Anterior Subcutaneous Transposition With Expanded Polytetrafluoroethylene (ASTEP) for Cubital Tunnel Syndrome: Technical Note.

BACKGROUND: Ulnar nerve entrapment neuropathy at the elbow is the most common upper-extremity entrapment neuropathy after carpal tunnel syndrome. Surgical treatment can be complicated by perineural scarring and fibrosis, which may lead to recurrent symptoms. Expanded polytetrafluoroethylene (ePTFE) is a synthetic polymer with antiadhesive properties. OBJECTIVE: To introduce the operative technique and outcomes of anterior subcutaneous transposition with ePTFE (ASTEP) in primary and recurrent cubital tunnel neuropathy. METHODS: We studied 14 adult patients (11 men, 3 women; mean age, 45 yr) with cubital tunnel neuropathy (10 primary, 4 revision) who underwent surgery with the ASTEP technique between January 2008 and May 2018. Pain, numbness in the fourth/fifth fingers, and weakness of the intrinsic hand muscles were the most common presenting symptoms. Surgical outcomes were assessed using the modified McGowan and Wilson-Krout criteria. RESULTS: The average (± standard deviation) preoperative symptom duration was 12.1 ± 5.2 mo (McGowan Grade 1, n = 5; Grade 2, n = 6; Grade 3, n = 3). No intraoperative or postoperative complications were observed with the ASTEP technique. Postoperative follow-up ranged from 9 mo to 7 yr (mean, 4.3 yr). All 14 patients experienced improvement in or complete resolution of their symptoms after this unique intervention. CONCLUSION: Our novel technique of anterior transposition of the ulnar nerve with ePTFE was safe and highly effective in treating primary and recurrent ulnar nerve entrapment neuropathy at the elbow and represents an alternative to the current techniques.

Marking Basilar Artery Using Neuronavigation During Endoscopic Third Ventriculostomy: A Clinical Study.

AIM: To evaluate the efficacy of using a neuronavigation system for demonstrating the relationship between the basilar artery (BA) and ventricular floor during endoscopic third ventriculostomy (ETV). MATERIAL AND METHODS: Records of 28 patients (16 females and 12 males) diagnosed with obstructive hydrocephalus who had undergone a neuroendoscopic procedure were retrospectively examined. Patient age ranged from 1 to 76 years (median 24.46 years). The BA was marked with using the neuronavigation system in all cases to visualise its relationship to the floor of the third ventricle in real time. RESULTS: ETV was successfully performed in 28 patients with obstructive hydrocephalus. Of these, 13 (46.4%) patients had a thickened tuber cinereum (TC) membrane and 3 (10.7%) showed lateralization of the BA under the ventricular floor. No contact with the BA or related complications (e.g., major bleeding) was encountered with BA marking by using neuronavigation. CONCLUSION: Even though thickening of the TC membrane and/or displacement of the BA might be seen otherwise, we describe a new method that combines marking the BA and using neuronavigation to provide greater safety in the area where the ventriculostomy will be performed. This permits clearer orientation for the surgeon which significantly contributes to minimizing surgical morbidity.

MR Navigation and Tractography-Assisted Transcranial Neuroendoscopic Aspiration of Pediatric Thalamic Abscess.

AIM: Management of thalamic abscess is being considered as a contentious issue in neurosurgery. Regarding these lesions, besides removing the abscess, the most minimal morbidity is targeted during surgery and planning. MATERIAL AND METHOD: A 5-year-old female presented with the symptoms of altered consciousness and left hemiparesis. Her medical history pointed out that she was being followed up for a congenital cardiac anomaly consisting of transposition of the great arteries and a ventricular septal defect. A cranial MRI revealed 2 masses with peripheral contrast enhancement in the right frontal and thalamic regions. She was operated immediately and the right frontal mass, compatible with abscess, was totally excised with frontal mini craniotomy. The patient was hospitalized and followed up under intensive parenteral antibiotics. Control cranial imaging revealed progression in the size of the thalamic abscess, which was corroborative with the increased left hemiparesis. MR tractography was obtained and the patient underwent MR navigation and tractography combined neuronavigation-assisted transcranial neuroendoscopic aspiration of the thalamic abscess. RESULTS: The patient was stable in the early and late postoperative periods and her hemiparesis showed a dramatic recovery with no additional neurological deficits. CONCLUSION: Neuronavigation is considered as one of the techniques that aid the neurosurgeon to augment the success of surgery and minimize the morbidity, especially in critically localized lesions, i.e., eloquent areas. Combining MR navigation with MR tractography images and using them during neuronavigation to assist endoscopic procedures may decrease the surgical morbidity as much as possible.

