Resection of intra- and paraventricular malignant brain tumors using fluorescein sodium-guided neuroendoscopic transtubular approach.

BACKGROUND: The requirement of brain retraction and difficulty in distinguishing the tumor demarcation are challenging in conventional approaches to intra- and paraventricular malignant tumors (IV-PVMTs). Tubular retractors can minimize the retraction injury, and fluorescein-guided (FG) surgery may promote the resection of tumors. Our aim is to evaluate the feasibility, safety, and effectiveness of fluorescein-guided endoscopic transtubular surgery for the resection of IV-PVMTs. METHODS: Twenty patients with IV-PVMTs underwent FG endoscopic transtubular tumor resection. Fluorescein sodium was administered before the dural opening. The intraoperative fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was assessed using postoperative magnetic resonance imaging. Karnofsky Performance Status (KPS) score was used to evaluate the general physical condition of patients. RESULTS: There were 9 glioblastomas, 4 anaplastic astrocytomas and 7 metastatic tumors. "Helpful" fluorescence staining was observed in 16(80%) of 20 patients. Gross total resection was achieved in 16(80%) cases, near-total in 3(15%) cases, and subtotal in 1 (5%) case. No intra- or postoperative complications related to the fluorescein sodium occurred. The median preoperative KPS score was 83, and the median KPS score 3-month after surgery was 88. CONCLUSION: FG endoscopic transtubular surgery is a feasible technique for the resection of IV-PVMTs. It may be a safe and effective option for patients with these tumors. Future prospective randomized studies with larger samples are needed to confirm these preliminary data.

Chemoresistance in Malignant Intracranial Tumors: Longer Survival with Negative MDR1 Expression.

AIM: To analyze the Glutathione S-transferase (GST)-P, GST-M, cytochrome p450 (CYP)1-A1, CYP1-B1, and multidrug resistance (MDR)-1 expressions in malignant intracranial tumor (ICT)s, and to elicit their role on patient survival. MATERIAL AND METHODS: GST-P, GST-M, CYP1-A1, CYP1-B1, and MDR-1 expressions were analyzed using immunostaining in 149 samples from 141 patients with preoperative ICT diagnosis. The case characteristics were reviewed, and the enzyme expressions were equated based on the age, gender, and tumor type. Then, 77 of 141 patients with malignant ICT and complete medical records postoperative were also investigated in detail for the relationship between the diagnosis, enzyme expression, and overall survival. RESULTS: The average age was 49.44 years, with 83 (58.45%) male patients. Among the 77 malignant ICTs, 38 (49.3%) and 29 were glial tumors and metastases, respectively, with a 13.35-month overall survival. Patients with metastatic tumor have approximately threefold higher GSTP level than those with glial tumors. MDR-1 expression was approximately twofold higher in > 60-year-old patients. No statistically significant association was found between patients? smoking behaviors, alcohol consumption, and overall survival. Only MDR-1 expression was correlated with overall survival. Better overall survival was observed in patients with a negative MDR-1 expression than those with a positive one. CONCLUSION: MDR-1 is an important indicator of survival in malignant intracranial tumor patients. Longer survival is associated with negative MDR-1 expression.

Fluorescein Sodium-Guided Neuroendoscopic Resection of Deep-Seated Malignant Brain Tumors: Preliminary Results of 18 Patients.

BACKGROUND: Deep-seated intracranial lesions are challenging to resect completely and safely. Fluorescence-guided surgery (FGS) promotes the resection of malignant brain tumors (MBTs). Classically, FGS is performed using microscope equipped with a special filter. Fluorescence-guided neuroendoscopic resection of deep-seated brain tumors has not been reported yet. OBJECTIVE: To evaluate the feasibility, safety, and effectiveness of the fluorescence-guided neuroendoscopic surgery in deep-seated MBTs. METHODS: A total of 18 patients with high-grade glioma (HGG) and metastatic tumor (MT) underwent fluorescein sodium (FS)-guided neuroendoscopic surgery. Tumor removal was carried out using bimanual microsurgical techniques under endoscopic view. The degree of fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was determined using magnetic resonance imaging (MRI). Karnofsky Performance Status (KPS) score was used for evaluation of general physical performances of patients. RESULTS: A total of 11 patients had HGG, and 7 had MT. No technical difficulty was encountered regarding the use of endoscopic technique. "Helpful" fluorescence staining was observed in 16 patients and fluorescent tissue was completely removed. Postoperative MRI confirmed gross total resection (88.9%). In 2 patients, FS enhancement was not helpful enough for tumor demarcation and postoperative MRI revealed near total resection (11.1%). No complication, adverse events, or side effects were encountered regarding the use of FS. KPS score of patients was improved at 3-mo follow-up. CONCLUSION: FS-guided endoscopic resection is a feasible technique for deep-seated MBTs. It is safe, effective, and allows for a high rate of resection. Future prospective randomized studies are needed to confirm these preliminary data.

