumbar burst fractures. MATERIALS AND METHODS: Seventy-four patients with thoracolumbar burst fracture undergoing instrumentation between 2010 and 2015 were analyzed retrospectively. The degree of neurological injury was determined using the American Spinal Injury Association (ASIA) scoring system. The association between the morphology of the fracture and the severity of neurological injury was analyzed. RESULTS: There was a strong association between fracture morphology and the severity of neurological injury. Of the patients, 77.5% with SI ≥20°, 81.6% with CC ≥40%, and 100% with LVBH ≥50% had lesion according to ASIA. All of 7 patients with ASIA A had SI ≥20°, CC ≥40%, and LVBH ≥50%. On the other hand, 79% of the patients with ASIA E had SI <20°, 83.7% of the patients with ASIA E had CC <40%, and all of the patients with ASIA E had LVBH <50%. SI, CC, and LVBH were lower in neurologically intact patients (ASIA E), whereas they were higher in patients with neurological deficits (ASIA A, B, C, D) (P = 0.001; P < 0.01). These measurements had 100% negative predictive values and relatively high positive predictive values. CONCLUSION: SI, CC, and LVBH are significantly associated with the severity of neurological injury in patients with thoracolumbar burst fractures. The patients with SI >25°, the patients with CC >40%, and the patients with LVBH >50% are likely to have a more severe neurological injury.

Foramen Magnum Decompression and Duraplasty is Superior to Only Foramen Magnum Decompression in Chiari Malformation Type 1 Associated with Syringomyelia in Adults.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To compare surgical results of foramen magnum decompression with and without duraplasty in Chiari malformation type 1 (CM-1) associated syringomyelia (SM). OVERVIEW OF LITERATURE: The optimal surgical treatment of CM-1 associated with SM is unclear. METHODS: Twenty-five cases of CM-1 with SM were included. There were 12 patients (48%) in the non-duraplasty group and 13 patients (52%) in the duraplasty group. The rate of improvement, state of postoperative SM size, amount of tonsillar herniation, preoperative symptom duration, complications and reoperation rates were analysed. RESULTS: The rate of clinical improvement was significantly higher with duraplasty (84.6%) than without (33.3%, p <0.05). The rate of postoperative syrinx regression was significantly higher in the duraplasty group (84.6%) than in the non-duraplasty group (33.3%, p <0.05). One case in the duraplasty group needed a reoperation compared with five cases in the non-duraplasty group (p =0.059). CONCLUSIONS: Duraplasty is superior to non-duraplasty in CM-1 associated with SM despite a slightly higher complication rate.