The Effect of Phenyramidol on Neural Development in Early Chicken Embryo Model.

AIM: To investigate the effects of Phenyramidol (Phe) on neural development in an early chicken embryo model. MATERIAL AND METHODS: Sixty fertile non-pathogenic Super Nick eggs were incubated for 24 hours (h) and divided into four groups of 15 eggs each. Phe was administrated through the sub-blastoderm, and the eggs were incubated for another 24 h. All eggs were opened after 48 h of incubation, and the embryos were evaluated morphologically and histopathologically. RESULTS: In Group 1 (control group), none exhibited neural tube defects (NTDs) (0%), 1 (6.6%) was undeveloped; in Group 2 (low dosages), 1 did not develop (6.6%); in Group 3 (normal dosages), 2 (13.4%) had NTDs, 1 (6.6%) was undeveloped; in Group 4 (high dosages), 5 (33.3%) had NTDs, 2 (13.3%) were undeveloped. CONCLUSION: In light of the results, it was determined that the use of increasing doses of Phe led to defects in midline closure in early chicken embryos. This is the first report in the literature on Phe used in an early chicken embryo model.

Coincidental FCoincidental Feeding Artery Aneurysm Presenting during Glioblastoma Surgery: A Case Report and Literature Revieweeding Artery Aneurysm Presenting during Glioblastoma Surgery: A Case Report and Literature Review.

The medical literature reports an association between cerebral neoplasms and aneurysm formation. Some related aneurysms are detected during preoperative screening, whereas others are detected during or after surgery. We report a patient with de novo cerebral feeding artery aneurysm that we managed during glioblastoma surgery. We present a brief review of the literature on the coexistence of brain tumors, particularly that related to high-grade glioma and aneurysms. The literature discusses several mechanisms underlying tumor formation accompanied by aneurysm formation. Some classifications were also proposed for grouping such aneurysms. We question the necessity of the routine use of vascular imaging for patients with glioblastoma.

Surgical Management of Spinal Arachnoid Cysts in Adults.

BACKGROUND: Spinal arachnoid cysts (SACs) are uncommon lesions in the spinal canal. They are usually asymptomatic, but can occasionally cause mass effect leading to neurologic symptoms. They can be congenital or secondary to a variety of causes. They can produce a variety of neurologic symptoms including pain, weakness, sensory changes, incontinence, and more. Surgical intervention may be necessary when SACs cause symptomatic mass effect. METHODS: Thirteen consecutive patients who underwent surgical intervention for an SAC were retrospectively reviewed. The data included presenting symptoms, imaging findings, neurologic status, and follow-up. RESULTS: Of the 13 patients, the majority of cases were located in the thoracic spine (54%) and all but one case were located dorsally or dorsolaterally. Furthermore, 38% were located extradurally and 54% were located intradurally. Pain (80%) was the most common presenting symptom. Most patients had improvement or complete resolution of their symptoms after intervention. Extradural SACs and their capsules were completely resected, whereas intradural SACs underwent fenestration. No complications occurred in this series. CONCLUSIONS: SACs are usually asymptomatic, but rarely cause mass effect and neurologic deficits requiring surgical intervention. Surgical intervention is tailored to the position of the cysts' dorsal or ventral locations. Pain and weakness are the most likely symptoms to improve, whereas sensory symptoms are least likely to improve.

Single-Center Surgical Experience of the Treatment of Craniopharyngiomas With Emphasis on the Operative Approach: Endoscopic Endonasal and Open Microscopic Transcranial Approaches.

This study aimed to report the authors' single-center clinical experience about craniopharyngiomas and discuss surgical outcomes of these patients according to the type of surgical approach (endoscopic endonasal or open microscopic transcranial approach).Twenty-four patients diagnosed with craniopharyngiomas between May 2013 and April 2017 were considered for inclusion. The patients were divided into 2 groups according to the surgical approach (open transcranial microscopic approach [group A] and endoscopic endonasal approach [group B]). These groups were compared in terms of postoperative surgical outcome scores (extent of tumor removal, visual deficit, hydrocephalus, metabolic disorders, and Glasgow coma scale) and hospitalization interval.There was no patient of mortality in both groups. In this study, 4 of the 13 patients in group A and 9 of the 11 patients in group B underwent gross total resection. However, 1 patient in group B underwent repair because of cerebrospinal fluid leakage postoperatively. In addition, 1 patient in group A had a wound healing problem postoperatively. The postoperative outcome scores were 9.5 in group A and 11.5 in group B. The hospitalization interval in group A (range, 7-9 days) was longer than that in group B (range, 5-7 days).The endoscopic endonasal approach should be considered the first-line surgical treatment modality in patients with a preliminary diagnosis of craniopharyngioma in terms of low complication risk, minimal invasiveness, and better outcome scores. Open microscopic transcranial procedures may be combined with this approach in a single session for challenging cases.