Extended endonasal endoscopic approach for anterior midline skull base lesions.

AIM: In recent years, extended endoscopic endonasal approach (EEEA) has been used as an alternative to transcranial approaches in the treatment of anterior midline skull base lesions. We retrospectively reviewed our cases operated using this technique and compared the results with current literature. METHOD: The data of 24 patients who were operated using EEEA in our department between 2010-2018 were retrospectively analyzed. The lesions were located in the midline between the posterior wall of the frontal sinus and tuberculum sella. Tumor locations, histopathological diagnoses, surgical techniques, outcomes and complications were documented. RESULTS: Eleven patients were female and 13 were male. Their ages ranged between 18-75 years (mean 40.5 years). Considering their locations; 12 were in the anterior fossa (50 %), 7 were in the tuberculum sella (29.1 %), and 5 were in both anatomic sites (20.8 %). Histopathologically, our series consisted of 15 meningiomas, 6 osteomas, 2 dermoid tumors and 1 metastatic carcinoma. We achieved gross total resection in 75 % of our patients. Ten patients presented with visual complaints and 7 of them improved postoperatively. Postoperative cerebrospinal fluid leakage (CSF) was observed in 3 patients and one of them developed meningitis and subsequently died of sepsis. CONCLUSION: Although the number of cases is low, EEEA seems like a safe, effective and well-tolerated treatment modality for anterior midline skull base lesions. But strict preventive measures should be taken for a possible CSF leak.

Sellar Defect Reconstruction with Vascularized Superior Turbinate Mucosal Flaps in Endonasal Endoscopic Transsellar Approach.

BACKGROUND: The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for most skull base defects in endonasal endoscopic approaches. The superior nasal turbinate (ST) has received little attention. We report our preliminary experience with the use of the ST mucosal flap in selected cases. METHODS: We performed a retrospective review of patients who underwent endonasal endoscopic approaches and identified 9 patients who were reconstructed with vascularized ST mucosal flaps as part of a double-layer or triple-layer reconstruction. When there was no intraoperative cerebrospinal fluid (CSF) leak, we used a double-layer technique. If there was an intraoperative CSF leak, regardless of the quality of leakage, we preferred a triple-layer repair technique. In patients with high-flow leaks, triple-layer repair was performed using only autologous tissue grafts and flaps. RESULTS: Intraoperative CSF leaks were noted in 7 of 9 patients. Among them, 4 patients had low-flow CSF leaks (grade 1 and 2) and 3 patients had high-flow CSF leaks (grade 3). All reconstructions had complete defect coverage with the ST flaps and NSFs were preserved. All the flaps were viable at 4 weeks without a CSF leak or complication at the reconstruction site. There was no contraction or partial loss of the flap. After a mean follow-up period of 9 months, none of the patients required a flap revision, developed a mucocele, infection, or other complication. CONCLUSIONS: An ST flap can be used for the vascularized reconstruction of sellar defects if it is bilaterally available. This option should not be overlooked and wasted.

Intracranial infections: lessons learned from 52 surgically treated cases.

