A rare disease: a single-center experience of cerebral alveolar echinococcosis in 12 operated patients.

OBJECTIVE: In this study, we have evaluated 12 patients with cerebral alveolar echinococcosis (AE). All patients underwent surgery for cerebral AE. We aimed to demonstrate the relationship between the demographic properties of patients and surgical outcomes as well as surgical suggestions about surgical approaches. PATIENTS AND METHODS: Patients were analyzed according to demographic properties, hepatic/ pulmonary AE lesion existence, symptoms, neurological and radiological examination, histopathological findings, and outcome after treatment. RESULTS: Preoperative diagnosis based on the history of the patient, neurological examination, serological tests, and radiology. When enhanced radiological imaging like MR-Tractography and intraoperative neuromonitoring is combined with precision surgical methods cerebral AE is treatable. Ten of twelve cerebral AE patients had favorable outcomes after surgery. CONCLUSIONS: AE of the brain is a rare but life-threatening parasitic disease. Wherever the primary focus is, surgery for cerebral involvement of AE is challenging but safe with appropriate surgical techniques and the help of radiological examination.

Therapeutic effect of vitamin D3 in a rat diffuse axonal injury model.

We investigated the therapeutic effect of vitamin D3 in a rat diffuse axonal injury model. A total of 60 male Sprague-Dawley rats weighing 175-200 g were anaesthetized and subjected to head trauma using Marmarou's impact-acceleration model. The rats were then separated into two groups; one group was treated with vitamin D3 and the other with saline for up to 4 days after the head trauma. Rats from both groups were killed 1, 3 or 8 days post-injury. The brains were examined histopathologically and scored according to the level of neuronal, vascular and axonal damage. There were no significant differences between the groups after 1 or 3 days, but evaluation after 8 days revealed a significant improvement in the group treated with vitamin D3. Our data indicate that vitamin D3 has a beneficial effect in diffuse axonal injury and may be useful in the management of this condition.

Measurements of the lumbar pedicles in the Eastern Anatolian population.

Pedicle screw fixation of the spine has become one of the most stable and versatile methods of spine fixation, and knowledge of pedicle morphology is crucial for the safe application of these systems. We undertook this study because only a few reports have investigated Eastern populations. Lumbar pedicle anatomy, i.e., pedicle width (PW) and pedicle height (PH), transverse and sagittal pedicle angles (TPA, SPA), and pedicle length (PL), were assessed in the following two groups: (1) computed tomography scans of 29 normal adults, and (2) 16 dried lumbar spines obtained from the Anatomy Department. Interpedicular distance was different in each group. PW ranged from 4 mm to 14 mm. In both groups, the narrowest PH was 8.2 mm, the widest 19.7 mm. TPA ranged from 6(o) to 19(o) and increased from L1 to L5. In the sagittal plane, the pedicles angled caudally at L5. PL was longest at L1 and shortest at L5. In conclusion, pedicle dimensions and angles may show individual and structural differences. Our data were not significantly different from previous reported data. A detailed knowledge of these relationships is important for any surgery involving screw purchase via a pedicle, to prevent screw cutout and failure of fixation or neurological injury. Selection of the proper diameter of screw is an important issue for safe placement. Knowledge of the pedicle axis length is essential in choosing screw lengths but should always be checked intraoperatively with fluoroscopic control during screw insertion.

Immune response to dehydrated human dura mater: evaluation in a rabbit model.

Ninety white hybrid rabbits, each weighing 2.5 to 3.5 kg, were used for this experimental model. Thirty rabbits were used for control, and sixty other rabbits were investigated for the response of host to the dural graft. In all animals, a dural defect, 1 x 1 cm in size, was created on the left parietal area following craniotomy. In the control group the excised free dural piece was then sutured again to the area from which it had been excised before. The dural defect was closed with dehydrated human dura mater (DHD) in the half of the rabbits in the group of study, and with autogenous fascia lata (AFL) in the other half. After operation, animals in each group were then subjected to one of five different groups comprising of 3,14,30,60 and 90 days follow-up periods. At the end of follow-up periods, histological, parameters such as cellular inflammatory response, development of fibrous tissue, capsulation, and calcification were examined in specimens obtained from the animals. There was no significant difference between AFL and DHD grafts. In conclusion, it seems that DHD is suitable as an ideal dural graft, because the immune response of host to DHD was almost similar to AFL.

Giant cavernous hemangioma of the scalp.

