Lateral Horizontal Head Position Approach for the Lateral and Anterior Third Ventricles: A Subependymoma Clinical Case and Literature Review.

Subependymomas are benign, slow-growing, noninvasive solitary lesions of World Health Organization Grade I cerebral ependymal origin that are rare compared with other types of ependymomas. Anterior third ventricle subependymomas are usually detected during autopsies in cases of sudden death due to acute or intermittent obstruction of the cerebrospinal fluid passage. Different surgical approaches are used for these cerebral lateral and third ventricular lesions. Serious complications can occur, either because of brain edema and acute intracranial pressure due to the lesion itself or the chosen head position and continuous use of brain retractors during the surgical procedure. In this case report, we trust that the surgical principles we applied with the aid of two cotton pads, gravity assist, and lateral horizontal head position, and without continuous use of brain retractors in the third ventricular lesion in the transcallosal interhemispheric approach are safe and secure in preventing perioperative brain edema or early postoperative neurological complications.

3D structural complexity analysis of cerebellum in Chiari malformation type I.

Chiari malformation type I (CM-I), described by a descent of the cerebellar tonsils, is assumed to be a neurological developmental disorder. The aim of the present study was to investigate morphological variance in cerebellar sub-structures, including gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF), using magnetic resonance (MR) images with three-dimensional (3D) fractal dimension (FD) analysis in patients with CM-I. MRI data of 16 patients and 15 control subjects were obtained, and structural complexity analyses were performed using a box-counting FD algorithm. Results showed that patients with CM-I had significantly reduced FD values for WM and CSF in comparison with controls, and statistically significant differences in cerebellar GM and CSF volumes between patients and controls were found. Moreover, a significant difference was not found between the WM volumes. This may suggest that there are changes in structural complexity in WM even when its volume is unaffected. We conclude that the findings of this preliminary study indicate the possibility of using FD analysis to understand the pathophysiology of CM-I in patients.

Effects of 4% Icodextrin on Experimental Spinal Epidural Fibrosis.

AIM: The aim of this experimental study was to investigate whether spinal epidural 4% glucose polymer solution is effective in the prevention of postoperative fibrosis. MATERIAL AND METHODS: Twenty eight adult Wistar albino rats were randomly divided into two equal groups, including treatment and control. Both groups underwent L1 vertebral total laminectomy to expose the dura. Topical treatment group received 4% icodextrin. Four weeks later, epidural fibrosis was examined in both groups histologically, biochemically and macroscopically. RESULTS: Topical use of 4% icodextrin prevented significantly epidural fibrosis following the laminectomy operation. CONCLUSION: Topical 4% icodextrin application inhibits postoperative epidural fibrosis with various mechanisms and prevents adhesions by playing barrier role between tissue surfaces through flotation. Our study is first to present evidence of experimental epidural fibrosis prevention with 4% icodextrin.

Outcome of surgical treatment of hippocampal sclerosis from relatively new epilepsy surgery center.

BACKGROUND: Surgery is apparently superior to prolonged medical therapy in therapy of efficacy and safety for mesial temporal lobe epilepsies. We ­ as a new center ­ presented outcome results and possible outcome predictors of 50 consecutive patients with hippocampal sclerosis underwent resective epilepsy surgery. METHODS: Between 2006 and 2011, fifty patients with intractable mesial temporal lobe epilepsy due to hippocampal sclerosis underwent anterior temporal lobectomy and they were followed-up at least 1 year postoperatively. Detailed neuropsychological tests, video-electroencephalography monitoring and magnetic resonance imaging with epilepsy protocol were obtained for all patients. Standard anteromedial temporal lobectomy was performed. Modified Engel and ILAE classifications were used for seizure outcome. All morbidities were recorded. Demographic variables, diagnostic tests and early postoperative outcome were analyzed for possible predictors of the ultimate seizure outcome. RESULTS: Fifty patients were evaluated. The mean follow-up duration was 47,1 month (range, 12-75 months). The favorable outcome at 1 year was 90% and 82% according to Engel and ILAE classifications respectively. These rates were almost same at the end of follow-up period (92% and 82% respectively). The completely seizure free rate at one year was 80% and decreased to 68% at the end of the follow-up. There was no mortality. Morbidity rate was 10% and none of them was permanent. Triple concordance of the noninvasive tests (neuropsychological tests, video- electroencephalography monitoring and magnetic resonance imaging) and favorable seizure outcome at the first year were predictors of the ultimate seizure outcome (P=0.01 and P=0.04 respectively). CONCLUSIONS: Our findings demonstrated that anteromedial temporal lobectomy is a safe and effective treatment method in well-chosen patients with hippocampal sclerosis. This surgical procedure can be performed with a low rate of morbidity even in relatively new epilepsy surgery center.