OBJECTIVE: Intracranial infections are serious and life-threatening health problems. They may present as subdural empyemas or intracerebral abscesses. Surgical drainage and subsequent antibiotic treatment is the main technique for a satisfactory clinical outcome. The aims of this study were to present a 10-year intracranial infection series and discuss the surgical characteristics in the light of literature. METHODS: Fifty-two patients with intracranial infection underwent surgical treatment between 2008 and 2018. Eleven patients were female and 41 patients were male. The mean age was 40.46 years (range 10-75 years). Eighteen patients had intracerebral abscesses, and 34 had subdural empyemas. All patients underwent surgical treatment as well as an antibiotic regimen. RESULTS: No etiological agent was isolated in 29 (56%) cases. Bacterial agents were detected in 20 cases, while fungi were observed in 3 cases. Staphylococci species were the most common agents and were isolated in 8 (15%) cases. Endoscopic aspiration was performed in 3 cases, while surgical drainage and capsule resection via craniotomy was performed in 49 cases. An associated intracranial tumor was diagnosed in 2 patients with brain abscesses. Four (8%) patients died despite surgical and medical treatments. CONCLUSIONS: Surgical treatment via craniotomy is an older method, but it is still the best to treat the intracranial infections not only for decompression of the brain but also to attain an accurate diagnosis. The abscess wall should always be histologically examined after surgery to rule out any intracranial tumor.

Expression of Sigma-Class Glutathione-S-Transferase in Fetal and Pediatric Filum Terminale Samples: A Comparative Study.

Background and objectives: The pathophysiology of tethered cord syndrome (TCS) in children is not well elucidated. An inelastic filum terminale (FT) is the main factor underlying the stretching of the spinal cord in TCS. Our study aimed to investigate the expression of glutathione-S-transferase (GST) in children and fetal FT samples in order to understand the relationship between this enzyme expression and the development of TCS. Materials and Methods: FT samples were obtained from ten children with TCS (Group 1) and histological and immunohistochemical examinations were performed. For comparison, FT samples from fifteen normal human fetuses (Group 2) were also analyzed using the same techniques. Statistical comparison was made using a Chi-square test. Results: Positive GST-sigma expression was detected in eight (80%) of 10 samples in Group 1. The positive GST-sigma expression was less frequent in nine (60%) of 15 samples from Group 2. No statistically significant difference was detected between the two groups (p = 0.197). Conclusions: Decreased FT elasticity in TCS may be associated with increased GST expression in FT. More prospective studies are needed to clarify the mechanism of the GST-TCS relationship in children.

Port-a-cath and ventriculoatrial shunt at the same atrium: technical note.

Hydrocephalus is a rare complication of brain involving acute lymphoblastic leukemia (ALL). The standard treatment is ventriculoperitoneal (VP) shunting, while ventriculoatrial (VA) shunting is the second option in a case of VP shunt failure in young children. But the presence of port catheter at the right atrium restricts and makes a VA shunt difficult to place in the same atrium. We presented a 4-year-old boy who had the diagnoses of ALL and underwent chemotherapy through a port-a-cath. He also had hydrocephalus due to the brain invasion of the ALL. He firstly underwent VP shunting for the treatment of hydrocephalus, but it failed due to an intraabdominal cyst. Then, he underwent VA shunting through the left internal jugular vein. This is the first case in the literature showing both catheters in the right atrium.

Limited Dorsal Myeloschisis with and without Type I Split Cord Malformation: Report of 3 Cases and Surgical Nuances.

Limited dorsal myeloschisis (LDM) is a rare form of spina bifida which is characterized by a fibroneural stalk between the inner part of the skin and the spinal cord. It may be associated with split cord malformation (SCM). Diagnosis and management of this complex malformation is challenging. We presented 3 different cases of LDM. Two of them were associated with Type I SCM and the other had no associated malformation. All of them were evaluated radiologically just after the birth and underwent surgical treatment under intraoperative neuromonitoring. They discharged without any complication. Newborns with spinal cystic lesions should be carefully evaluated for spinal malformations after the birth and treated surgically as soon as possible in order to prevent neurological and urological complications secondary to tethered cord syndrome. Surgical technique in LDM-SCM patients is quite different than the patients with solitary LDM.

Glutathione S-Transferases and Cytochrome P450 Enzyme Expression in Patients with Intracranial Tumors: Preliminary Report of 55 Patients.

