Effectiveness and Safety of Epilepsy Surgery for Pediatric Patients with Intractable Epilepsy: A Clinical Retrospective Study from a Single-Center Experience.

INTRODUCTION: Pediatric epilepsy surgery is an effective treatment modality for patients with drug-resistant epilepsy (DRE). Early pediatric surgery yields favorable results for DRE in terms of seizure control and neurophysiological outcome. In this study, pediatric patients were categorized based on their age (above 3 years old and below 3 years old) to demonstrate the effectiveness and safety of surgical procedures. METHODS: In this retrospective, single-center study, 60 pediatric patients who underwent epilepsy surgery at Istanbul Faculty of Medicine between 2002 and 2018 were evaluated. Overall morbidity and mortality rates, as well as seizure outcomes of the patients, were assessed and compared based on two age groups: those aged 3 years old or younger and those older than 3 years old. The effectiveness of invasive monitoring was also evaluated in relation to pathological results. The postoperative seizure outcome rates were evaluated using Engel's classification, with an average follow-up period of 8.7 years. RESULTS: Out of the total number of patients, 47 (78.4%) underwent resective surgery, while 13 (21.6%) had palliative surgery. Ten patients (16.6%) had invasive monitoring. Among all patients, 34 were classified as Engel I and II (56.6%), while 26 were classified as Engel III and IV (43.4%) postoperatively. 47% of patients who were under 3 years old, 60.4% of patients who were over 3 years old, and 50% of patients who underwent invasive monitoring had a favorable seizure outcome (Engel I-II). Postoperative morbidity and mortality rates were 35% (n = 21) and 1.6% (n = 1), respectively. CONCLUSION: Pediatric epilepsy surgery is an important treatment modality for preserving cognitive abilities and providing effective treatment for pediatric DRE. In our study, we claim that both invasive monitoring and epilepsy surgery lead to favorable seizure outcomes for all age groups. Further clinical studies should be conducted to provide more reliable data on the safety and effectiveness of the surgery, particularly in patients under the age of three.

Focal cortical dysplasia pathology: diagnostic difficulty, classification, and utility for pathogenesis.

OBJECTIVE: In the histopathological examination of treatment-resistant epilepsy, focal cortical dysplasia (FCD) is the most common diagnosis in the pediatric group. FCD is classified histopathologically according to the International League Against Epilepsy (ILAE) classification. In the last decade since the ILAE classification has been released, molecular genetic studies have revealed mTOR pathway-related mutations as a major etiology. The objective of this study was to determine the incidence of FCD in treatment-resistant epilepsy patients, explore histomorphological and immunohistochemical features, examine clinicopathological correlation, demonstrate mTOR pathway activation using a pS6 antibody immunohistochemically, and try to introduce a candidate for possible targeted therapies. METHODS: Paraffin blocks and slides of tissue from patients with treatment-resistant epilepsy were reexamined retrospectively. Histopathological subtypes of FCD were determined according to the ILAE classification. NeuN and neurofilament H (NF-H) staining were performed, and additionally a pS6 antibody was used to demonstrate mTOR pathway activation. RESULTS: In 32 cases diagnosed with FCD, or 17.5% of 183 surgical epilepsy materials, there were no significant differences in the statistical analysis of clinical variables between the ILAE FCD subtypes. Recommended antibody NeuN revealed microcolumnar alignment in the FCD type Ia and IIIa groups and the loss of lamination in the type Ib group. Another recommended antibody, NF-H, was not found to be useful in discriminating between normal and dysmorphic neurons. pS6 expression, showing mTOR pathway activation, was observed in dysmorphic neurons and balloon cells in all FCD type II cases. CONCLUSIONS: Significant pS6 expression in FCD type II represents the genomic nature of the disease noted in the literature. Nevertheless, the known MTOR gene and mTOR pathway-related mutations remain behind proportionally to explain the mTOR pathway activation in all FCD type II cases. Clinicopathologically and genetically integrated classification and usage of mTOR pathway inhibitors in treatment are expected as a recent evolution.

Intracranial cystic meningiomas: A series of six patients / Meningiomas quísticos intracraneales: una serie de seis pacientes

Objective: Although meningiomas are the most common primary non-glial intracranial tumors, cystic meningiomas are quite rare. This study presents six cases in order to discuss the radiological and pathological features of cystic meningiomas. Patients and methods: Six patients with cystic meningiomas were included in the study. All patients underwent a cranial computed tomography scan and magnetic resonance imaging (MRI) evaluation, pre- and postoperatively. Results: All patients presented with long standing headache dating back at least two years. There was no gender predominance in our series. Radiological evaluation revealed two parasagittal and two convexity meningiomas located at the frontal region. Two lesions were located at the tuberculum sellae and the foramen magnum. All of the tumors were totally excised (Simpson Grade I or II). Pathology results included meningothelial meningioma in three patients, angiomatous meningioma in two patients, and metaplastic meningioma in one patient. In two patients, the cystic meningiomas were resected with the use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter. Na-Fl was found to be very useful in demonstrating the brain-tumor interface, and it was especially effective in resecting the cyst wall of the peritumoural cystic meningiomas. None of the patients had any complications, and no recurrences were noted in any of the patients within the mean follow-up period of 51 months (range: 16-102 months). Conclusion: It is important to note MRI changes specific to cystic meningioma and include meningiomas in the differential diagnosis of intracranial cystic lesions. The use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter is a useful tool to differentiate the brain-tumor interface, as well as to identify the cyst wall in order to fully resect the tumor with the cystic component to avoid recurrence and achieve better clinical results