Fractal dimension analysis of cerebellum in Chiari Malformation type I.

Chiari Malformation type I (CM-I) is a serious neurological disorder that is characterized by hindbrain herniation. Our aim was to evaluate the usefulness of fractal analysis in CM-I patients. To examine the morphological complexity features of this disorder, fractal dimension (FD) of cerebellar regions were estimated from magnetic resonance images (MRI) of 17 patients with CM-I and 16 healthy control subjects in this study. The areas of white matter (WM), gray matter (GM) and cerebrospinal fluid (CSF) were calculated and the corresponding FD values were computed using a 2D box-counting method in both groups. The results indicated that CM-I patients had significantly higher (p<0.05) FD values of GM, WM and CSF tissues compared to control group. According to the results of correlation analysis between FD values and the corresponding area values, FD and area values of GM tissues in the patients group were found to be correlated. The results of the present study suggest that FD values of cerebellar regions may be a discriminative feature and a useful marker for investigation of abnormalities in the cerebellum of CM-I patients. Further studies to explore the changes in cerebellar regions with the help of 3D FD analysis and volumetric calculations should be performed as a future work.

Efficacy of clinical prognostic factors on survival in patients with glioblastoma.

AIM: Glioblastoma is the most common and highest-grade infiltrative astrocytoma. It is usually associated with a bad prognosis. Histological grading is highly predictive of an aggressive behavior, with a mean survival rate of 1 year. Nonetheless, individual patient survival can vary substantially, ranging from 1 month to over 5 years. Several distinct clinical parameters and molecular alterations have recently been described in glioblastoma. The present study compares clinical, radiologic and therapeutic parameters in a series of glioblastomas to identify prognostic factors. MATERIAL AND METHODS: We evaluated 50 cases who were operated on for intracranial glioblastoma between January 1998-March 2004 retrospectively. All clinical records, radiological records and management modalities were evaluated as prognostic value. RESULTS: The mean survival time was 7.5 months (range, 1-18 months). We confirmed the patients' age, gender, Karnofsky Performance Scale score at discharge, postoperative radiotherapy and reoperation as decisive prognostic factors after multivariate analyses. CONCLUSION: We could show that some clinical parameters and treatment modalities were associated with prognosis. Younger age, male gender, higher Karnofsky Performance Score at discharge, total surgical resection, radiotherapy and reoperation were predictor for better prognosis.

Morphometric analysis of the influence of selenium over vasospastic femoral artery in rats.

BACKGROUND: Cerebral vasospasm (CV) is the leading cause of morbidity and mortality occurring after subarachnoid hemorrhage (SAH). Etiopathogenesis of CV is multifactorial. Selenium is the cofactor of the glutathione peroxidase (GSH-Px) enzyme which is a very important defense mechanism against antioxidants. According to the literature, oxidants are known to play a remarkable role in the pathogenesis of vasospasm occurring after SAH. Therefore, many studies have been conducted with antioxidant agents, based on the theory that elevated activity of GSH-Px enzyme might prevent the development of CV after SAH. Majority of those studies reported positive results. However, as a result of our literature review, we came across no study which involves the investigation of the role of selenium alone in the prevention of CV after SAH. In our study, we aim to find the answer to the following question: "Can selenium alone prevent cerebral vasospasm following SAH at early stage?" METHODS: We used the "rat femoral artery vasospasm model" of Okada et al. as the vasospasm model of our study. First, rats were divided into three groups: group 1 (n = 8), control group; group 2 (n = 8), vasospasm group; and group 3 (n = 8), vasospasm + selenium group. Statistical comparison of groups 1 and 2 revealed significant thickening in the vascular wall and a decrease in the lumen diameter in group 2, compared with group 1. Statistical comparison of the vascular lumen diameters of groups 1 and 3 showed no significant difference, whereas the comparison of mean vascular wall thickness displayed a significant increase in group 3. Moreover, statistical comparison of groups 2 and 3 regarding vascular lumen diameters showed a significant decrease in group 2, whereas group 3 displayed a significant decrease in terms of vascular wall thickness. CONCLUSION: According to the results of our study, selenium morphometrically prevents the development of peripheral vasospasms.

Delayed intraventricular tension pneumocephalus due to scalp-ventricle fistula: a very rare complication of shunt surgery.

BACKGROUND: Although pneumocephalus and pneumoventricle are well known entities in neurosurgery practice, delayed intraventricular tension pneumocephalus following shunt surgery is extremely rare. CASE DESCRIPTION: A 60-year-old man presented with vomiting, drowsiness, walking difficulty, urinary incontinence and headache one month after shunt placement for communicant hydrocephalus developing secondary to aneurysmal subarachnoid hemorrhage. Skull X- Rays and Computed Tomography (CT) revealed marked air in both lateral ventricles. Neither physical and neurological examinations nor laboratory studies and cerebrospinal fluid evaluations suggested central nervous system infection. He gradually improved after repairing the scalp incision defect above the previously opened burr-hole and bed rest. CONCLUSION: In contrast to reported cases with delayed pneumocephalus developing after shunting, air entry was in skull base, air source was the scalpventricular fistula in the present case.

