Anatomical surgical approach to lateral vetricle masses and histopathological findings of the brain.

BACKGROUND: The selection of surgical approach to the lateral ventricular masses includes difficulties due to their deep localizations, close proximity to the vascular and the eloquent brain structures. The most appropriate approach that should be chosen in surgical treatment of lateral ventricular masses is still controversial. In this study, the factors in the choice of surgical approach to the lateral ventricle masses and the results of them were investigated. MATERIALS AND METHODS: In this study, 80 patients who underwent surgery in our clinic due to the lateral ventricular masses were retrospectively analyzed between the years 2002-2013. All of the cases were evaluated in terms of clinical and neuroradiological results pre and postoperatively. In 24 cases the anterior interhemispheric transcallosal, in 4 cases the posterior interhemispheric transcallosal, in 30 cases the posterior interhemispheric precuneal, in 14 cases the transcortical and in 8 cases the combined surgical approaches were performed. RESULTS: Gender distribution of the cases were 45 male/35 female and the mean age of them was 31.7 years (7 month - 73 years). In 64 patients the gross total resection was performed, whereas in 16 patients subtotal resection was performed due to the infiltration of eloquent brain areas. In the histopathological examination; 52 neuroepithelial, 8 mixed neuroglial, 3 meningeal, 2 lympho-hematopoietic system, 1 pine blastoma, 1 germ cell, 5 metastatic and 8 other benign masses were observed. After surgery, additional neurological deficits developed in 9 patients. The mortality was observed in 6 patients postoperatively. The average follow-up time was 13 (1-83) months. CONCLUSIONS: The essential factors which affect the results of surgical treatment of lateral ventricular masses are; the size of the mass, histopathology, location, extension, and the relationship to the neurovascular structures. The goal of surgery is to provide the histopathological diagnosis, gross total resection, if it is possible, and to normalize the flow of cerebrospinal fluid by eliminating the mass effect of pressure.

Foramen Magnum Meningiomas: A Report of 10 Cases and Literature Review.

AIM: To present the findings and surgical results of foramen magnum meningioma surgeries performed by the authors. MATERIAL AND METHODS: Ten patients operated between 2014 and 2019 were retrospectively analyzed in terms of age, gender, neurological examination, and postoperative status. The female-to-male (F/M) ratio of the patients was 6/4, and the age range was 19?70 years (mean = 59). All patients presented with occipitocervical pain and were operated using the midline lateral suboccipital approach. RESULTS: One of the operated patients died in the intensive care unit due to upper gastrointestinal tract bleeding. Additionally, one patient had paresis in the early postoperative period, which resolved in the third follow-up month. CONCLUSION: Foramen magnum meningiomas are operated safely by microsurgical methods using the midline lateral suboccipital approach after suboccipital triangle and vertebral artery are exposed.

Parieto-Occipital Interhemispheric Precuneal Approach to the Lesions of the Atrium: Experience with 66 patients.

AIM: The atrium (trigone) is the most common site for intraventricular lesions. The parieto-occipital interhemispheric precuneal approach (POIPA) is one of the particular ways to reach these lesions. The aim of this study was to draw specific attention to the surgical difficulties of these lesions and to present our experience with this operative approach. MATERIAL AND METHODS: Sixty-six patients with lesions located in the atrium of the lateral ventricles underwent surgical treatment in our institution using POIPA over a 13-year period. The clinical, radiological and surgical characteristics of these patients were retrieved and reviewed retrospectively. The histological diagnosis of the cases and postoperative complications were specifically focused on in this study. RESULTS: Thirty-six (54.5%) patients were male and 30 patients were female with a mean age 37.9 years (range between 8 and 74 years). The lesion was in the right atrium in 25 cases and in the left in 41 (62.1%) patients. POIPA was used in all cases to remove the lesions. The most common tumor was glioblastoma (34.8%), followed by glial tumors grade I, II and III and meningiomas. The other lesions were metastases, ganglioglioma, epidermoid cysts and arteriovenous malformations. Gross total resection of the tumors was achieved in 59 patients (89.4%) while subtotal removal was performed in 7 cases. Five (7.5%) patients died within the first month after surgery. Conclusion: POIPA provides a safe and effective way to reach lesions located in the atrium of the lateral ventricle. Knowledge of precise anatomy associated with the meticulous surgical techniques decreases the surgical morbidity and mortality of the patients.

Anterior Skull Base Defects Reconstructed Using Three-Layer Method: 78 Consecutive Cases with Long-Term Follow-Up.