OBJECTIVE: Intracranial tumors are one of the most frightening and difficult-to-treat tumor types. In addition to surgery, protocols such as chemotherapy and radiotherapy also take place in the treatment. Glutathione S-transferase (GST) and cytochrome P450 (CYP) enzymes are prominent drug-metabolizing enzymes in the human body. The aim of this study is to show the expression of GSTP1, GSTM1, CYP1A1, and CYP1B1 in different types of brain tumors and compare our results with those in the literature. SUBJECTS AND METHODS: The expression of GSTP1, GSTM1, CYP1A1, and CYP1B1 was analyzed using immunostaining in 55 patients with intracranial tumors in 2016-2017. For GST and CYP expression in normal brain tissue, samples of a portion of surrounding normal brain tissue as well as a matched far neighbor of tumor tissue were used. The demographic features of the patients were documented and the expression results compared. RESULTS: The mean age of the patients was 46.72 years; 29 patients were female and 26 were male. Fifty-seven specimens were obtained from 55 patients. Among them, meningioma was diagnosed in 12, metastases in 12, glioblastoma in 9, and pituitary adenoma in 5. The highest GSTP1, GSTM1, and CYP-1A1 expressions were observed in pituitary adenomas. The lowest GSTP1 expression was detected in glioblastomas and the lowest CYP1B1 expression in pituitary adenomas. CONCLUSION: GSTP1 and CYP expression is increased in intracranial tumors. These results should be confirmed with a larger series and different enzyme subtypes.

Two-Micron Continuous-Wave Laser-Assisted Neuroendoscopy: Clinical Experience of Two Institutions in 524 Procedures.

OBJECTIVE: To present the clinical experience of 2 neurosurgical centers with the use of a 2-micron continuous-wave laser (2µ-cwL) system as standard tool in neuroendoscopic procedures and to discuss the safety and efficacy of this system. METHODS: In total, 469 patients underwent neuroendoscopic procedures using 2µ-cwL between September 2009 and January 2015. All patient data were retrospectively reviewed. In total, 241 (51%) patients were children and 228 (49%) adults. Mean age was 27.5 years (range: 3 days to 83 years). Intraoperative ultrasonography or neuronavigation were used to guide ventricular or cyst puncture and for intraventricular or intracystic orientation if necessary. RESULTS: A total of 524 neuroendoscopic procedures using 2µ-cwL were performed. Laser-assisted endoscopic third ventriculostomy was the most common procedure in 302 (64%) patients. Cyst fenestration was performed in 124 (26%), septostomy in 45, tumor biopsy in 41, tumor resection in 8, and choroid plexus coagulation in 3 patients. There was no intraoperative complication directly attributable to the use of laser and an overall procedural complication rate of 4.8%. CONCLUSIONS: This large series of 2µ-cwL as a routine tool in neuroendoscopic procedures demonstrates that 2µ-cwL is safe for endoscopic third ventriculostomy, septostomy, cyst fenestration, and intraventricular tumor biopsy or resection. As a cutting and coagulation tool, it combines the action of mechanical tools like forceps, balloons, and scissors plus those of electric tools. It therefore renders neuroendoscopic procedures more straightforward with a minimum need to change tools.

Lhermitte-Duclos Disease in a Six-Year Old Child: A Rare Presentation.

Lhermitte-Duclos disease (LDD) is a rare, slow-growing, benign lesion of the cerebellum. It is often seen in the second and fourth decades. This disease is extremely rare in childhood. A 6-year-old girl presented with loss of balance. A mass lesion in the right cerebellum was detected by magnetic resonance imaging. The patient underwent surgical removal of the lesion, and the histological diagnosis was dysplastic gangliocytoma (LDD). The patient was discharged without complication, and her balance improved in the follow-up period. In this report, we present this rare occurrence in childhood and discuss the clinical course and management. LDD is very rare in early childhood and should be considered in the differential diagnosis of posterior fossa lesions.

U-shaped durotomy for midline posterior fossa tumor removal: technical note and evaluation of results.

