Postsurgical Size-Changing Temporal Lobe Arachnoid Cysts in Patients with Trigonocephaly Who Underwent Reconstructive Surgery: A Two-Case Report.

INTRODUCTION: Trigonocephaly (TC), the tapering of the metopic suture toward the anterior, lateral inadequacy of supraorbital bar, hypoplasia of the ethmoid bone, and hypotelorism due to orbital medialization leads to a triangular shape in the head together with frontotemporal stenosis and widening of the biparietal diameter. Arachnoid cysts (ACs) are benign cysts, which are formed by cerebrospinal-fluid entrapment into the arachnoid membrane due to duplication or separation of the arachnoid membrane layers. ACs are typically located in the middle cranial fossa and Sylvian fissure region. They are mostly detected incidentally through neuroimaging. The coexistence of TC and AC is considerably rare; hence, its actual incidence is unknown. To our knowledge, the coexistence of nonsyndromic TC and AC has been revealed in only 2 publications in the literature. In this case study, 2 patients, one of whom were with unilateral and the other with bilateral temporally localized ACs, sizes of which increased following the reconstructive surgeries, and who underwent reconstructive surgery for TC, were presented. CASE REPORT: Both of the 2 patients that we have presented in our study are 7 months old and male. Fronto-orbital advancement and calvarial remodeling operations were performed on both. ACs of the patients were not intervened. However, in the post-op follow-ups, the left temporal cyst of the 1st case and the right cyst of the 2nd case grew radiologically, and the left cyst became very small. DISCUSSION/CONCLUSION: TC must be treated surgically. ACs may show changes in size secondary to the increase in intracranial volume following reconstructive surgery for TC. However, if it does not give rise to any complaints, it can be followed-up clinically and radiologically. Patients should be followed-up for many years, given that neurodevelopmental and behavioral problems may occur later in both pathologies.

Management of Traumatic Epidural Hematoma in Infants Younger than One Year: 50 Cases - Single Center Experience.

AIM AND BACKGROUND: Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature. MATERIAL AND METHODS: There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology. RESULTS: Patients' age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (<1 m) was the most frequent trauma mechanism, with a 96% rate. The most common finding was irritability and unusual crying (88%). The CCS score was 5-15 (median 13). The hematoma was located most frequently in the parietal region (48%) and least frequently in the posterior fossa (2%). Linear fracture was observed in 62% of the cases. Thirty-nine (78%) patients were treated conservatively (hematoma thickness ≤17 mm). Eleven (22%) cases were surgically treated (hematoma thickness was between 15 and 40 mm (26.3 ± 6.6 mm, mean ± standard deviation [SD]). The midline shift in the operated cases was between 1.8 and 11.8 mm (6.4 ± 3 mm, mean ± SD). One of them with a hematoma thickness of 15 mm was operated for associated open depression fracture above the hematoma. Other 10 patients were operated for primarily hematoma evacuation. None of the patients treated conservatively worsened neurologically or required operation during or after hospitalization. Two patients died (4%) during hospitalization, and both of them were anisocoric on admission. The hospital stay was between 1 and 10 (median 3) days, and the follow-up period of the living patients was between 1 month and 6 years (median 24 months). All of the living patients were neurologically normal on their last controls. CONCLUSIONS: Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.

The Importance of Spinopelvic Parameters in Recurrent Lumbar Disk Herniation.