In this article, a quite rare giant cavernous hemangioma located in right frontoparietal region of a 16 year-old boy is presented. Cavernous hemangiomas are commonly seen in extremities, neck, face and sometimes scalp, cutaneous or subcutaneous in localization. Giant cavernous hemangioma in the right frontoparietal region have been seen in two cases so far. In this article, we discussed the differential diagnosis, characteristics and therapy methods of giant cavernous hemangioma of the scalp.

Primary multiple hydatid cysts localizing in the petroclival area.

Hydatid cyst of the posterior fossa is very rare. In this report we present a 22-year-old female who had primary multiple hydatid cysts localizing in the petroclival areas. The report is noteworthy because of the unusual location, and the cranial and spinal dissemination of cysts despite previous treatment.

The anatomical variations of sylvian veins and cisterns.

The anatomical variations of sylvian vein and cistern were investigated during the pterional approach in 750 operative cases with different pathologies. All patients were operated on at the Neurosurgical Department of Ataturk University Medical School, Erzurum, Turkiye. The patients underwent surgery for the lesions necessitating the right or left pterional approach. The findings were recorded during surgical intervention and observed through the operative sketches of the pathologies, the slides, and videotapes of the operations. In our study, we surgically classified the variations of sylvian vein, according to its branching and draining patterns. Type I: The fronto-orbital (frontosylvian), fronto-parietal (parietosylvian) and anterior temporal (temporosylvian) veins drain into one sylvian vein. Type II: Two superficial sylvian veins with separated basal vein draining into the sphenoparietal and Rosenthal's basal vein. Type III: Two superficial sylvian veins draining into the sphenoparietal and the superior petrosal veins. Type IV: Hypoplastic superficial sylvian vein and the deep one. Four types of sylvian vein variations were defined as follows. The type I was seen in 52.8% (n = 396), the type II was found in 19.2% (n = 144), type III was recorded in 18.2% (n = 137), and type IV, or hypoplastic and deep form was discovered in 9.8% (n = 73) of patients. The coursing of sylvian vein was in the temporal side (Temporal Coursing) in 62.4 percent of the cases (n = 469), in the frontal side (Frontal Coursing) in 25 % of the patients (n = 187) and in 9 percent of the cases (n = 67) in the deep localization (Deep Coursing). Only 3.6% of the cases (n = 27) showed Mixed Coursing. The variations of the sylvian cisterns were classified into three types, according to the relationships between the lateral fronto-orbital gyrus and the superior temporal gyrus. In Sylvian type, the frontal and temporal lobes are loosely (Sylvian Type A, wide and large) or tightly (Sylvian Type B, close and narrow) approximated on the surface thereby covering the substance of the sylvian cistern. In Frontal Type, the proximal part of the lateral fronto-orbital gyrus herniated into the temporal lobe. In Temporal Type, the proximal part of the superior temporal gyrus herniated into the lateral fronto-orbital gyrus. The variations of the sylvian cisterns in 750 patients with different pathologies, were as follows: in 47.7% (n = 358) Sylvian type A, in 27.2% percent (n = 204) Sylvian type B, in 16.3% (n = 122) frontal type and in 8.8% (n = 66) temporal type. We concluded that venous perfusion discorder of the brain is the most important factor during the pterional approach. Careful intraoperative assessment and protection of the sylvian vein, which is a surgical pitfall, is an indispensable part of the operation. The recognition of the anatomical variations of the sylvian vein and cistern, and the detailed knowledge of the microvascular relationships and the importance of preservation of this vein at that level, will allow the neurosurgeon, believing in the minimally invasive neurosurgical techniques, to construct a better and safer microdissection plan, to save time, and can prevent postoperative neurological deficits.

Vascular variations associated with anterior communicating artery aneurysms-an intraoperative study.

This microsurgical study attempts to analyze the intraoperative anatomic vascular variations associated with the anterior communicating artery (ACoA) aneurysms in 120 patients who were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right pterional approach. The findings were recorded during surgical intervention and through the slides and videotapes of the operations. A total of 72 (60%) of our patients had vascular variations in the vicinity of the ACoA. Marked hypoplasia of the A1 segment of anterior cerebral artery (ACA) at the right or left side (26.6%, n = 32), median artery of the corpus callosum (MACC) (14%, n = 17), duplication of the ACoA (8.3%, n = 10), duplication of the A1 segment of ACA (7.5%, n = 9) and azygous pericallosal artery (3.3%, n = 4) were the variations that were observed during operations. A retrospective study of the cerebral angiograms of the cases indicated that preoperative diagnosis of the A1 or ACoA duplication was not possible, 14 (82.4%) of the 17 MACC's were easily identified, while three (17.6%) could not be diagnosed. From this intraoperative study, we concluded that, regardless of whether a vascular variation has been identified preoperatively, ACoA aneurysm surgery should be undertaken with the possibility of an MACC in mind. The recognition of the anatomic variations of the ACoA and the detailed knowledge of the microvascular relationships of the aneurysms will allow the neurosurgeons to construct a better and safer microdissection plan to save time on the one hand and to prevent postoperative neurological deficits on the other.