Effect of Riluzole on Spinal Cord Regeneration with Hemisection Method Before Injury.

OBJECTIVE: The pathophysiology of spinal cord injury (SCI) with the information obtained to date has not been elucidated fully. A safe drug or treatment protocol that results in cell regeneration for SCI remains unknown. Neuroprotective and neuroregenerative effects of riluzole, administered after a SCI, have been shown in experimental studies. This study aimed to investigate the effect of riluzole on neural regeneration in a rat SCI model. METHODS: Thirty-two rats were divided into 8 groups, with 4 rats in each group. Hemisection method was performed after T7-T9 laminectomy. Rats were intraperitoneally aministered with riluzole (6 mg/kg). Locomotor recovery of the rats was assessed at 1 day, and 1, 2, 3, and 4 weeks after the 21-point Basso, Beattie, and Bresnahan test. Subsequently, the spinal cords of the rats were scored according to a semiquantitative grading system using a light microscope, and the numbers of myelinated axons, neurons, and glial cells were calculated. RESULTS: Basso, Beattie, and Bresnahan test changes were statistically significant when groups 4-6 and 8 were compared with the other groups (P < 0.05, P < 0.00625). The results of the numbers of neurons, glial cells, and myelinated axons were statistically significant. Especially group 8, in which riluzole was administered 5 days before injury, more positive clinical and histopathologic results were obtained. CONCLUSIONS: Riluzole treatment is more effective when provided before injury. Riluzole may contribute to functional recovery when used in the preoperative period in patients who are at a high risk for permanent neurologic deficit.

Surgical Management of Supratentorial Intracerebral Hemorrhages: Endoscopic Versus Open Surgery.

OBJECTIVE: Intracerebral hemorrhage continues to be a major global problem. No standard treatment or surgical procedure has been identified for intracerebral hemorrhages. High morbidity and mortality rates caused by conventional approaches and the disease itself have necessitated more-invasive treatment methods. The endoscopic approach is a more minimally invasive method than craniotomy, which is another alternative surgical treatment. METHODS: We compared intracerebral hematoma drainage in 2 groups of 17 patients each, treated with minimally invasive endoscopic method versus craniotomy. All the patients were treated for supratentorial spontaneous hemorrhage between December 2013 and February 2017 at the Neurosurgery Clinic of Ankara University Faculty of Medicine. RESULTS: We retrospectively evaluated 34 patients surgically treated between December 2013 and February 2017. All patients underwent surgery within the first 24 hours. Patients in the early surgery group had better surgical outcomes. In the neuroendoscopic group, Glasgow Coma Scale increased from 6 to 11 at 1 week postoperatively compared with 5 to 9 in the craniotomy group. CONCLUSIONS: Minimally invasive endoscopic hematoma evacuation may be a good alternative surgical method for treating supratentorial spontaneous cerebral hematomas.

FATAL RUPTURE OF DISSECTING ANTERIOR INFERIOR CEREBELLAR ARTERY ANEURYSM AS AN UNEXPECTED COMPLICATION AFTER ANTERIOR SKULL BASE SURGERY: A CASE REPORT.

Aneurysm of the anterior inferior cerebellar artery (AICA) is a very rare entity and the manifestation and manipulation of such aneurysms remain contentious. In this paper, we report a case where a successful surgery for an olfactory groove meningioma was performed and the patient discharged but readmitted to hospital with loss of consciousness and subsequently passed away three hours after re-admission. The patient was diagnosed with subarachnoid hemorrhage. The cause of the fatal subarachnoid hemorrhage was rupture of a new onsetting AICA dissecting aneurysm which had provided neither clinical nor radiological signs before the operation. We discuss the possible causes of the formation of such aneurysm.

Visualization of Superficial Cerebral Lesions Using a Smartphone Application.