Objectives Anterior skull base defects are potentially lethal and surgical treatment must be performed as soon as possible. The purpose of this study was to evaluate whether our technique is effective or not in long-term period. Design Retrospective chart review of all patients whose data were entered into the Hospital Registry System between 1995 and 2015. Setting/Participants This study was performed at the Gaziantep University School of Medicine, Gaziantep, Turkey, in 2015 and included 78 patients who in the past 20 years underwent three-layer reconstruction surgery for anterior skull base defects at the same university. Main Outcome Measures Among the patients, defects repaired by transcranial approach had the lowest recurrence rate. Overall, successful repair was achieved in 100% of the patients. Results Pure transbasal approach was used as a single procedure on 71 (91%) patients. Combined approaches were used in seven (9%) cases. The extended transbasal approach was combined with a transfacial approach in four patients and with a pterional approach in three patients. Conclusion We encourage the use of three-layer reconstruction and recommend free fascia lata grafts and galeal flaps with vascularized pedicle as sealing material of choice in all types of cases such as tumor and trauma.

Urodynamic outcomes of detethering in children: experience with 46 pediatric patients.

AIM: Tethered cord syndrome (TCS) manifests with neurological and urological complaints. Surgical detethering is the main treatment for TCS. Children with urological symptoms are required objective pre- and postoperative evaluations in order to predict urological outcome. The aims of this study are to investigate the effects of detethering procedure on the urodynamic tests and to determine the relationship between the changes of urodynamic tests and the patients' age and gender. MATERIAL AND METHODS: The data of urodynamic tests in 46 pediatric patients, who underwent surgery for TCS, were retrospectively evaluated. Bladder capacity, post-voiding residual urine volume, maximum intravesical pressure, and bladder compliance of each patient were measured in preoperative period and at the third month after surgery. These parameters were statistically compared, and the correlations of these parameters with age, gender, and etiology of the TCS were also investigated. RESULTS: Bladder capacity and post-voiding residual urine volume were decreased and maximum intravesical pressure and bladder compliance were increased after surgery for TCS. The decrease in bladder capacity was significant in patients older than 10 years (p < 0.05). The increase in maximum intravesical pressure was also positively correlated with age (p < 0.05). But the increase in bladder compliance was negatively correlated with age (p < 0.05). CONCLUSION: Bladder capacity, post-voiding residual urine volume, and bladder compliance are mainly affected by surgery in patients with TCS. From the urological viewpoint, children older than 10 years are most likely to benefit from surgery for TCS.

Multicentric Dentigerous Dermoid Cyst with an Unusual Location in the Central Nervous System.

Dermoid cysts are benign and congenital ectodermal inclusions. Their occurrence in an intracranial location is quite rare. They constitute 0.1 to 0.7% of all intracranial tumors. Their occurrence in the fourth ventricle and their multicentric feature are extraordinary. A 12-year-old boy was admitted to our clinic with a dermoid cyst with sixth cranial nerve involvement. He had symptoms of increased intracranial pressure. This case is the first dermoid cyst in the literature at this unusual location; a mature tooth structure was found within the cyst, which extended over the cervical subsegments. There was a second dermoid cyst in the thoracic spine (multicentric). Our aim is to present an atypical dermoid cyst along with radiodiagnostic characteristics and macroscopic findings.

Tethered cord syndrome in children: a single-center experience with 162 patients.

PURPOSE: Tethered cord syndrome (TCS) is not an uncommon clinical problem in children. The aim of this retrospective study is to document our experience on the surgical treatment of TCS in childhood. METHODS: The data of 162 children who underwent surgical treatment for TCS in a 15-year period were reviewed retrospectively. Their demographic, clinical, radiological, and surgical features were documented. They were divided into two groups as primary and secondary TCS, and the surgical technique for each group was demonstrated. Untethering the spinal cord and correction of the associated malformation were the standard surgical technique for each patient. The results of the treatment were summarized. RESULTS: Among the 162 children, 101 (62.3%) of them were female and 61 were male with a mean age of 62 months. Primary TCS was detected in 43 patients while secondary TCS was found in 119 (73.4%) patients. Hypertrichosis was the most common physical finding while back pain was the common complaint. Lipoma, split cord malformation, dermal sinus tract, and myelomeningocele were the associated malformations for secondary TCS. CONCLUSIONS: Children should be individualized for the treatment of TCS. Each patient must be evaluated neurologically and radiologically for the accurate diagnosis. Surgical untethering is the safe and effective method of treatment for children with TCS.

Early cyclosporin A treatment retards axonal degeneration in an experimental peripheral nerve injection injury model.