Postoperative anosmia after anterior communicating artery aneurysms surgery by the pterional approach.

Damage to the olfactory nerve during the pterional approach to the anterior communicating artery aneurysms has not previously been investigated in a quantified manner. In this retrospective study, 100 patients with anterior communicating artery aneurysms, for whom the pterional approach was employed, were observed from the point of view of postoperative olfactory nerve function. In the postoperative period only three cases suffered from the impaired sense of smell ipsilateral to the side of surgery. 15 patients objectively showed olfactory nerve distinctions. The functions of olfactory nerve could be preserved at a relatively high rate of 85 per cent. This high rate resulted from the microtechnique employed as well as the relatively cautious frontal lobe retraction which was less than 1.5 cm.

The variations of lenticulostriate arteries in the middle cerebral artery aneurysms.

This study attempts to analyse the intra-operative anatomical findings of the lenticulostriate artery (LSA) in 60 patients with middle cerebral artery (MCA) aneurysms who were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right or left pterional approach. The findings were recorded during surgical intervention using slides and videotapes of the operations. On average there were 4 (range, 1-14, total number = 240) LSAs, in one hemisphere, per case with MCA aneurysm. Twenty percent of LSAs (n = 48) arise from the prebifurcation part of the M1 segment, 65% (n = 156) arise from the postbifurcation part of the M1 segment, and 15% (n = 36) arise from the proximal part of the M2 segment. The great majority of the LSAs (85%, n = 204) originated along the proximal part of the MCA. Of a total of 240 LSAs, 125 (52%) originated from one single large vessel, a stem artery which then divided after 2-10 mm into many branches, 85 (35%) originated as two large proximal trunks, and 30 (13%) originated as multiple small arteries arising along the whole infero-medial wall of the M1 segment of MCA. We concluded that recognition of the anatomical variations of the LSA and detailed knowledge of the microvascular relationships of the MCA aneurysms, will allow neurosurgeons to construct a better and safer microdissection plan, to save time, and to prevent postoperative neurological deficits.

Optochiasmatic tuberculoma--case report and review.

An optochiasmatic tuberculoma, encasing the chiasm and optic nerves, was found in a 58-year-old woman complaining of sudden beginning and progressive visual failure. The patient was treated by surgery and prolonged corticosteroids and continued triple antituberculous therapy. Pathological diagnosis was a tuberculoma confirmed by postoperative positive polymerase chain reaction against M. tuberculosis. Because the incidence of tuberculomas has increased, especially in developing countries, in recent years and they also involve optic nerves and chiasm, it is important to include optochiasmatic tuberculoma in the differential diagnosis of optic nerve and chiasm tumors. Including this case, only 31 instances of optochiasmatic tuberculoma have been reported in the literature.

The variations of Sylvian veins and cisterns in anterior circulation aneurysms. An operative study.

