Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique".

BACKGROUND AND OBJECTIVES: Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers. METHODS: Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump. RESULTS: Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications. CONCLUSION: The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.

The efficacy of preoperative diffusion tensor tractography on surgical planning and outcomes in patients with intramedullary spinal tumor.

PURPOSE: The aim of this study was to investigate the efficacy of diffusion tensor tractography (DTT) of spinal cord on surgical planning and postoperative neurological outcomes in patients with spinal intramedullary tumors. METHODS: The study was conducted retrospectively from the radiological and clinical data of our hospital database. Patients with intramedullary spinal cord tumors who underwent diffusion tensor imaging for spinal cord lesions were selected between 2019 and 2022. Demographic characteristics and intraoperative neurophysiological monitoring data were evaluated. The McCormick scale was used to grade the pre- and postoperative neurological status of the patients. The tumoral lesions were categorized into 3 types according to the fiber course on DTT. RESULTS: Eleven patients were found to have radiological findings that were compatible with intramedullary tumor; eight (72.7%) of them ultimately underwent surgery following being approved as surgical candidates in the spinal diffusion tensor imaging studies. Six cases had Type 1, one case had Type 2, and 4 cases had Type 3 tumors according to the fiber course. All Type 1 tumors were classified as resectable and all of them were gross totally resected. Type 2 lesion that was rated as resectable by DTI was subtotally resected. Type 3 lesions were followed without surgery except the one with tumoral progression and neurological deficit. The postoperative neurological outcomes were compatible with intraoperative neurophysiological monitoring results. CONCLUSION: Diffusion tensor imaging and tractography may be beneficial regarding the selection of patients suitable for surgery and in the subsequent surgical planning.

Case report: Spinal drop metastasis of IDH-mutant, 1p/19q-codeleted oligodendroglioma.

Background: Symptomatic spinal metastases of oligodendroglioma are rare. Moreover, none of the previously published cases demonstrated the typical IDH mutation and 1p/19q-codeletion for this glial tumor. This case presents an IDH mutant, 1p/19q-codeleted oligodendroglioma with multiple spinal drop metastases. Case description: We report a case of a 55-year-old woman with left frontal grade 3 oligodendroglioma diagnosed 3 years ago. No tumor recurrence was observed in post-operative follow-up MRI examinations. However, she was admitted to our institution again with severe low back pain. Gadolinium enhanced MRI of the spine revealed an intradural, extramedullary metastatic lesion between T11-L1 levels and multiple enhancing metastatic tumor deposits around cauda equine roots between L4-S1. T11-T12 midline laminectomy was performed and gross total resection of metastatic lesions was achieved. Final histological diagnosis of the spinal lesions was WHO Grade 3 Oligodendroglioma, IDH-mutant, 1p/19q-codeleted. Conclusion: This case is the first molecularly-defined spinal metastatic oligodendroglioma. The possibility of drop metastasis should be kept in mind in oligodendroglioma patients with spinal cord-related symptoms. There is no standard approach for the diagnosis and treatment of spinal metastases of this type of glial tumor.

Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study.

BACKGROUND: There is an increased attention to stroke following SARS-CoV-2. The goal of this study was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients. METHODS: This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines. FINDINGS: We received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke. INTERPRETATION: The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients. FUNDING: None.

Surgical management of spinal intramedullary tumors: Ten-year experience in a single institution.

Despite their rare occurrence, intramedullary spinal cord tumors can cause considerable morbidity and mortality without treatment. Timing of surgery, extent of resection and selection of favorable treatment option are important considerations for a good surgical outcome. In this clinical study, we report our patient series and convey our treatment strategy. We retrospectively reviewed 91 patients with primary intramedullary spinal cord tumors who underwent microsurgical resection at our institution between 2008 and 2018. Data were collected consisting of age, sex, location and histology of tumor, extent of resection, presenting symptoms and neurological outcomes. Modified McCormick Scale was used to assess neurological status of patients. 47 female and 44 male patients were followed-up for a mean period of 35.7 months. The most frequent pathological diagnosis was ependymoma in 56 patients, followed by astrocytoma in 21 and hemangioblastoma in 5 patients. The rest of the tumors consisted of 3 cavernomas, 3 mature cystic teratomas, 2 PNET, one epidermoid tumor. Gross total resection was achieved in 67 patients, while subtotal resection and biopsy was performed in 15 and 9 respectively. The most commonly involved localization was cervical (n = 39), followed by thoracic region (n = 24). Despite immediate postoperative worsening of neurological status, a great number of patients improved at the last follow-up. Gross total resection remains the primary goal of treatment while adjuvant radiation and/or chemotherapy may be alternative options for high grade tumors. Preoperative neurological status was the most important and the strongest predictor of functional outcome.

Combined Spinal Arteriovenous Malformation and Spinal Dysraphism.

BACKGROUND: Spinal vascular malformations as a group are rare, and coexistence of a spinal arteriovenous malformation (AVM) in or around the spinal dysraphism is extremely rare. We report 2 cases of combined spinal dysraphism and vascular malformations of the spinal cord. CASE DESCRIPTION: The first case was an AVM located in a filum terminale lipoma fed by the artery of the filum terminale. This case was managed by multiple endovascular embolizations followed by surgery. The second case was an AVM located in a lumbar lipomyelocele managed by endovascular embolization. These cases illustrate the imaging findings of a rare entity and present the diagnostic and therapeutic challenges. CONCLUSIONS: Endovascular embolization combined with surgical resection is the most commonly used treatment for spinal dysraphism with spinal cord AVM. Careful analysis of spinal angiography is necessary owing to the distorted vascular and surgical anatomy of the region affected by spinal dysraphism.

Which is better Stainless Steel or Titanium alloy?

AIM: To investigate immunologic reactions after implantation of stainless steel (SS) alloy and titanium (Ti) alloy in a rat model. Macrophage and cytokine responses have been reported after the in vivo and in vitro application of different biomaterials. MATERIAL AND METHODS: Wistar albino rats after an exploration of the thoracolumbar paravertebral muscle tissue of the subjects, group I underwent a sham surgery, and groups II and III were implanted Ti alloy and SS alloy rods respectively. The CD4, CD8, CD25 (IL-2R) (lymphocyte and CD4 gate), CD4+CD8+ and CD4+CD25+Foxp3+ (Tregs), IL-4, IL-10, IL-6, IL-17A, TGF-ß, TNF-α in the blood were analyzed. RESULTS: CD4, CD25 (IL-2R), CD4+CD8+ and Tregs levels were lower in the Group III compared to the sham and Group IIs. IL-6, IL-17A, TGF-ß and TNF-α levels in the G III showed a significant increase on all days in comparison with the sham and Group II. IL-4 and IL-10 levels, were lower in the Group III than those in the Group II; and a significant decrease was observed in the IL-10 level. While there was a reduction in IL-6 and IL-17A levels in the Group II as opposed to the sham group. CONCLUSION: As opposed to SS alloy, Ti alloy suppresses the development of inflammations by inhibiting proinflammatory response; strengthens the humoral immune system by intensifying the antibody-dependent immune response; triggers the development of immune tolerance by regulating the immune response; and activates the mechanism that prevents immune response-related damage from occurring.