BACKGROUND: The classical dura opening for midline posterior fossa tumors in and around the 4th ventricle and the craniocervical junction is a Y-shaped incision. Several potential problems are associated with this technique. We used a technical variant, the U-shaped durotomy, previously described by Rhoton, offering several advantages. We report on the surgical results of the technique in a consecutive series of posterior fossa cases in children and adolescents. METHODS: In all midline posterior fossa approaches, a U-shaped dural incision is standard in our institution. All cases were retrospectively analyzed regarding hydrocephalus, placement of EVD or lumbar drain, need for ETV or shunting during follow-up, and frequency of duraplasty, of pseudomeningocele, of primary watertight dural closure, of CSF leakage, and of venous sinus hemorrhage at opening. RESULTS: Fifty pediatric patients were included. In all easy occipital sinus, control was achieved and no additional dural retraction for tumor exposure required. In 49/50 patients, a primary watertight dura closure without duraplasty was achieved, also in re-do cases with previous U-shaped opening. One patient received a small periostium graft after having had a duraplasty following Y-shaped opening beforehand. No CSF fistula ever occurred and no pseudomeningocele was detected in any follow-up MRI. CONCLUSION: The U-shaped durotomy for dorsal midline approach to the 4th ventricle and craniocervical junction provides wide exposure to all tumors and allows for primary and watertight dura closure. Compared to published results and complications of classic Y-shaped dural opening, this method of durotomy and closure seems most advantageous.

Intracavitary amphotericin B in the treatment of intracranial aspergillosis.

Intracranial aspergillosis is a rare infectious disease of the central nervous system with high mortality rates. Our aim is to present 3 cases of intracranial aspergillosis who were surgically treated with intracavitary amphotericin B administration. First case was a 21-year-old male patient. Allogeneic stem cell transplantation treatment was performed because of aplastic anemia and vocal cord paralysis developed 10 days after treatment. Multiple aspergillosis abscesses were observed in the cranial magnetic resonance imaging (MRI). Cerebral lesions were excised and 0.3 cc of amphotericin B was applied locally. Second case was a 18-year-old male patient treated for acute lymphocytic leukemia. MRI was performed on the development of consciousness change during treatment and right frontal abscess was detected. The abscess was excised and amphotericin B was applied locally. Third case was a 45-year-old woman with mastectomy. She had chemotherapy after surgery and had blood stem cell transplantation because of pancytopenia. Two months after treatments, MRI was performed on the development of ataxia and a cerebellar abscess was detected. The abscess was surgically excised and local amphotericin B was applied. The first case deceased 2 weeks after surgery and the second case died 2.5 years later due to multi-organ failure. The third case is stil alive and neurologically stable after 14 years of surgical treatment. In intracranial aspergillosis, intracavitary amphotericin B therapy may be used as an adjunct after the surgical excision of abscess. This procedure may contributes to the regression of abscess or prevention of the recurrence. But comparative clinical studies are needed for more accurate conclusions.

The evaluation of the effects of steroid treatment on the tumor and peritumoral edema by DWI and MR spectroscopy in brain tumors.

OBJECTIVE: To investigate the effects of dexamethasone on brain tumor and peritumoral edema by different sequences of magnetic resonance imaging (MRI). MATERIALS AND METHODS: MRI was performed in 28 patients with brain tumor. Patients were divided into the 3 groups based on the histological diagnosis; Group I: high-grade glial tumor, Group II: low-grade glial tumor, and Group III: brain metastasis. The measurements of peritumoral edema volume and apparent diffusion coefficient (ADC) values were performed while the peak areas of cerebral metabolites were measured by spectroscopy in groups I and II. The changes in edema volumes, ADC values and cholin/creatine peak areas were compared. RESULTS: The volume of peritumoral edema was decreased in groups I and II, but increased in group III after dexamethasone treatment. These changes were not statistically significant for 3 groups. ADC value was decreased in group I and increased in groups II and III. Changes in ADC values were statistically significant. Cholin/creatine peak areas were decreased after dexamethasone in groups I and II, but these changes were also not significant. CONCLUSION: Dexamethasone has no significant effect on the volume of peritumoral edema in glial tumor and metastasis. Moreover, dexamethasone increases the fluid movements in low grade gliomas and metastases, decreases in high grade gliomas. However, more comprehensive clinical studies are needed to show the effects of dexamethasone on brain tumors and peritumoral edema.