AIM: Accurate localizations of cerebral lesions ensure good surgical outcomes and minimize intraoperative complications. Currently, microscope-integrated neuronavigation systems compensate these requirements. Since these units are expensive and large, the need to create more practical and portable systems in this "smart" century has become apparent. MATERIAL AND METHODS: The See-Through Camera smartphone application (app) is a photography app that penetrates the existing background picture and merges this with a camera image on the smartphone display. This app was applied to neurosurgery for visualization of the projection of the tumors over head in 20 patients. App accuracy was tested according to neuronavigation system. RESULTS: Precision of the app was evaluated according to the superposition ratio of the tumor image drawn by the navigation system with the tumor picture on the smartphone display. This ratio was 40%-100% in 16 (80%) patients and below 40% as an unfavorable result in the rest of the patients. CONCLUSION: Basic rationality of this app can provide the basis of future pocket navigation systems in terms of its design and principles.

Preoperative Exposure of Sigmoid Sinus Trajectory in Posterolateral Cranial Base Approaches Using a New Landmark Through a Neurosurgical Perspective.

The location of burr holes in posterolateral cranial base approaches should be appropriate to provide an adequate operative field, and surgical freedom is crucial for bone window opening. The aim of this study was to search for more convenient and easily detectable landmarks in comparison with current landmarks in posterolateral cranial base surgery. Twenty 3-dimensional reconstructed head and neck computed tomography angiography images (group 1) and 20 cadaver heads (group 2) were evaluated. An imaginary line connecting the angle of the mandible and the mastoid tip was extended upward. A second line passing through the lateral edge of the zygomatic arch was also extended posteriorly. The authors examined if the first line met with the sigmoid sinus throughout its course and determined the location of the intersection point of these 2 lines relative to the sigmoid-transverse sinus junction. The intersection point did not correspond to the sinus region in 3 images from group 1 and 4 specimens from group 2. The matching of the mandibula-mastoid line trajectory with the sigmoid sinus course was unacceptable in 4 images and 5 cadavers. For venous anatomy preservation and anatomic skull base fossa orientation during posterolateral cranial base approaches, upward extension of the mandibula-mastoid line can be a proper landmark for surgical planning in this region. The authors' proposed superficial anatomical line and intersection point over the skull could be used as a reliable indicator for the external projection of the sigmoid sinus and an appropriate initial burr-hole location.

Staged Bilateral Nucleus Caudalis DREZ Lesioning for Persistent Idiopathic Facial Pain: Exceptional Case Report.

Persistent idiopathic facial pain (PIFP) is a rare but challenging type of facial pain. How to manipulate such a problem becomes more contentious in cases with bilateral complaints. In situations when conventional treatments fail to reduce the pain, some treatment options like nucleus caudalis dorsal root entry zone (DREZ) lesioning shine as valuable means of managing such intractable problems. Herein, we report an individual with bilateral PIFP in which the patient suffered from intractable pain and was the first to undergo bilateral nucleus caudalis DREZ operation for PIFP. The patient was followed up and the procedure resulted in immediate and complete pain relief.

A curative treatment option for Complex Regional Pain Syndrome (CRPS) Type I: dorsal root entry zone operation (report of two cases).

Complex Regional Pain Syndrome Type I (CRPS-I) is a debated health problem concerning its pathophysiology and treatment strategies. A 12-year-old boy and a 35-year-old woman were diagnosed with CRPS-I at different times. They had previously undergone various types of interventions with no success. After one year of follow-up and observation, DREZ lesioning operation was performed. Afterwards, both cases had transient lower extremity ataxia. The first case was followed for 60 months with no recurrence and total cure. The second case was pain-free until the 6th month, when she required psychological support; she was followed for 33 months with partial satisfactory outcome. Although not a first-line option, DREZ lesioning procedure can be chosen and may be a curative option in selected cases of CRPS-I who are unresponsive to conventional therapies.

New practical landmarks to determine sigmoid sinus free zones for suboccipital approaches: an anatomical study.

Literature defines the landmarks to identify the courses and locations of the transverse and sigmoid sinuses on the outer surface of the skull and inner surface of the scalp. These natural landmarks may only be helpful after skin incision and are inadequate to determine the length and size of the skin incision. Still, there is a need to identify palpable landmarks easily to determine the ideal location to open the initial burr hole before an operation. Twenty-eight dried adult human skulls and 2 cadavers were evaluated. The zygomatic root, the inion, and the mastoid process were identified on the external, and the grooves for sigmoid and transverse sinuses, on the internal surfaces. The distances between the 3 landmarks and the midpoints, and the shortest distances of the midpoints to the border of the groove for sigmoid sinus and groove for transverse sinus were measured. Statistically significant differences were evaluated for both sides. Based on the measurements, the defined "artificial landmarks" can be considered safe points that involve no vascular structures and may be used to perform the initial burr hole during posterolateral approaches. Identification of the midpoints and palpation of the defined landmarks easily before the operation render the study feasible and practical unlike with natural landmarks. To avoid venous injury, the midpoints of mastoid-inion line and zygomatic root-inion line can be used safely in skin incision during posterior fossa approaches and craniotomy.