The anatomical variations of Sylvian vein and cistern were investigated during the pterional approach in 230 patients with 276 aneurysms of anterior circulation arteries, that were operated on at the Neurosurgical Department of Atatürk University Medical School. Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right or left pterional approach. The findings were recorded during surgical intervention and observed through the slides and videotapes of the operations. In our study, we surgically classified the variations of the Sylvian vein, according to its branching and draining patterns. Type I: The fronto-orbital (frontosylvian), fronto-parietal (parietosylvian) and anterior temporal (temporosylvian) veins drain into one sylvian vein. Type II: Two superficial Sylvian veins with separated basal vein draining into the sphenoparietal and Rosenthal's basal vein. Type III: Two superficial Sylvian veins draining into the sphenoparietal and the superior petrosal veins. Type IV: Hypoplastic superficial Sylvian vein and the deep one. Four types of Sylvian vein variations were defined as follows. The Type I was seen in 45% (n = 103), the Type II was found in 29% (n = 67), Type III was recorded in 15% (n = 34) and Type IV, or hypoplastic and deep form was discovered in 11% (n = 26) of patients. The course of the Sylvian vein was on the temporal side (Temporal Coursing) in 70 percent of the cases (n = 160), on the frontal side (Frontal Coursing) in 19% of the patients (n = 45) and in 8 percent of the cases (n = 18) in the deep localization (Deep Coursing). Only 3 percent of the cases (n = 7) showed a mixed course. The variations of the Sylvian cisterns were classified into three types, according to the relationships between the lateral fronto-orbital gyrus and the superior temporal gyrus. In Sylvian Type, the frontal and temporal lobes are loosely (Sylvian Type A, Large) or tightly (Sylvian Type B, Close and Narrow) approximated on the surface thereby covering the area of the Sylvian cistern. In frontal type, the proximal, part of the lateral fronto-orbital gyrus herniated into the temporal lobe. In temporal type, the proximal part of the superior temporal gyrus hemiated into the lateral fronto-orbital gyrus. The variations of the Sylvian cisterns in 230 patients were as follows: in 31% (n = 71) Sylvian Type A, in 21% (n = 48) Sylvian Type B, in 34% (n = 78) Frontal Type, and in 14% (n = 33) Temporal Type. We concluded that venous perfusion disorder of the brain is the most important factor during the pterional approach. Careful intraoperative assessment and protection of the Sylvian vein, which is a surgical pitfall, is an indispensable part of the operation. The recognition of the anatomical variations of the Sylvian vein and cistern, and the detailed knowledge of the microvascular relationships at that level will allow the neurosurgeon to construct a better and safter microdissection plan, to save time and can prevent postoperative neurological deficits.

Pitfalls in the pterional approach to the parasellar area (review).

The pterional approach is commonly employed in surgery of the anterior circulation and upper basilar artery aneurysms, as well as for the tumors of orbital, retroorbital, sellar, chiasmatic, subfrontal and prepontine areas and lesions around the sella especially for lesions behind the clivus. Also tumors arising from the medial sphenoid ridge, the superior orbital fissure, the anteromedial temporal surface, or the cavernous sinus region are approached through a pterional exposure. The surgical technique is based on the experience, training and observation of the neurosurgeon. One technique is not necessarily better than another. Regardless of the surgical technique, the end results depend on a rigorous, methodical, systematic, and step-by-step approach to the target, securing it with minimal injury to surrounding structures. In this study, we have analyzed the intraoperative anatomical findings of the Sylvian vein and fissure, lenticulostriatal artery, olfactory nerve, and recurrent artery of Heubner and showed the surgical pitfalls in 700 patients with different diagnoses that were operated on with the pterional approach. The findings were recorded during surgical interventions and through the slides and videotapes of the operations. Also, we have stressed the preservation of the frontotemporal branch of the facial nerve, the delicate retraction of frontal lobe, the cottonoid retraction in temporal lobe and the preservation of olfactory nerve functions.

The effect of urokinase on experimental intracerebral haematomas.

Intracerebral-intraventricular haematoma was created experimentally by injecting coagulated autologous blood into the left cerebral hemispheres of rats, stereotactically 2200 U. Urokinase was injected into the haematomas of the treated group and the same volume of physiologic saline solution into the control group. Macroscopic evaluations were made at the end of 24 and 48 hours and lysis of the haematoma was observed in 90% of cases in the group treated with Urokinase. This ratio was 20% in the control group (P < 0.00001). In microscopical evaluation, no histopathological changes were observed in surrounding tissues in either group. It is concluded that local Urokinase administration may be an effective method of treatment in intracerebral aematomas.

Heubner's artery variations in anterior communicating artery aneurysms.

This study attempts to analyse the intra-operative anatomical findings of the recurrent artery of Heubner in 48 patients with Anterior Communicating Artery Aneurysm who were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right pterional approach. The findings were recorded during surgical intervention and through the dias and videotapes of the operations. The artery of Heubner originated from the junction of the A1 and A2 segments of the anterior cerebral artery (ACA) in 58%, from the A2 segment of ACA in 23%, and from the A1 segment of ACA 4%. It was asymmetrically taking off in 13% and hypoplastic in 2% of the cases. Three types of recurrent artery courses were defined. The type I or the superior course was seen in 71%, the type II or the anterior course was found in 25% and type III or the posterior course was recorded in 4% of patients. We concluded that the recognition of the anatomical variations of the recurrent artery of Heubner and the detailed knowledge of the microvascular relationships of the anterior communicating artery (ACoA) complex, will allow neurosurgeons to construct a better and safer microdissection plan, to save time, and so prevent postoperative neurological deficit.

Fibrinolytic activity in experimental intracerebral hematoma.