STUDY DESIGN: Retrospective clinical study. OBJECTIVES: We aimed to investigate preoperative spinopelvic mismatch as a risk factor for recurrent lumbar disk herniation (RLDH) in patients undergoing lumbar disk herniation (LDH) surgery. SUMMARY OF BACKGROUND DATA: Spinopelvic parameters have been associated with lumbar degenerative diseases, particularly LDH. However, the relationship between these parameters and RLDH has yet to be studied. MATERIALS AND METHODS: Data of 1453 patients aged ≥18 who underwent single-level, unilateral fenestration microdiscectomy for the first time in our hospital between 2013 and 2019 were reviewed. The study group comprised 88 patients who underwent surgery for RLDH. The control group comprised 101 randomly selected patients who underwent surgery for LDH but not RLDH. Age, sex, body mass index, occupational activity level, operative level, Roussouly classification type, and time to recurrence were recorded. Moreover, pelvic incidence, lumbar lordosis (LL), interverteberal disk height (IDH), segmental lordosis, sacral slope (SS), pelvic tilt (PT), and sacral table angle (ST) were measured for each patient. Pelvic mismatch was calculated. RESULTS: Mean age was 46.5±11.4 y (range, 20-70). Both groups were similar concerning age, sex, body mass index, occupational activity level, and level of surgery. The mean time to recurrence was 167.3±36.6 d (range, 62-363). Measurements in the RLDH group were as follows: IDH=7.6±1.5 mm, pelvic incidence =54.4°±10.1°, LL=47.3°±13°, segmental lordosis =9.3°±5°, SS=35.1°±9.9°, and PT=19.3°±7.3°. Mean IDH was significantly lower in the RLDH group ( P =0.02). Less LL and lower PT at L3-4 level and increased SS at L5-S1 level were considered risk factors for RLDH. CONCLUSION: This study showed that preoperative low IDH is at higher risk for RLDH in patients undergoing LDH surgery. LL, PT, and SS may be risk factors for specific levels.

Craniometric Measurements and Surgical Outcomes in Trigonocephaly Patients Who Underwent Surgical Treatment.

Objective The aim of this study was to discuss the results of craniometric measurements and surgical treatments in patients operated for isolated trigonocephaly (TC) in light of the current literature. Methods A total of 18 cases who underwent surgery for isolated TC were included in the study. Age, gender, family history, follow-up time, complications, duration of surgery, surgical blood loss, and amount of blood replacement in these patients were recorded. Craniometric measurements such as metopic angle (MA), cephalic index (CI), interparietal distance (IPD), intercoronal distance (ICD), and their ratio to each other were evaluated according to pre-and postoperative parameters. Photographs of the patients were taken before and after the operation. The Whitaker classification and Kampf "aesthetic outcome staging" were used in the evaluations. Results The mean MA values after the operation increased to reach above 147 degrees in all cases. The average CI did not change. ICD measurement averages increased significantly. The average IPD/ICD ratio decreased due to the increase in ICD and the enlargement of the anterior fossa after the operation. According to the Whitaker classification and Kampf "aesthetic outcome staging" scale, 17 of our cases were at stage I, rated as perfect, and one was at stage II, rated as good. Conclusion Surgery performed at the appropriate time for TC yields cosmetically satisfactory results. Since potential neurological and cognitive morbidities occur mostly in school-age patients, long-term follow-up of the cases is required. Performing craniometric measurements enables patients to be evaluated with objective and measurable numerical data.

Which Objective Nutritional Index Is Better for the Prediction of Adverse Medical Events in Elderly Patients Undergoing Spinal Surgery?

OBJECTIVE: The relationship of preoperative malnutrition with perioperative adverse medical events (PAMEs) has not been well studied in elderly patients undergoing spinal surgery (SS). We aimed to compare the Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT) score, and Geriatric Nutritional Risk Index (GNRI) for prediction of PAMEs in elderly patients undergoing SS. METHODS: Data of 454 patients ≥65 years old undergoing SS were reviewed. PAMEs were defined as death, cardiopulmonary complications, respiratory failure, acute kidney injury, pneumonia, delirium, cerebrovascular events, and sepsis. The area under the receiver operating characteristic curve was used to compare the predictive value of each nutritional index for PAMEs. RESULTS: Incidence of PAMEs was 15.3%. Patients who had PAMEs had significantly lower GNRI and PNI but higher CONUT score before surgery compared with patients without PAMEs. Multivariate analysis showed that age (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.01-4.75, P = 0.014), chronic renal failure (OR 1.34, 95% CI 1.03-3.82, P = 0.002), coronary artery disease (OR 1.12, 95% CI 1.11-3.54, P = 0.028), PNI <45.4 (OR 2.12, 95% CI 1.16-4.80, P = 0.011), CONUT score >5 (OR 2.17, 95% CI 1.03-3.76, P = 0.001), and GNRI <92 (OR 2.68, 95% CI 1.20-6.45, P < 0.001) were significant predictors of PAMEs. The receiver operating characteristic curve showed that GNRI had much greater discriminatory ability regarding PAMEs than PNI and CONUT score. CONCLUSIONS: Preoperative malnutrition is associated with PAMEs in elderly patients undergoing SS. GNRI had the highest accuracy for predicting PAMEs among the nutritional indices studied.