Objetivo: Aunque los meningiomas son los tumores intracraneales primarios no gliales más frecuentes, los meningiomas quísticos son bastante raros. Este estudio presenta 6 casos para discutir las características radiológicas y patológicas de los meningiomas quísticos. Pacientes y métodos: Se incluyeron 6 pacientes con meningiomas quísticos en el estudio. Todos los pacientes se sometieron a una tomografía computarizada craneal y a una evaluación por resonancia magnética, antes y después de la operación. Resultados: Todos los pacientes presentaron dolor de cabeza de larga duración de al menos 2 años. No hubo predominio de género. La evaluación radiológica reveló 2 meningiomas parasagitales y 2 de la convexidad ubicados en la región frontal. En los otros 2 pacientes las lesiones se ubicaron en el tubérculo selar y en el foramen magno respectivamente. Todos los tumores fueron totalmente extirpados (grado de Simpson I o II). En 2 pacientes, los meningiomas quísticos se resecaron con el uso de fluoresceína de sodio bajo un filtro de microscopio AMARILLO de 560nm. Se encontró que la fluoresceína de sodio era muy útil para demostrar la interfaz entre el cerebro y el tumor, y fue especialmente eficaz para resecar la pared de los quistes peritumorales. Los resultados de histopatología incluyeron meningioma meningotelial en 3 pacientes, meningioma angiomatoso en 2 y meningioma metaplásico en uno. Ninguno de los pacientes presentó ninguna complicación, y no se observaron recurrencias en ningún paciente dentro del período de seguimiento medio de 51 meses (rango: 16-102 meses). Conclusión: Es importante tener en cuenta los cambios en la resonancia magnética específicos de los meningiomas quísticos e incluir estos tumores en el diagnóstico diferencial de las lesiones quísticas intracraneales. El uso de fluoresceína de sodio bajo un filtro de microscopio AMARILLO de 560nm es una herramienta útil para diferenciar la interfaz cerebro-tumor, así como para identificar la pared del quiste y resecar completamente el tumor con el componente quístico para evitar la recidiva y conseguir mejores resultados clínicos

Aortic Injury by Thoracic Pedicle Screw. When Is Aortic Repair Required? Literature Review and Three New Cases.

PURPOSE: Aortic injury by pedicle screw is rare but can cause serious complications. It has not been clearly determined when aortic repair is necessary in cases of screw impingement without perforation of the aortic wall. In this article, we review the treatment and clinical course of pedicle screw aortic impingement and attempt to clarify this issue. METHODS: Cases of aortic injury during thoracic screw procedures were found using a MEDLINE search and analyzed together with 3 new cases that we present. RESULTS: Nineteen cases collected from the literature and 3 new cases were included in the study. In 7 of the cases, aortic impingement by the pedicle screw was detected during postoperative follow-up (day 1) radiologic examinations. In the other cases, time to presentation of aortic impingement ranged between 2 weeks and 60 months after fixation. The main indications for thoracic spinal fixation were post-traumatic vertebral fracture and kyphoscoliosis/scoliosis. Repair of the aortic damage ranged from primary repair to stent and tube graft placement by the thoracic endovascular aortic repair method. CONCLUSIONS: In cases in which the screw impinges less than 5 mm into the aortic wall, hardware revision without aortic repair may be sufficient if recognized early and there are no sign of aortic leakage in vascular imaging. However, cases with more than 5 mm of screw impingement should undergo aortic repair first, even in the absence of aortic leakage, following by screw revision.

Intracranial cystic meningiomas: A series of six patients.