We investigated the tissue fibrinolytic activity in an experimental model of intracerebral hematoma was developed in the guinea pig. Intracerebral hematoma was created by stereotaxically injecting 0.2 ml autologous blood into the left frontal lobe of a total 63 anesthetized adult male albino guinea pigs (weighing 280-350 gr.). The fibrinolytic activity was studied using conventional histochemical stain techniques. 20 guinea pigs were used for developing the intracerebral hematoma model; in the 43 guinea pigs, the intracerebral hematomas were studied sequentially. Intracerebral hematoma formation failed in 10 of 43 guinea pigs. Three guinea pigs died in the immediate postoperative period. It was diagnosed histopathologically purulent meningitis and ventriculitis in four guinea pigs. Tissue fibrinolytic activity was increased in the meninges and choroid plexus. No fibrinolytic activity was observed a during the first days (1 to 3 days after hematoma production). 3 to 5 days later, fibrinolytic activity was seen in the capillary buds surrounding the hematoma and among the infiltrating mononuclear cells. This activity reached highest levels for 7-14 days following production of the hematoma and decreased after 20 days. In conclusion, tissue fibrinolytic activity associated with neovascularisation and mononuclear cell infiltration appears to be important in lysis of intracerebral hematoma.

Giant intracranial aneurysms in children and adolescents.

10 giant intracranial aneurysms in children were treated consecutively in Neurosurgical Department of Atatürk University, Erzurum, Turkey between 1985-1989. A total of 60 aneurysms of normal size were operated on in the same period. Of the ten cases 6 were male and 4 were female. All the patients were under 17-years old. In 6 cases, the onset of symptoms was sudden subarachnoid hemorrhage, in 3 cases presenting symptoms were insidious imitating a intracranial mass, and in one case, clinical manifestation was epileptic seizure. Among 6 cases with subarachnoid hemorrhage, 3 were in IV grade according to Hunt-Hess scale, 2 were in III grade and one in II grade. Angiographic localisation of the aneurysms was in the middle cerebral artery in 9 cases and in the anterior communicating artery in one case. During the operation, blood pressure was not lowered. All the patients were operated on with normal blood pressure without hypotension. In 4 cases, intramural thrombosis was detected. The necks of aneurysms were occluded by suitable clips. The aneurysms were excised in 4 cases after clipping. One patient died in the early postoperative period, and 9 cases remained alive and were free of symptoms after the operation for one to 4 years. We conclude that especially giant aneurysms in children should be treated surgically without exercising hypotension during operation.

Postoperative anosmia after removal of pituitary gland adenomas using the pterional approach.

There have been several studies on anosmia following operations on anterior circulation aneurysms, but no similar study has yet been reported on pituitary gland adenomas which required the transcranial approach. In this study, 38 cases with pituitary gland adenomas, for whom the pterional approach was employed, were observed retrospectively from the point of view of postoperative olfactory nerve function. In the postoperative period only one case complained of impaired sense of smell on the operated side. Eight cases objectively showed olfactory nerve dysfunctions. The olfactory nerve function could be preserved at a relatively high rate of 79 per cent. This high rate, we think, resulted from the microtechnique employed as well as the relatively cautious frontal retraction which was less than 1.5 cm.

Clinical analysis of cerebral abscesses.

42 patients with cerebral abscesses were treated from 1979 until the end of the first six months of 1987 at the Neurosurgical Department of the Faculty of Medicine, Atatürk University, Erzurum, Turkey. The present study aims at studying these patients to determine the factors affecting on prognosis. The patients were studied for the duration of complaints, pre-operational condition, the location of the abscesses, the microorganisms responsible for them, and the techniques of operation applied, by taking their sex and age into consideration. All of the cases were treated operatively. Of these, 18 were treated by excision and 24 were applied drainage, whose percentage was 43 and 57 respectively, 85% of the cases were under 60 years of age. The rate of mortality of the cases with cerebral abscesses was 19%. This rate was between 15% and 37.5% in the cases of several age groups whose complaints lasted less than two months. This rate reached 100% with a sudden increase in the cases who had a duration of complaints over four months. The rate of mortality was 6.2% in the cases with a clear conscious and cooperative ability while it had a significant increase in the patients in pre-coma or coma to go up to 50% and 75% respectively. No correlation was observed between the rate of mortality and the age of the patients but the location and extension of the abscesses had an effect on this rate. The abscesses, covering more than one lobe, had a mortality rate of 31.2%, while the ones with parietal location caused no single death. To conclude, we can say, based on this study, that the age and sex of patients and the operative technique have no effect on the rate of mortality while it is obviously influenced by the duration of the complaints and the pre-operative condition. Consequently, we would like to stress up on early diagnosis and treatment of such cases.