Injury to peripheral nerves during injections of therapeutic agents such as penicillin G potassium is common in developing countries. It has been shown that cyclosporin A, a powerful immunosuppressive agent, can retard Wallerian degeneration after peripheral nerve crush injury. However, few studies are reported on the effects of cyclosporin A on peripheral nerve drug injection injury. This study aimed to assess the time-dependent efficacy of cyclosporine-A as an immunosuppressant therapy in an experimental rat nerve injection injury model established by penicillin G potassium injection. The rats were randomly divided into three groups based on the length of time after nerve injury induced by cyclosporine-A administration (30 minutes, 8 or 24 hours). The compound muscle action potentials were recorded pre-injury, early post-injury (within 1 hour) and 4 weeks after injury and compared statistically. Tissue samples were taken from each animal for histological analysis. Compared to the control group, a significant improvement of the compound muscle action potential amplitude value was observed only when cyclosporine-A was administered within 30 minutes of the injection injury (P < 0.05); at 8 or 24 hours after cyclosporine-A administration, compound muscle action potential amplitude was not changed compared with the control group. Thus, early immunosuppressant drug therapy may be a good alternative neuroprotective therapy option in experimental nerve injection injury induced by penicillin G potassium injection.

[Postspinal subacute subdural hematoma: case report]. / Postspinal subakut subdural hematom: Olgu sunumu.

The development of intracranial subdural hematoma after spinal anesthesia is a rare and serious complication that can be fatal if untreated. Needle puncture to the dura mater can cause leakage of cerebrospinal fluid, and lead to stretching and rupture of the meningeal blood vessels with resultant bleeding. A 24-year-old patient, with a completely normal history and laboratory analysis, has got a L4-5 level spinal anesthesia well done at first try, using a Quinke 25 G needle and 12,5 mg bupivacaine heavy. The first day after spinal anesthesia, the patient started to have a headache. He applied to another hospital where he received conservative treatment with a diagnosis of post-spinal headache. But, persistence of the headache made the patient refer to our pain clinic. The headache was located behind the left ear non-postural in nature, and was associated with tinnitus. Emergency cranial computerized tomography was obtained and acute fronto-temporo-parietal subdural hematoma was reported. After spinal anesthesia, continued atypical headache and presence of tinnitus must alert against an underlying subdural hematoma. Early diagnosis can be made by history of the patient combined with neurological and radiological imaging methods.

Complications and treatment of chronic otitis media.

OBJECTIVE: The aim of this study was to investigate the etiologic factors and treatment types for chronic otitis media (COM) complications. METHODS: In this study, the data from 82 patients who had been diagnosed and treated at the Departments of Otolaryngology and Neurosurgery of Gaziantep University between 1999 and 2011 for complications from COM were retrospectively reviewed. The chosen surgical procedure was based on the type of complication and the ear pathology. RESULTS: The study included 55 male and 27 female patients. Ten patients (12.2%) had intracranial complications, and 72 patients (87.80%) had extracranial complications. There were 47 patients with cholesteatoma. Radical mastoidectomy was performed on 46 patients, canal-wall-down mastoidectomy was performed on 30 patients, and canal-wall-up mastoidectomy was performed on 6 patients. Five patients underwent neurosurgical operations because of COM complications. CONCLUSIONS: Although the rate of COM complications has recently declined, it remains important to diagnose COM without delay and to use appropriate treatments for the patients because COM complications are associated with poor outcomes.

Correlation between Rho-kinase pathway gene expressions and development and progression of glioblastoma multiforme.

Glioblastoma multiforme (GBM) is the most common and the most aggressive primary malignant tumor of the brain. Prognostic factors in GBM can be sorted as age, tumor localization, tumor diameter, symptom period and type, the extent of surgery, postoperative tumor volume, and adjuvant radiotherapy and/or chemotherapy status. Besides the interactions between actin microfilaments, microtubules, and intermediate filaments, environmental factors and intracellular signals which regulate them affect the cell invasion. Rho proteins and therefore Rho-kinase activation play important role at these changes. The aim of this study is to evaluate the relationship between the Rho-kinase pathway gene expressions and prognosis in GBM. Ninety-eight patients diagnosed as GBM between 2001 and 2010 were enrolled into the study. RNA was obtained from the paraffinized tumor tissue of the patients with formalin-fixed, paraffin-embedded RNA isolation kit and the mRNA expressions of 26 genes were investigated. There was a statistically significant negative correlation between the ages at the diagnosis and survival. There was a significant relationship between the overexpression of Rho-kinase pathway-related genes LIMK1, CFL1, CFL2, and BCL2 and low expression of MAPK1 gene and the survival of the patients. These results demonstrate for the first time that there is a marked contribution of Rho-kinase pathway-related genes to the progression and survival of the GBM. The expression of these genes may be related to response of multimodal therapy or these parameters could be used to determine possible unresponsive patients before treatment.

