Endoscopic clipping of a middle cerebral artery aneurysm in a middle fossa arachnoid cyst and review of the literature.

BACKGROUND: Arachnoid cysts are often associated with subdural hematoma following head trauma. The incidental finding of an aneurysma and a cyst is rare. We describe for the first time the treatment of such a case using endoscopic techniques. CASE REPORT: A 44-year-old man was admitted to our hospital with a mild headache and a hemifacial spasm attack at the right side of his face. The radiological examinations demonstrated bilateral slyvian fissure arachnoid cysts and an aneurysm with the dome projecting superolaterally, at the bifurcation of the right middle cerebral artery in the arachnoid cyst. The patient underwent a complete endoscopic surgical clipping of the aneurysm, and partial excision of the right cyst wall and bilateral fenestration to the basal cistern via a single burr-hole craniectomy at the right temporal region. The patient had an uneventful postoperative course without neurological impairment and complication. However, his complaints still persisted postoperatively. CONCLUSION: Endoscopic management of arachnoid cysts is an effective and less morbid treatment. This less invasive option might be safe for the clipping of aneurysms within an arachnoid cyst with no additional morbidity for the patient. With smaller operative exposures and yet better visualization offered, neuroendoscopy may reduce operative morbidity.

Diagnosis of central nervous system infection by CSF sampling of the myelomeningocele sac as an alternative to ventricular tap.

BACKGROUND: Infection significantly affects mortality and morbidity in myelomeningocele cases. Ventricular tap is the most common method performed to diagnose central nervous system (CNS) infection in myelomeningocele patients. However, the ventricular tap can cause serious trauma to the baby and to the family. Here we discuss the technique of taking a cerebrospinal fluid (CSF) sample from the sac in myelomeningocele cases. METHODS: The study comprised 24 myelomeningocele patients undergoing sac repair; 7 patients in the early period and 17 in the late period (after the first 24 hours). CSF samples were taken from the sac and via ventricular tap. In all patients' samples, cell count and cultures were compared. RESULTS: In patients who underwent early meningomyelocele repair there was no significant difference between sac and ventricular CSF. There were also no positive cultures in samples taken from both areas. In comparison, in the group submitted to late repair, the number of cells in the sac and ventricle CSF samples was over 10 in 4 of the 17 patients. The cultures from CSF samples taken from both areas were positive for E. coli. In 13 of 17 patients who were admitted to our clinic for late repair, there was no significant difference between the number of cells in the sac and in ventricular samples. Cultures taken from these patients were negative. CONCLUSION: Puncture of the sac represents a quicker and more convenient way to obtain CSF in myelomeningocele cases. In addition, there was no increase in pain to a level that would cause stress for the baby. A CSF sample can be taken from the sac for diagnosis of CNS infection in myelomeningocele patients. This method, therefore, represents a safer and more comfortable option for both the patient and doctor.

Diagnosis of central nervous system infection by CSF sampling of the myelomeningocelesac as an alternative to ventricular tap

Background. Infection significantly affects mortalityand morbidity in myelomeningocele cases. Ventriculartap is the most common method performed to diagnosecentral nervous system (CNS) infection in myelomeningocelepatients. However, the ventricular tap can causeserious trauma to the baby and to the family. Here wediscuss the technique of taking a cerebrospinal fluid(CSF) sample from the sac in myelomeningocele cases.Methods. The study comprised 24 myelomeningocelepatients undergoing sac repair; 7 patients in theearly period and 17 in the late period (after the first 24hours). CSF samples were taken from the sac and viaventricular tap. In all patients’ samples, cell count andcultures were compared.Results. In patients who underwent early meningomyelocelerepair there was no significant differencebetween sac and ventricular CSF. There were also nopositive cultures in samples taken from both areas. Incomparison, in the group submitted to late repair, thenumber of cells in the sac and ventricle CSF sampleswas over 10 in 4 of the 17 patients. The cultures fromCSF samples taken from both areas were positive for E.coli. In 13 of 17 patients who were admitted to our clinicfor late repair, there was no significant difference betweenthe number of cells in the sac and in ventricularsamples. Cultures taken from these patients were negative.Conclusion. Puncture of the sac represents a quickerand more convenient way to obtain CSF in myelomeningocelecases. In addition, there was no increase inpain to a level that would cause stress for the baby. ACSF sample can be taken from the sac for diagnosisof CNS infection in myelomeningocele patients. Thismethod, therefore, represents a safer and more comfortableoption for both the patient and doctor (AU)