Multiple intradural spinal hydatid disease: a case report and review of literature.

STUDY DESIGN: A case report. OBJECTIVE: We present an unusual case of pathologically confirmed multiple distinct spinal intradural extramedullar spinal hydatid cyst after 1 year of lung cyst hydatid operation. SUMMARY OF BACKGROUND DATA: Hydatid disease is usually diagnosed in endemic regions. Spinal involvement of disease is very unusual and the literature about this entity is generally restricted to regional publications. Furthermore, intradural multiple involvement was not reported in literature. METHODS: A 14-year-old boy admitted to our clinic with pain in the back, both of leg and disability in walking. The patient presented with back pain, asymmetrical paraparesis, right more than left and weakness. Multiple distinct spinal intradural extramedullary cystic lesion was identified with magnetic resonance imaging and was shown to be hydatid cyst by histopathologic confirmation after the surgical removal. RESULTS: T5 and L4, L5, S1 laminectomies were performed at the same session, after these a lot of pearly white hydatid cysts located intradural extramedullary were removed totally with their capsule, and the cavity was irrigated with 20% hypertonic saline. Surgical treatment was uneventful. Second-month follow-up neurologic examination was normal and the hydatid cysts had totally disappeared in both regions in the second month of postoperative magnetic resonance imaging. CONCLUSION: Spinal hydatid disease are uncommon. Among these, multiple distinct spinal intradural extramedullar location is extremely rare. Although total removal of the cysts without rupture should be the surgical goal in all cases, the best treatment remains an active nationwide prevention of the disease.

Atypical intracerebral schwannoma mimicking glial tumor: case report.

A rare case of a solitary schwannoma arising within parenchyma of the brain is reported. A 37-year old right-handed man presented with a 3- month history of progressive headaches, lethargy and vomiting. The initial diagnosis being considered was primary intracranial tumor, including high-grade astrocytoma, metastasis or lymphoma Histopathological examination revealed schwannoma. Cysts, calcification and mild to moderate peritumoral edema are common in intracerebral schwannomas. However, our case is atypical and has no cystic component, calcification or vascularization. The pathogenesis and neuroradiological findings of intraparenchymal schwannomas are discussed and we review the related literature.

Cervical spondylotic myelopathy and radiculopathy treated by oblique corpectomies without fusion.

Oblique corpectomy (OC) is an alternative technique for the resection of spondylotic spurs ventral to the cervical spinal cord contributing to cervical spondylotic myelopathy (CSM) and cervical spondylotic radiculopathy (CSR). To evaluate the efficacy of OC for the treatment of cervical spondylotic myeloradiculopathy, we reviewed our experience with OC. Twenty-six patients, 18 males and 8 females, were studied. They averaged 51.3 years of age (range 30-72), Thirteen had myelopathy and 13, radiculopathy. Both magnetic resonance (MR) imaging and computed tomography (CT) were performed preoperatively to define the extent of pathology. The Modified Japanese Orthopedic Association (JOA) score was used to grade the quality of the outcome. Neurologic and radiologic results were assessed. Good and excellent results were observed in 76.9% of the cases with myelopathy. Improvement of radicular symptoms was noted in 84.6% of the cases with radiculopathy. Neuroimaging studies confirmed satisfactory anatomical decompression in all patients. Sagittal alignment decreased from 13 degrees to 12 degrees. The degree of postoperative recovery seemed to be directly related to the age and severity of the preoperative myelopathy. This surgical technique has shown excellent clinical outcomes with fast recovery and adequate anatomical decompression in patients with CSM and CSR.

[MRI findings of orbital hemangiomas]. / Orbital hemanjiyomlarin MRG bulgulari.