Extended endoscopic endonasal approach to the ventral skull base lesions.

OBJECTIVE: With the use of multiple endoscopic endonasal surgical corridors, extended endoscopic endonasal approaches (EEEAs) are now being used to treat a wide range of ventral skull base lesions. Our aim was to present our experience with EEEAs to the ventral skull base lesions. PATIENTS AND METHODS: The study group consisted of 106 patients (57 men and 49 women) who underwent surgery for skull base lesions using EEEAs from 2010 to 2017. The EEEA was most commonly used for giant pituitary macroadenomas, sinonasal malignancies, cerebrospinal fluid (CSF) leaks, meningiomas, craniopharyngiomas, and fibro-osseous lesions. Four different approaches were used including transtuberculum-transplanum, transethmoidal-transcribriform, transclival, and transmaxillary-transpterygoidal. RESULTS: The overall gross total resection (GTR) rate for these diverse pathologies was 75.0% in 88 patients (excluding the operations performed for non-neoplastic pathologies). GTR was achieved in 100%, 77.8%, 75%, 75%, 72.2%, 62.5%, 60% of fibro-osseous lesions, giant/large pitutary adenomas, meningiomas, esthesioneuroblastomas, sinonasal malignancies, craniopharyngiomas, and chordomas, respectively. The overall rate of improvement in visual fields was 86%. The overall rate of CSF leak was 8.4%. Other surgical complications included intracerebral hematoma and tension pneumocephalus. The mortality rate was 0.9%. CONCLUSION: EEEA is a safe, well-tolerated and effective surgical treatment modality in the management of ventral skull base lesions. It should be performed with close interdisciplinary collaboration. Appropriate case selection is mandatory. However, despite improved reconstruction techniques, postoperative CSF leakage still remains a challenge.

Comparison of Electrophysiological Outcomes of Tethered Cord Syndrome and Spinal Intradural Tumors: A Retrospective Clinical Study.

AIM: Electrophysiological evaluation of the outcomes of spinal procedures is important for neurosurgeons. Somatosensorial evoked potentials (SSEPs) are used for electrophysiological evaluation of tethered cord syndrome (TCS) and spinal intradural tumors (SIT). The aim of this study was to document the electrophysiological outcomes of surgery for TCS and SIT and to compare the results based on the preoperative diagnosis. MATERIAL AND METHODS: The data of 30 patients, who were operated for TCS and SIT between 2011 and 2013, were reviewed retrospectively. Surgical release of the spinal cord was performed for TCS and tumor removal was performed for SIT. Median and tibial nerve SSEPs at the left and right sides were measured at preoperative, early and late postoperative periods and compared statistically based on the diagnosis and the time of electrophysiological assessment. RESULTS: The diagnosis was TCS in 12 (40%) patients and SIT in 18 (60%) patients. There was a significant difference between preoperative, and early and late postoperative SSEPs values. Tibial nerve latencies were prolonged in the early postoperative, but shortened in the late postoperative period. In contrast, median nerve latencies were shortened in the early postoperative, but prolonged in the late postoperative period. There was no significant difference between the TCS and SIT groups based on the surgical intervention. CONCLUSION: Tibial nerve latency may be prolonged in the early postoperative period of TCS and SIT patients. However, electrophysiological changes were not predictive for these patients. Further studies with more patients are needed for other spinal lesions.

Endoscopic Removal of Suprasellar Colloid Cyst with Interpeduncular and Prepontine Cisterns Extension.

BACKGROUND: Colloid cysts (CCs) are rarely found in the sellar-suprasellar region. Differential diagnosis of CCs is more challenging in this region because many other cystic lesions may locate or invade sellar or suprasellar structures. We present a large and unusual case of sellar-suprasellar CC with extension into the suprasellar, interpeduncular, and prepontine cisterns. This is the first case of sellar-suprasellar CC treated with an endoscopic transsphenoidal approach. CASE DESCRIPTION: A 33-year-old woman presented with a 1-year history of recurrent headaches. Her headaches had been unresponsive to medical treatment for the last 2 weeks. She had normal neurologic and ophthalmologic examinations. Neuroradiologic studies showed a large cystic sellar lesion with extension into the suprasellar, interpeduncular, and prepontine cisterns. The lesion did not show any enhancement, not even in the cyst wall. Her hormonal status was also normal. The cystic lesion was totally resected via a purely endoscopic endonasal approach. There were no complications, and the patient was recovered completely with improvement of her headache. Pathology was consistent with a CC. At 6-month follow-up, magnetic resonance imaging did not show any evidence of the residual or recurrent lesion. CONCLUSIONS: Although rarely found in this location, CC should be considered in the differential diagnosis in patients who present with a sellar-suprasellar cystic lesion. Additionally, sellar-suprasellar CC would be a good candidate for the endoscopic endonasal approach.