Fundamentos. La infección de LCR afecta significativamentela mortalidad y morbilidad en pacientes conmielomeningocele. La punción ventricular es la técnicamás frecuentemente utilizada para detectar infección delSNC en los casos de mielomeningocele. Sin embargo, lapunción ventricular puede causar un grave estrés tantopara el niño como para la familia. En nuestro estudio,presentamos la técnica y resultados del examen de LCRobtenido a partir del saco del mielomeningocele.Pacientes y métodos. El estudio comprende 24 pacientescon mielomeningocele sometidos a cierre quirúrgicode la malformación, 7 pacientes con reparaciónprecoz y 17 con cirugía tardía (después de las primeras24 horas). Las muestras de LCR fueron obtenidas delsaco de la malformación y de los ventrículos mediantepunción ventricular. Se compararon los resultados delrecuento de células y los cultivos realizados a todos lospacientes.Resultados. En los pacientes operados precozmente,no se encontraron diferencias significativas entre elLCR lumbar y ventricular. Tampoco se obtuvieroncultivos positivos en las muestras tomadas de ambasáreas. En los operados después de las primeras 24horas, el recuento de células del LCR del saco y delventrículo fue alrededor de 10 en 4 de los 17 pacientes.Se obtuvieron cultivos positivos (E. coli) de las muestrasde LCR tomadas de ambas áreas. En 13 de 17 pacientesque fueron admitidos a nuestra clínica para reparacióntardía, no hubo una diferencia significativa entre elnúmero de células del saco y del LCR ventricular. Loscultivos de LCR obtenidos en estos pacientes fueron (..) (AU)

Endoscopic approaches to the orbit: a cadaveric study.

INTRODUCTION: The role of the endoscopic management of lesions located in the anterior cranial fossa and skull base continues to expand. MATERIALS AND METHODS: An endoscopic anatomic study was conducted on cadaver specimens. 10 orbits from 5 cadaveric heads fixed in formalin were examined after the vascular structures had been perfused with colored latex and silicone. Endoscopic dissections were performed using rigid endoscopes of 4 mm diameter, 18 cm length, and equipped with 0 degrees , and 30 degrees lenses, according to the different steps of the anatomic dissection protocol. RESULTS: We have identified and described three endoscopic approaches to the orbit: 1) an inferolateral endoscopic orbital approach (IL-EOA), 2) an endoscopic endonasal medial orbital approach (EEM-OA), and 3) a transcranial key hole endoscopic orbital approach (TCK-EOA). DISCUSSION: The IL-EOA provides excellent exposure of the temporal compartment of the orbit. In this approach special care should be taken to preserve the ciliary ganglion, the ciliary artery and the ciliary nerves. The EEM-OA offers direct access to the medial and inferomedial orbit, the medial part of the optic nerve and orbital apex through its anteromedial walls. The EEM-OA is simple, relatively quick and has superiority over microsurgical operations by excluding the potential complications of intracranial operations. The EEM-OA is minimally invasive and cosmetically acceptable. The TCK-EOA offers an exposure of the orbital roof and the superior part of the optic nerve as well as other intraorbital structures from above. The TCK-EOA is a potentially safe approach for tumors extending from the orbital wall to the anterior cranial fossa and the parasellar region.

Glioblastoma multiforme of the lateral ventricle: report of nine cases.

