Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization.

AIM: Brain arteriovenous malformations (AVMs) are congenital anomalies that present as intracranial hemorrhage or epilepsy. AVMs often remain clinically silent for extended periods. Although AVM treatment methods are controversial, three treatment strategies are usually combined or applied alone: surgical removal, embolization and stereotactic radiosurgery. We compared clinical and radiological outcomes in intracranial AVM patients treated via surgical resection with and without prior embolization. MATERIALS AND METHODS: Patients who did (30 patients) and did not (30 patients) undergo endovascular embolization before surgical resection at the Izmir Katip Çelebi University Atatürk Training and Research Hospital Neurosurgery Clinic from 2011 to 2019 were included in this retrospective, cohort study. Symptoms at diagnosis, comorbidities and clinical (AVM and Spetzler-Martin grade) and morphological characteristics were assessed. RESULTS: A mean one-year follow-up assessed outcomes using the modified Rankin score, and imaging studies assessed AVM obliteration post-procedure. Mean operation times for surgical resection with and without embolization were 166.50 ± 32.02 and 204.47 ± 26.66 min, respectively. Mean patient hospitalization periods for surgical resection with and without embolization were 8.43 ± 3.60 and 12.00 ± 5.51 days, respectively. CONCLUSION: Among patients who underwent surgical resection, significant operation time and hospitalization time differences were observed in favor of patients who underwent embolization, indicating that preoperative embolization is a safe and beneficial method for treating ruptured and non-ruptured AVMs.

Modified Tap-drilling Technique for Mid-cervical Pedicle Screw Placement: A Case Series of 473 Consecutive Screws.

STUDY DESIGN: Retrospective cohort study. OBJECTION: To report our modified tap-drilling technique for mid-cervical pedicle screw placement and to evaluate its safety and accuracy. SUMMARY OF BACKGROUND DATA: Cervical pedicle screw fixation, which provides a strong stabilization, has been a major concern due to the potential risks to neurovascular structures despite its increasing use. Several insertion techniques have been described so far to improve the cervical pedicle screw placement accuracy. METHODS: This study retrospectively reviewed patients who underwent mid-cervical (C3-C6) pedicle screw fixation between September 2005 and September 2020. Laminectomy, laminoforaminotomy, or notch-referred anatomic landmark methods were used to adjust the entry point and the direction of the screws. After the cortical bone was removed at the entry point with a diamond burr, the cancellous bone was slowly drilled with a hand drill starting from 8 to 10 millimeters in length. Then, all of the bone walls were checked with a ball-tip probe to determine if there was any breach. The procedure was repeated several times. After completing the drilling, the screw was inserted without tapping. The breach rate of pedicle screws was analyzed on postoperative computed tomography scans. RESULTS: A total of 473 mid-cervical pedicle screws were placed in 122 consecutive patients. No navigation or computer-assisted system was used, and the first 2 authors inserted all of the screws. All patients completed the surgery, and no evident intraoperative complications occurred. Postoperative CT scans were obtained for 405 screws. Although deviation was observed for 131 pedicle screws, a critical deviation was observed for only 25 pedicle screws. CONCLUSIONS: Cervical pedicle screw insertion is a risky but applicable technique. Checking all of the bone walls with a ball-tip probe before gradually advancing the hand drill in small amounts, as presented in this article, may lead to the safe and effective placement of cervical pedicle screws.

Evaluation of Percutaneous Unilateral Kyphoplasty Results in Osteoporotic Vertebral Compression Fractures Using Individual 3D Printed Guide Template Support.

AIM: To compare the clinical and radiological outcomes of unilateral percutaneous kyphoplasty (PKP) surgeries performed using 3D printing technology in patients with osteoporotic compression fractures to conventional unilateral PKP surgeries. MATERIAL AND METHODS: Patients with acute painful single-level osteoporotic vertebral compression fracture (OVCF) who need surgical treatment were divided into two groups: group A (patients who had 3D template-guided PKP) and group B (patients who conventional PKP). To compare the two surgical procedures, Total Absorbed Radiation Dose (TARD), pre- and postoperative visual analog scale (VAS) scores, and Total Surgery Time (TST) were calculated and compared between groups in both surgical groups. RESULTS: A total of 44 patients with single-level OVCF who were experiencing acute pain were successfully operated on, with 22 patients in each group. TARD (2.6 ± 0.4 mGy vs. 6.1 ± 1.9 mGy, p < 0.05) and TST (12.4 ± 2.6 min vs. 20.2 ± 3.2 min, p < 0.05) differed significantly different between groups A and B. There was no statistically significant difference between the patient groups in preoperative and postoperative VAS values (p > 0.05). Cement leakage was lower in group A (3/22, 13.6%) than in group B (6/22, 27.3%) (p > 0.05). There were no neurological complications or infections in either group. CONCLUSION: When compared to the conventional procedure, the unilateral percutaneous kyphoplasty method was supported by a 3D printing guide template. By reducing operative time and radiation exposure, tt has resulted in a more effective surgical procedure for patients and a safer surgical procedure for surgeons and anaesthesiologists.