Unusual penetration of a construction nail through the orbit to the cranium: a case report.

Penetrating head and neck trauma with construction nails are uncommon life-threatening injuries and an important problem in developing countries. Assessment of the neurovascular and systemic physical status is a first requirement, and the decision concerning which surgical approach to perform for the removal of the nail is of critical importance. A 10-year-old girl was presented one hour after a fall injury with complaint of a swelling and foreign body lodgment on the left forehead. Neurological and systemic physical examinations were normal except for weak direct pupillary light reflex on the left side and the patient's state of uneasiness. Radiological investigations showed that the head of the nail had entered from the left infra-orbital region and become lodged through the orbital roof, below the frontal bone. Surgical extraction of the nail in the operating room was performed successfully using left pterional craniotomy and lateral orbitotomy technique, and there was no complication after surgery. Here, we report a case with a rare craniocerebral penetrating wound and type, with the head of the nail lodged in the anterior fossa through the orbital roof, which may be defined as 'reverse penetration of the nail'.

Efficacy of fentanyl and/or lidocaine on total antioxidants and total oxidants during craniotomy.

OBJECTIVE: The aim of this study was to investigate the oxidative, hemodynamic, and analgesic effects of local lidocaine infiltration, or intravenous (IV) fentanyl injection, or a combination of lidocaine and IV fentanyl during head fixation in a 3-pin headrest in patients undergoing elective craniotomy. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: Gaziantep University Medical Faculty, Department of Anesthesiology and Reanimation. METHODS: Eighty patients were randomly assigned to one of four groups. Five minutes before pin fixation, patients in group L received 1 mg/kg of lidocaine 2% for scalp infiltration (n=20), group F received 1 µg/kg of IV fentanyl (n=20), group FL received 1 mg/kg of lidocaine 2% and 1 µg/kg of fentanyl (n=20), and group P received a placebo (n=20). Following standard anesthesia, basal, pre- and post-fixational hemodynamic data were recorded. Blood samples were taken for evaluation of oxidant and antioxidant levels before and after pin fixation. RESULTS: The total antioxidant levels after pin fixation were highest in group FL followed by group F, then group L and finally group P (ie, FL>F>L>P) (P<0.05). The mean arterial blood pressure (MAP) after pin fixation was higher than the MAP before pin fixation in groups L and P (P<0.05), but was lower in groups F and FL (P<0.05). CONCLUSION: The combination of fentanyl and lidocaine before pin fixation is useful in preventing severe hemodynamic response to pain stimuli, such as pin fixation, and in increasing total antioxidant levels in the post-fixational period during craniotomy in adults.

Premedication with dexmedetomidine alone or together with 0.5% lidocaine for IVRA.

BACKGROUND: This study aimed to compare the effects of low and same dose of dexmedetomidine when added to lidocaine for intravenous regional anesthesia (IVRA) and when administered for premedication before IVRA. MATERIAL AND METHODS: In this double blind study, 45 patients with ASA physical status I-II were scheduled to undergo carpal tunnel release as an outpatient procedure and were randomly divided into three groups. IVRA was performed with 40 mL of 0.5% lidocaine in the operating room. A single dose of dexmedetomidine 0.5 µg/kg and placebo (saline) solution in a total volume of 20 mL were administered intravenously to group P (n=15) and group S (n=15), respectively, before IVRA. 0.5 µg/kg of dexmedetomidine was added to lidocaine in group A (n=15) during IVRA. The onset and recovery time of sensory and motor block, intraoperative-postoperative visual analog scale (VAS) and Ramsay sedation scores (RSS), analgesic requirement, hemodynamic variables, and side effects were noted. RESULTS: Significantly shortened sensory block onset and recovery time in group P and A, shortened motor block onset time in group P, and decreased intra-postoperative VAS scores and analgesic requirement in groups P and A were found. Intraoperative RSS in group P and postoperative RSS in groups P and A were higher than in group S. Intraoperative and postoperative heart rate and postoperative mean arterial blood pressure (MAP) of group P was significantly lower than groups A and group S, respectively. CONCLUSION: Both addition of dexmedetomidine to lidocaine and premedication with dexmedetomidine for IVRA similarly improve quality of anesthesia and perioperative analgesia without important side effects.

Antiepileptogenic effects of glutathione against increased brain ADA in PTZ-induced epilepsy.