Fully Endoscopic Resection of Intra-Axial Brain Lesions Using Neuronavigated Pediatric Anoscope.

AIM: To present a new simple disposable tubular retractor which provides fully endoscopic resections of the intraaxial brain lesions. MATERIAL AND METHODS: A total of 13 patients underwent surgical resection of an intraaxial brain lesion larger than 3 cm with a fully endoscopic approach using the navigation-guided pediatric anoscope. The anoscope was adapted to serve as a tubular retractor. All lesions were resected under endoscopic visualization and navigation guidance. There were 7 men and 6 women with a mean age of 49.6 years (range, 19-76 years). Lesion location was as follows: frontal (n=4), parietal (n=1), frontoparietal (n=2), temporal (n=2), and intraventricular (n=4). RESULTS: With the use of this technique, preoperative goals of surgery were met in all patients. Gross total resection of the lesions was achieved in 7 of 13 patients (53.8%), near-total resection in 3 patients (23.1%) and subtotal resection in 3 (23.1%) patients. The histological diagnosis included 2 metastases, 5 (38.5%) glioblastomas, 3 meningiomas, 2 low grade gliomas and one oligodendroglioma. There were no complications related to the surgical procedure. Duration of surgery ranged from 60 to 110 minutes, with an average 90 minutes. The average postoperative hospital stay was 2.7 days. CONCLUSION: Endoscopic resection of deep-seated brain lesions with the neuronavigated tubular retractor is a safe and an effective technique and may be a feasible alternative to conventional microsurgical or endoscope-assisted methods in selected patients. The modified transparent plastic pediatric anoscope can be used as a tubular retractor and it is easy to apply, simple, lightweight, inexpensive and effective.

The Use of Neuronavigation and Intraoperative Imaging in Spinal Stabilization Surgery.

AIM: Misplacement of pedicle screw is the serious complication of spinal surgeries. Intraoperative imaging techniques and navigation systems are currently in use for the prevention of this complication. The aim of this study was to document the results of our experience with the navigation and intraoperative imaging technique and to share our experience with our colleagues. MATERIAL AND METHODS: Between 2011 and 2014, one hundred and two patients underwent instrumented spinal surgery while using intraoperative computed tomography (iCT) and a navigation system. All patients had a CT scan performed no more than three days postoperatively to confirm adequate placement of the screws. The accuracy of pedicle screw placement was assessed by postoperative CT scan. Pedicle violations were graded according to an established classification system. RESULTS: In the 36-month period, a total of 610 screws in 102 patients were evaluated. Stabilization surgery was performed in the lumbosacral region in 51 (50%) patients, lumbar region in 35 (34.31%) patients, cervical region in 5 (4.9%) patients, thoracolumbar region in 7 (6.86%) patients and thoracic region in 4 (3.92%) patients. Of the 610 screws, 396 (64.91%) were placed in lumbar, 66 (10.81%) in thoracic, 106 (17.37%) in sacral and 42 (6.8%) in cervical vertebrae. Of the 610 screws, 599 screws (98.18%) were placed without a breach. Grade 1 breaches occurred in 8 screws (1.31%), Grade 2 breaches occurred in 2 screws (0.32%), and Grade 3 breaches in 1 screw (0.16%). No dural defect or neurological deficit occurred after the surgeries. CONCLUSION: The use of an iCT scan associated with a navigation system increases the accuracy of pedicle screw placement. This system protects the surgical team from fluoroscopic radiation exposure and the patient from the complications of screw misplacement and repeated surgeries.