Importance of Preoperative Vertical Geometric Analysis in Surgery for Anterior Communicating Artery Aneurysm.

OBJECTIVE: In this study, we analyzed the vertical geometry of the anterior communicating artery (AComA) complex with the aim to improve the surgical site orientation during aneurysm operations. Further, the geometric data that can contribute to the success of the surgical technique applied for AComA aneurysms are reported. METHODS: Computed tomography angiography data of the cerebral arteries of 100 patients who visited our clinic were analyzed. A three-dimensional examination was performed according to the Frankfurt horizontal plane (FHP) using the RadiAnt DICOM Viewer (Medixant, Poznan, Poland), and vertical measurements of the AComA complex were calculated. RESULTS: The Willis polygon values were found to be consistent with those in the literature. The mean height of the AComA complex was 30.58 ± 4.80 mm according to the FHP. CONCLUSIONS: Preoperative evaluation of the vertical geometry of the AComA complex is essential for AComA aneurysm surgery. The height of the AComA complex is a key parameter affecting intraoperative surgical site visibility. Preoperative calculation of the height of the AComA complex relative to FHP can facilitate intraoperative surgical site orientation.

The Healing Effect of Digoxin on Peripheral Nerve Damage and Its Relation to IL-17/IL-10.

AIM: To demonstrate the curative effect of digoxin on peripheral nerve damage with its anti-inflammatory role on interleukin (IL)-17. MATERIAL AND METHODS: The study was conducted with 30 male Sprague Dawley albino mature rats, of which 10 formed the control group, 10 were surgically treated and administered saline (group S), and another 10 were surgically treated and administered digoxin (group D). Motor functions and immunohistochemical and biochemical variables of the rats were assessed after therapy. RESULTS: The amplitude of the inclined plane test scores and the compound muscle action potential levels were greater in group D than in group S. Likewise, there were higher nerve growth factor percentages, higher axon counts, and lower fibrosis score percentages in group D than is group S. Lastly, lower tissue malondialdehyde and plasma IL-17 levels were determined in group D, while the IL-10 level was higher. CONCLUSION: Digoxin contributes to nerve healing and neuroprotective effect by demonstrating its anti-inflammatory effect on IL-17. It can be considered an adjunctive therapy for peripheral nerve injury.

Reparative, Neuroprotective and Anti-neurodegenerative Effects of Granulocyte Colony Stimulating Factor in Radiation-Induced Brain Injury Model.

OBJECTIVE: This animal model aimed to compare the rat group that received brain irradiation and did not receive additional treatment (only saline) and the rat group that underwent brain irradiation and received Granulocyte colony stimulating factor (G-CSF) treatment. In addition, the effects of G-CSF on brain functions were examined by magnetic resonance (MR) imaging and histopathologically. METHODS: This study used 24 female Wistar albino rats. Drug administration (saline or G-CSF) was started at the beginning of the study and continued for 15 days after whole-brain radiotherapy (WBRT). WBRT was given on day 7 of the start of the study. At the end of 15 days, the behavioral tests, including the three-chamber sociability test, open field test, and passive avoidance learning test, were done. After the behavioral test, the animals performed the MR spectroscopy procedure. At the end of the study, cervical dislocation was applied to all animals. RESULTS: G-CSF treatment positively affected the results of the three-chamber sociability test, open-space test and passive avoidance learning test, cornu Ammonis (CA) 1, CA3, and Purkinje neuron counts, and the brain levels of brain-derived neurotrophic factor and postsynaptic density protein-95. However, G-CSF treatment reduced the glial fibrillary acidic protein immunostaining index and brain levels of malondialdehyde, tumor necrosis factor-alpha, nuclear factor kappa-B, and lactate. In addition, on MR spectroscopy, G-CSF had a reversible effect on brain lactate levels. CONCLUSION: In this first designed brain irradiation animal model, which evaluated G-CSF effects, we observed that G-CSF had reparative, neuroprotective and anti-neurodegenerative effects and had increased neurotrophic factor expression, neuronal counts, and morphology changes. In addition, G-CSF had a proven lactate-lowering effect in MR spectroscopy and brain materials.

Preoperatively, Which Parameter Allows Us to Predict the C5 Palsy After Cervical Open-Door Laminoplasty?