Adenosine has been shown to play a significant role as a modulator of neuronal activity in convulsive disorders, acting as an endogenous anticonvulsant agent. Any change in adenosine deaminase (ADA) levels will reflect to adenosine levels. In the present study, we have investigated the effect of glutathione on brain tissue ADA levels due to seizures induced by convulsive and subconvulsive dose of pentylenetetrazol (PTZ) in mice. ADA levels due to seizures induced by convulsive and subconvulsive pentylenetetrazol were measured using the Giusti method. ADA levels were higher in the experimental epilepsy groups than in the control and sham groups. ADA levels significantly decreased in the glutathione groups, which may have antiseizure effects. Decreased levels of ADA would be due to increased adenosine levels, protecting against oxidative stress.

Effects of progesterone on total brain tissue adenosine deaminase activity in experimental epilepsy.

Single seizure and epilepsy is one of the most commonly encountered neurologic disorders in elderly individuals, arising as a result of complex and often multiple acquired underlying pathologies. Adenosine, acting at A1 receptors, exhibits anticonvulsant effects in experimental epilepsy and inhibits progression to status epilepticus. Adenosine deaminase is the enzyme for the regulation of adenosine levels. Therefore any change in adenosine deaminase levels will reflect to adenosine levels. Adenosine deaminase levels were decreased in the groups that were given progesterone. Progesterone may have an antiseizure effect with the additional finding decreased levels of adenosine deaminase that would have resulted in increased adenosine levels that exerts anticonvulsant effect via GABA-A receptors. Further studies are needed to evaluate the role of progesterone effects on adenosine deaminase levels and its mechanism(s) in the pathogenesis.

Spinal drop metastases from a papillary meningioma: a case report and review of the literature: utility of CSF sampling.

In this paper, we report a rare case of a 29-year-old boy who presented with papillary meningioma originating from the posterior fossa meninges. After a long, disease-free period, however, spinal drop metastases occurred 32 months after resection of the primary tumor. The primary and metastatic lesions had a similar histological appearance, meaning that multiple spinal metastatic lesions occurred through CSF route even after a gross total resection of the tumor. Tumor seeding during surgery is the evident reason for spinal metastasis, although we strictly adhered to the standard precautions for operations for malignant tumors such as obstruction of the cisterna magna with cotton paddies, and changing surgical gloves and instruments during the operation. In this report, we briefly discuss an exceedingly rare variant of meningioma, the papillary variant, and suggest a new approach, a CSF sampling, in the management of both malignant and benign meningiomas. CSF sampling allows for the early detection of metastasis and of tumor cells before metastasis has occurred, thus allowing treatment to begin as soon as possible. This early detection and management is possibly associated with longer survival. Furthermore, we discussed that meningiomas are tumors that are not as benign as initially thought.

Modified IDARAM chemotherapy regimen for primary central nervous system lymphoma: experience of three cases.

The use of radiotherapy (RT) with chemotherapy has improved disease free survival and control in primary central nervous system lymphoma (PCNSL). We have encountered three patients with histologically documented central nervous system lymphoma. In all patients pathological diagnosis was B-cell lymphoma. We modified IDARAM regimen to R-IDARAM to enhance and optimize chemotherapeutic components for the treatment of PCNSL. We made three changes: (i) we added rituximab 375 mg/m(2) day 1; (ii) increased dose of MTX from 2 to 3 g/m(2); and (iii) administered two additional courses of R-IDARAM after cranial RT. Following complete staging after course 2, radiotherapy was applied at a dosage of 3600-4140 cGy in conventional schedule (180 or 200 cGy per day) to whole brain (with 3600 cGy to eyes in one case because of eye involvement) and then 2 additional courses of R-IDARAM (totally four courses) chemotherapy regimen were applied. Complete remission (CR) was achieved after first two cycles of R-IDARAM in patient 1 and 3 and after four cycles in patient 2. Currently, three patients have been alive for 29, 10, 15 months respectively. Currently there is no standard treatment modality for PCNSL. Increased dosage of MTX, adding rituximab and consolidation of the IDARAM to R-IDARAM regimen may improve disease control and outcome in PCNSL patients.

Primary spinal epidural extraosseous Ewing's sarcoma mimicking a spinal abscess.

Ewing's sarcoma is one of the most common malignant tumors of the skeletal system in children and young adults. It most frequently stems from the long bones of the extremities. However, though uncommon, extraosseous localization can be seen. Epidural extraosseous presentations are extremely rare. In this case, the authors report on the long-term follow-up of a patient with this well-demonstrated, but uncommon localization, and the initial unique presentation of the patient, which clinically and radiologically mimicked a cervical abscess.