Olfactory functions after transsphenoidal pituitary surgery: endoscopic versus microscopic approach.

OBJECTIVES/HYPOTHESIS: Olfactory disturbances could be observed following transsphenoidal pituitary surgeries. To our knowledge, no previous comparative studies on olfactory functions after transsphenoidal endoscopic and microscopic approaches have been performed. STUDY DESIGN: Prospective study comparing olfactory functions between endoscopic and microscopic transsphenoidal pituitary surgery. METHOD: Twenty-five patients operated on with the endoscopic approach and 25 patients operated on with the microscopic transsphenoidal approach have been evaluated. The Smell Diskettes Olfaction Test was used during the preoperative period, 1 month after the operation, and 6 months after the operation. In addition, the relationship between intraoperative cerebrospinal fluid leakage from the pituitary and postoperative synechiae formation with olfaction system was evaluated. The results were analyzed using the Friedman test, Mann-Whitney test, and Chi-Square test. RESULTS: In the endoscopic group, there were two hyposmic patients and no anosmic patients. In the microscopic group, there were 13 hyposmic patients and five anosmic patients. The data was statistically different between both groups (P <0.05). Cerebrospinal fluid leakage was observed in nine patients in the endoscopic group and in 10 patients in the microscopic group. There was no statistically significant difference between cerebrospinal fluid leakage and olfactory disturbances in both groups (P >0.05). Synechia was observed in nine patients in the microscopic group and in only one patient in the endoscopic group. There was a statistically significant difference between the presence of synechia and olfactory disturbances (P <0.05). CONCLUSIONS: This is the first study to seek the difference between the endoscopic and microscopic transsphenoidal approaches on the olfactory system during pituitary surgery. The obtained results indicate that an endoscopic approach seems to be more advantageous than a microscopic approach for protecting olfactory system and function.

CT-guided percutaneous cordotomy for intractable pain in what is more than a disease: lung malignancies.

AIM: Lung cancer is the leading cause of cancer-related mortality worldwide. Pain is a common problem in these patients, yet inadequate or dissatisfactory management is prevalent. MATERIAL AND METHODS: Between 1987 and 2012, 224 patients with intractable pain were treated with computerized tomography (CT)- guided cordotomy. Among them, 210 had intractable pain due to malignancies. The majority of the cases were diagnosed as pulmonary malignancies (108 patients). Sixty-seven were pulmonary carcinoma, 26 mesothelioma and 15 Pancoast tumors. RESULTS: After cordotomy, 98.13% of cancer patients reported initial pain relief. Minimum and maximum preoperative scores of the Karnofsky Performance Scale were 20 and 70, versus postoperative scores of 40 and 90 (p < 0.001). The median preoperative VAS score was 8 (6-9). On the first postoperative day, the score dropped sharply to 0 (0-8) (p < 0.001). In this selected series of 108 percutaneous cordotomy procedures, as well as in the total series of 224 patients, there was no mortality or major morbidity. CONCLUSION: CT-guided percutaneous cordotomy is an effective procedure that should be used in the treatment of cancer-related pain problems. We suggest that cordotomy should be preferred as soon as possible in patients who fail to respond to the classic analgesic therapy.

Management of bilateral trigeminal neuralgia with trigeminal radiofrequency rhizotomy: a treatment strategy for the life-long disease.

BACKGROUND: The objective of this study was to evaluate the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). Patients were analyzed after RF-TR in terms of outcome, safety and complications. METHODS: Eighty-nine BTN patients underwent 186 RF-TR procedures. Eighty-seven patients had idiopathic trigeminal neuralgia (ITN) and two patients had multiple sclerosis (2.2%). Fifty-six (62.9%) were women and 33 (37.1%) were men. Ages ranged from 29 to 85 years. Anesthesia was administered at a determined optimal level, allowing patient cooperation for controlled and selective lesioning. RESULTS: The mean follow-up period was 101.71 ± 77.7 months. Familial occurrence was seen in two (2.2%) patients. Synchronized pain was observed in 25 (28.2%) patients. Pain occurrence on the contralateral side was observed with an average duration of 124.7 ± 87.13 months. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%). CONCLUSIONS: RF-TR is an effective, selective, well-controlled, and effortlessly repeatable procedure for treating BTN, especially in the elderly, in terms of low morbidity and mortality rates and high rate of satisfactory pain relief.