AIM: To uncover factors that can predict the development of C5 palsy before surgery by evaluating several different parameters. MATERIAL AND METHODS: A total of 177 patients who underwent surgery between 2015 and 2020 were included in the study. In total, C5 palsy was observed in 22 (12.4%) of our patients. The radiological and clinical data of the patients were retrospectively analyzed and added to the data. RESULTS: A total of 177 patients who satisfied the criteria were included in the study, among whom 117 (66.1%) and 60 (33.9%) were male and female, respectively. Patients with ossified posterior longitudinal ligament (OPLL) (92; 52.0%) needed surgery the most. C5 palsy developed in 16/92 (17.3%) patients who had surgery for OPLL. This result was statistically significant (p < 0.001). However, a significant difference in the postoperative Pavlov ratio was noted between both groups (p=0.027). The foraminal dimensions for the C5 palsy group were significantly lower than those for the non-C5 palsy group. CONCLUSION: Smaller C5 root foramina diameter measurements were the most important predictive factor for the development of C5 palsy after open-door cervical laminoplasty. Although the pathophysiology remains to be fully understood, ischemia-reperfusion injury supposedly plays a role therein.

Is Balloon Kyphoplasty Effective for Bone Remodeling of AO-Type A3-4 Fractures at the Thoracolumbar Junction?

AIM: Vertebral compression fractures (VCF) occur most commonly at the thoracolumbar junction (TLJ). Balloon kyphoplasty (BKP) is an effective method of bone remodeling in these cases. In this study, we evaluate the parameters that affect bone retropulsion and restoration in TLJ VCF without neurological deficits. MATERIAL AND METHODS: Thirty-one of Frankel E and AO A3-4 type VCFs fractures at the TLJ, with bone retropulsion into the spinal canal, from 2017 to 2020, were evaluated retrospectively. Data was gathered on patient demographics and medical histories. Measurements of anterior vertebral heights, posterior vertebral heights, local kyphotic angles, spinal cord area, and bone retropulsion into the spinal canal (BRC) were evaluated preoperatively, early postoperatively, and late postoperatively. RESULTS: In those patients who underwent early surgery ( 4 weeks postfracture), a significantly greater increase in anterior vertebral heights was seen between early postoperative and preoperative measurements than in patients who underwent late surgery ( 4 weeks postfracture) (p = 0.016). At the six-month follow-up, a significantly greater decrease in local kyphotic angle measurements was seen in patients over 65 years of age than those under 65 (p = 0.023). Comparison of local kyphotic angles between sexes revealed a significant decrease in measurements at follow-up in female patients (p = 0.029). Both early postoperative and late postoperative local kyphotic angle measurements of patients with a body mass index (BMI) ≥25 were significantly lower than those of patients with a BMI 25 (p = 0.012). CONCLUSION: The restoration of vertebral angles and heights with the maximum level of BKP can effectively reduce BRC.

The Restorative Effect of Gallic Acid on the Experimental Sciatic Nerve Damage Model.

OBJECTIVE: Peripheral nerve injuries occur mostly as a result of mechanical trauma. Due to the microvascular deterioration in peripheral nerve damage, it becomes challenging to remove free oxygen radicals. Gallic acid is a powerful antioxidant with anti-inflammatory effects and a free radical scavenger. The purpose of the study is to show that gallic acid contributes to the restorative effect in mechanical nerve damage, considering its antioxidant and anti-inflammatory effects. METHODS: Thirty male Sprague Dawley albino mature rats were included in the study. Ten of them constituted the control group, 10 out of 20 rats for which sciatic nerve damage was caused, constituted the saline group, and 10 formed the gallic acid group. Post-treatment motor functions, histological, immunohistochemical, and biochemical parameters of the rats were evaluated. RESULTS: Compared to the surgery+saline group, lower compound muscle action potential (CMAP) latency, higher CMAP amplitude, and higher inclined plane test values were found in the surgery+gallic acid group. Similarly, a higher nerve growth factor (NGF) percentage, a higher number of axons, and a lower percentage of fibrosis scores were observed in the surgery+gallic acid group. Finally, lower tissue malondialdehyde (MDA) and higher heat shock protein-70 (HSP-70) values were determined in the surgery+gallic acid group. CONCLUSION: Gallic acid positively affects peripheral nerve injury healing due to its anti-inflammatory and antioxidant effects. It has been thought that gallic acid can be used as a supportive treatment in peripheral nerve damage.

Three-Dimensional Printing Assisted Preoperative Surgical Planning for Cerebral Arteriovenous Malformation.