Glioblastoma multiforme is the most common lethal primary central nervous system (CNS) tumour in adults and they are rarely seen as primary intraventricular tumours. We present nine cases with lateral ventricle glioblastoma multiforme treated in our department. Seven of the nine tumours were located at the body of the lateral ventricle, whereas the other tumours were arising from septum pellicidum. Five patients were operated through an anterior transcallosal approach and four patients were operated through frontal transcortical approach. Total tumour excision was achieved only in one patient. Median survival time was 18.8 months. Three patients were alive at the end of study, and received radiotherapy and chemotherapy. Our goal was the decompressive surgery for these tumours without harming eloquent structures. In our opinion, patient's life quality is critically important in the postoperative period for these mortal tumours with rapid progression.

Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour.

Dermoid and epidermoid cysts are congenital, slowly growing tumours that usually become symptomatic when patients reach the middle of their third decade. An otherwise healthy 20-year-old man presented with an epileptic attack. Imaging studies including computed tomography and magnetic resonance imaging revealed an intradural cystic lesion located in the anterior subfrontal region. Choices of traditional approaches for such a lesion are a bicoronal craniotomy or a transfacial procedure. Taking the advantage of the endoscope, the authors decided to remove the lesion via an endonasal route. After a fully endoscopic endonasal operation, gross total resection of the dermoid tumour was achieved. We have not observed cerebrospinal fluid leakage or any infectious complication after the operation. In this report the technique of operation and reconstruction method are described. The endoscopic endonasal approach offers a good option for lesions located in the anterior skull base. Carefully piecemeal resection of the tumour while preserving the underlying neural and vascular structures should be the main strategy of the operation. Reconstruction is very important after the surgery and a carefully planned pedicled graft technique may help in the prevention of cerebrospinal fluid leakage.

The effect of cranioplasty on cerebral hemodynamics: evaluation with transcranial Doppler sonography.

BACKGROUND: The purpose of cranioplasty is not only cosmetic repair but also neurological improvement. The effect of cranioplasty on the cerebral hemodynamics flow has not been investigated by ultrasonographic techniques. AIMS: To investigate changes of cerebral hemodynamics after cranioplasty in patients with cranial defect using transcranial Doppler sonography (TCDS). SETTING: The Departments of Neurosurgery and Radiology of a university hospital. DESIGN: A prospective clinical study. MATERIAL AND METHODS: We prospectively examined the cerebral hemodynamics with TCDS pre- and postoperatively in 18 patients with cranial defect who underwent cranioplasty. All postoperative studies were done between the 7th and 15th day after cranioplasty. The anterior cerebral artery was examined through the transtemporal and transorbital windows, the middle cerebral artery through the transtemporal window, and the posterior cerebral artery through the transforaminal window. Bilaterally, the peak systolic, end diastolic and mean blood flow velocities of these arteries were measured. STATISTICAL ANALYSIS: Wilcoxon matched-pairs signed-ranks test. RESULTS: Before cranioplasty all the velocities ipsilateral to the cranial defect were significantly low, while in the contralateral side they were near normal. Ipsilateral low cerebral blood flows increased and reached normal levels (P<0.05) after cranioplasty. During the follow-up, neurological improvement was observed. CONCLUSION: Cranioplasty is carried out not only for preserving normal appearances and physical barrier but also for neurological improvement. This should be explained by the normalization of cerebral hemodynamics.

Microsurgical anatomy of the orbital part of oculomotor nerve.

The microsurgical anatomy of the oculomotor nerve through its intraorbital course and branching was studied in 30 specimens obtained from 15 cadaver heads fixed in formalin. The superior and inferior divisions of the oculomotor nerve were shown and neural and vascular relationships of each division were examined, then some measurements were performed. In this part of the oculomotor nerve, some critical key points to the various orbital approaches were determined and microanatomic relationships of the orbital contents were revised.

Spinal epidural cavernous angioma: case report.

Epidural cavernous angiomas are apparently rare lesions. We present a case of paraplegia with acute onset secondary to spinal epidural cavernous angioma at levels C7 and T1. Magnetic resonance imaging gave the clinician the opportunity to diagnose the lesion preoperatively. In this article, we present and discuss this rare case with a review of the literature.