PURPOSE: To evaluate the MR imaging findings of orbital hemangiomas in pediatric and adult groups. MATERIALS AND METHODS: MR imaging findings of seven orbital hemangiomas were reviewed. All patients had axial and coronal T1 and T2 weighted images. Axial and coronal fat suppressed (STIR) images and postcontrast T1 weighted images in three planes were obtained in order to evaluate the relation with surrounding structures. Localization, size, margins and signal characteristics of the lesions were analyzed. RESULTS: Four of the cavernous hemangiomas were intraconal, one was extraconal. The location of the lesions was superomedial in two, middle medial, inferomedial and inferolateral in one lesion. The lesions were iso-hypointense to muscle on T1W, hyperintense on T2W and markedly hyperintense on STIR images. All cases had a capsule. In four cases a chemical shift artifact was seen. Contrast enhancement was patchy in early images and homogenous in late images. Cavernous hemangiomas were well circumscribed. All cases underwent operation and had a histopathologic diagnosis. The capillary hemangioma seen in a ten-year-old case was superomedial in localization and had irregular contours. The other case was a one year old. The lesion surrounded the superolateral margin of the bulbus and involved the lateral rectus, the eyelid and neighboring skin. The lesions were hypointense on T1W and hyperintense on T2W images, with diffuse homogenous contrast enhancement. CONCLUSION: With MRI, orbital hemangiomas, the most common cause of chemosis and proptosis are easily detected. MR findings are not only helpful for diagnosing the lesion but also for choosing the appropriate surgical approach.

Transbasal approaches: surgical details, pitfalls and avoidances.

Lesions involving the anterior skull base and sphenoclival region are difficult surgical problems. This paper presents surgical details, pitfalls, avoidances and our experiences in the surgical treatment of lesions of the anterior skull base using neuronavigation. Between 1999 and 2003, 33 patients with pathology of the anterior skull base were operated on via the traditional transbasal and the extended transbasal approach. A passive-marker-based neuronavigation system has been used for intraoperative image guidance since April 2000. The patients consisted of 11 men and 22 women. Their ages ranged from 3 to 76 years, with a mean of 41 years. The lesions for which the approach was used included 9 cerebrospinal fluid (CSF) fistulae and 24 neoplastic lesions including meningioma (16 cases), metastasis (3 cases), chordoma (3 cases), plasmacytoma (1 case), and osteoma (1 case). Gross total removal of the tumors was accomplished in 22 out of 24 patients with tumor (91.6%). Postoperative complications include CSF leakage (2 cases), infection (2 cases) and transient impaired vision (1 case). One patient (3%) died postoperatively from hypothalamic dysfunction after removal of a benign tumor extending to the anterior third ventricle. Despite the incidence of postoperative infection and the high rate of CSF leakage and death, it is possible to obtain long-term survival for patients with tumors previously considered challenging and difficult surgical problems.

Clivus fractures: clinical presentations and courses.

Fractures in the clivus region are usually associated with blunt head trauma. They may cause many cranial nerve deficits and vascular complications. The mortality rate is high because of brainstem trauma or vertebrobasilar occlusion. The diagnosis of clivus fracture (CF) is difficult with routine cranial radiography due to the presence of dense petrous temporal bones. Because of this, few cases have been described in the past. In this study, we report nine cases of CF observed and treated in our department during the last 5 years. Computed tomographic (CT) scanning revealed CF in nine of 2500 patients with head trauma (0.36%). The patients ranged in age from 17 to 68 years (mean 38.3). Five patients had had motor vehicle accidents, three were injured in falls, and one was a pedestrian injured by a motor vehicle. Five patients had longitudinal fractures and four had transverse fractures. Cranial nerve deficits were recorded in all patients. Deficits of cranial nerves VI and VII were the most frequently observed (six patients, 66.6%). We review the literature to highlight the differences in clinical presentation and the course in cranial nerve deficits. The diagnosis of CF is made by high-resolution, fine-cut CT using standard and bone window settings. Its presence should alert clinicians to the potential complications.

Growing skull fracture of the orbital roof: Report of two cases and review of the literature.

In this report, the authors describe two cases of growing fracture of the orbital roof. The aim is to draw attention to this rare complication and discuss the role of three-dimensional computed tomography in radiological findings and surgical planning. Relevant literature is also reviewed.

Effects of mexiletine, ginkgo biloba extract (EGb 761), and their combination on experimental head injury.

Lipid peroxidation (LP) and brain edema are important factors that produce tissue damage in head injury. The purpose of this study was to investigate the effect of mexiletine, gingko biloba extract (EGb 761), and their combination on LP and edema after moderate head trauma. Forty rats were randomly and blindly divided into four groups of ten animals each: control group (bolus injection of physiological saline), mexiletine group (50 mg/kg per injection), EGb 761 group (30 mg/kg per injection), and mexiletine plus EGb 761 group (50 mg/kg and 30 mg/kg per injection, respectively). The injections were given intraperitoneally at 1 h, 9 h, and 17 h after trauma. Twenty-four hours after injury, the rats were killed, and malondialdehyde (MDA) levels and brain water content were determined. Rats treated with mexiletine, EGb 761, and mexiletine plus EGb 761 had significantly lower MDA levels than the control group (P<0.01). The lowest MDA levels were measured in the mexiletine plus EGb 761 group. However, there was no significant difference in brain water content between treated groups and the control group (P>0.05). These findings show the usefulness of mexiletine and its combination with EGb 761 as a cerebroprotective agent in this model of experimental head injury.