OBJECTIVE: The aim of this study to investigate the benefits of patient-based 3-dimensional (3D) cerebral arteriovenous malformation (AVM) models for preoperative surgical planning and education. METHODS: Fifteen patients were operated on for AVMs between 2015 and 2019 with patient-based 3D models. Ten patients' preoperative cranial angiogram screenings were evaluated preoperatively or perioperatively via patient-based 3D models. Two patients needed emergent surgical intervention; their models were solely designed based on their AVMs and used during the operation. However, the other patients who underwent elective surgery had the modeling starting from the skull base. These models were used both preoperatively and perioperatively. The benefits of patients arising from treatment with these models were evaluated via patient files and radiological data. RESULTS: Fifteen patients (10 males and five females) between 16 and 66 years underwent surgery. The mean age of the patients was 40.0±14.72. The most frequent symptom patients observed were headaches. Four patients had intracranial bleeding; the symptom of admission was a loss of consciousness. Two patients (13.3%) belonged to Spetzler-Martin (SM) grade I, four (26.7%) belonged to SM grade II, eight (53.3%) belonged to SM grade III, and one (6.7%) belonged to SM grade IV. The mean operation duration was 3.44±0.47 hours. Three patients (20%) developed transient neurologic deficits postoperatively, whereas three other patients died (20%). CONCLUSION: Several technological innovations have emerged in recent years to reduce undesired outcomes and support the surgical team. For example, 3D models have been employed in various surgical procedures in the last decade. The routine usage of patient-based 3D models will not only support better surgical planning and practice, but it will also be useful in educating assistants and explaining the situation to the patient as well.

Evaluation of the neuroprotective effects of ozone in an experimental spine injury model.

OBJECTIVE: The pathophysiology of spine injury consists of primary and secondary damage mechanisms. The vast majority of treatments aim to prevent or at least stop the progression of secondary neurotoxic events during the acute period. Ozone has been found to have potent antiinflammatory effects, to activate the immune system, and to have a substantial impact on the antioxidant system. In this study the authors aimed to evaluate the neuroprotective effects of ozone and their possible roles in recovery from spine injury, assessed based on biochemical, histological, and neurological parameters using an experimental spine injury model in rats. METHODS: The study included 31 female Wistar albino rats. The rats were divided randomly into 5 groups, with 7 rats in each group except the sham group, which contained 3 rats, as follows: group 1 (sham), laminectomy; group 2 (control), laminectomy and spinal trauma with no medical treatment (0.5 ml isotonic saline applied 1 hour postsurgery); group 3, single medical treatment with 30 mg/kg methylprednisolone applied intraperitoneally 1 hour after laminectomy and trauma; group 4, single medical treatment with 60 µg/ml ozone at 0.7 mg/kg applied intraperitoneally 1 hour after laminectomy and trauma; and group 5, double medical treatment with 30 mg/kg methylprednisolone and 60 µg/ml ozone at 0.7 mg/kg applied intraperitoneally 1 hour after laminectomy and trauma. After neurosurgery, neurobehavioral tests were performed in all groups. After 7 days of follow-up, all the rats were killed. Biopsy specimens obtained from trauma sites were examined using H & E, cresyl violet, immunohistochemical (anticonnexin-43), and TUNEL staining processes. Levels of interleukin (IL)-1ß, IL-6, and tumor necrosis factor-α (TNF-α) and total oxidant status (TOS) and total antioxidant status (TAS) were measured in blood samples. RESULTS: The level of neurobehavioral healing was the highest in the double-treatment group (group 5), and the difference between the groups was significant. The minimum IL-6 level was found in group 5, indicating that the antiinflammatory impact was the most significant in this group (p = 0.01). Additionally, ozone was found to reduce oxidant stress more effectively than methylprednisolone (p = 0.03). Although methylprednisolone was superior to ozone in terms of the antiinflammatory effect, this effect was greater in group 5. Nevertheless, the number of neurons in group 5 was close to that of the control group, and the number of apoptotic cells was the least in group 5 (p < 0.001). CONCLUSIONS: In acute spinal injury, the combined application of methylprednisolone and ozone was found to have a greater antiinflammatory effect, hasten clinical recovery, and increase histological recovery compared with methylprednisolone therapy alone. This study showed that this combination therapy of methylprednisolone with the addition of ozone might have a more beneficial effect in the treatment of spinal injury than methylprednisolone therapy alone.

Growing Hemorrhagic Choroidal Fissure Cyst.

Choroidal fissure cysts are often incidentally discovered. They are usually asymptomatic. The authors report a case of growing and hemorrhagic choroidal fissure cyst which was treated surgically. A 22-year-old female presented with headache. Cranial MRI showed a left-sided choroidal fissure cyst. Follow-up MRI showed that the size of the cyst had increased gradually. Twenty months later, the patient was admitted to our emergency department with severe headache. MRI and CT showed an intracystic hematoma. Although such cysts usually have a benign course without symptoms and progression, they may rarely present with intracystic hemorrhage, enlargement of the cyst and increasing symptomatology.