OBJECTIVE: Although meningiomas are the most common primary non-glial intracranial tumors, cystic meningiomas are quite rare. This study presents six cases in order to discuss the radiological and pathological features of cystic meningiomas. PATIENTS AND METHODS: Six patients with cystic meningiomas were included in the study. All patients underwent a cranial computed tomography scan and magnetic resonance imaging (MRI) evaluation, pre- and postoperatively. RESULTS: All patients presented with long standing headache dating back at least two years. There was no gender predominance in our series. Radiological evaluation revealed two parasagittal and two convexity meningiomas located at the frontal region. Two lesions were located at the tuberculum sellae and the foramen magnum. All of the tumors were totally excised (Simpson Grade I or II). Pathology results included meningothelial meningioma in three patients, angiomatous meningioma in two patients, and metaplastic meningioma in one patient. In two patients, the cystic meningiomas were resected with the use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter. Na-Fl was found to be very useful in demonstrating the brain-tumor interface, and it was especially effective in resecting the cyst wall of the peritumoural cystic meningiomas. None of the patients had any complications, and no recurrences were noted in any of the patients within the mean follow-up period of 51 months (range: 16-102 months). CONCLUSION: It is important to note MRI changes specific to cystic meningioma and include meningiomas in the differential diagnosis of intracranial cystic lesions. The use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter is a useful tool to differentiate the brain-tumor interface, as well as to identify the cyst wall in order to fully resect the tumor with the cystic component to avoid recurrence and achieve better clinical results.

Combined and individual use of pancaspase inhibitor Q-VD-OPh and NMDA receptor antagonist riluzole in experimental spinal cord injury.

BACKGROUND: We investigated the effects of an N-methyl-D-aspartate receptor antagonist, riluzole, and a pancaspase inhibitor and basic apoptosis mediator, Q-VD-OPh, in combination or alone in posttraumatic spinal cord injury. METHODS: In our study, 45 healthy male Sprague Dawley rats were used. Spinal trauma was induced by the clip compression technique via thoracal 7, 8, 9 laminectomies. After inducing the trauma, the drug was continuously administered intraperitoneally for 5 days. After inducing the trauma, the subjects were assessed using Tarlov's motor grading scale and inclined plane test. Five days after the trauma, the spinal cord specimens were harvested, and a histopathological examination was performed. RESULTS: Compared with the other groups, a statistically significant difference with regard to better results for necrosis, inflammation, and apoptosis was observed in the riluzole only and combination groups. Statistically better motor function scores were observed in the Q-VD-OPh only group than in the other groups. CONCLUSION: With regard to limiting secondary damage after trauma, statistically significant results were observed in the Q-VDOPh only and Q-VD-OPh-riluzole combination groups. More extensive laboratory studies are required to limit and control the effects of secondary damage after spinal cord trauma.

Percutaneous Fully Endoscopic Interlaminar Approach to the Filum Terminale: A Cadaveric Study.

OBJECTIVE: To investigate the utility, safety, and feasibility of a novel endoscopic technique for the visualization and surgical manipulation of the filum terminale in fresh postmortem adult human cadavers. METHODS: The filums from 18 fresh postmortem adult human cadavers were explored with a percutaneous fully endoscopic interlaminar approach. After the filum was identified and the nerve roots were dissected away from it, the filum was cut. A specimen was sent for histopathologic examination. RESULTS: In 15 of 18 (83%) cadavers, the filum terminale could be visualized. A specimen for histopathologic examination was obtained from 11 of 15 (73%) visualized filums. Histopathologic examination revealed that 2 of them were fatty filums, 7 were normal filums, and 2 were peripheral nerves. CONCLUSIONS: We have described a successful and feasible percutaneous fully endoscopic interlaminar approach to the filum terminale. This technique provides a smaller skin incision, narrow durotomy, and minimal tissue damage. Animal studies are necessary to prove the feasibility and safety of our method before clinical use.

Serum creatine phosphokinase levels as an indicator of muscle injury following lumbar disc surgery: Comparison of fully endoscopic discectomy and microdiscectomy.

OBJECTIVE: The aim of this study is to make a comparison between fully endoscopic lumbar discectomy (FELD) and conventional microdiscectomy (MD) by using pre- and postoperative serum creatine phosphokinase (CPK) levels in correlation with postoperative low-back pain. METHODS: Fortyfive consecutive patients who underwent surgery for lumbar disc herniation were allocated into three groups with 15 patients on each: (1) FELD with interlaminar approach (IL), (2) FELD with transforaminal approach (TF), (3) Conventional MD. Serum CPK levels pre- and 1, 6, 12 and 24h postoperatively, patients' body mass index (BMI), operation duration and hospital stays were recorded. The low-back pain pre- and postoperatively was assessed with the use of the 100mm visual analog scale (VAS) and the "Oswestry Disability Index" (ODI). RESULTS: There were 16 female (35.5%) and 29 male (64.5%) patients with a mean age of 44.1 years. CPK levels at 6th, 12th and 24th hours postoperatively were found significantly lower in TF and IL groups compared to MD group (p<0.004). Mean operation duration was significantly shorter in MD group (p: 0.014). There was a significant decrease in both the VAS and ODI scores after the surgery in all patient groups (p<0.001). Postoperative VAS scores were found significantly higher in MD group (p: 0.04). CONCLUSION: Minimal invasive nature of FELD procedures compared to the MD was substantiated by serum CPK levels in this study. To draw definitive conclusions regarding pain relief, larger patient samples should be evaluated, although postoperative VAS scores were found in favor of FELD.