Unresponsiveness to Chiari Malformation Type I Surgery Can Be Related to the Accompanying Chiari Network.

Surgical treatment is indicated for Chiari malformation type 1 (CMI) with tonsillar descent (TD) of >5 mm and other clinical manifestations. However, some patients remain unresponsive to surgery; this is an active topic of discussion. A patient presented to the emergency department with dizziness and an impaired gait. He had a history of hypertension. Magnetic resonance investigations revealed a 9-mm TD and cervical syringomyelia. There was no evidence of interatrial septum pathology on transthoracic echocardiography performed preoperatively. Although his complaints were attributed to CMI and surgery was performed, his symptoms remained persistent. Two years later, when the patient's dizziness increased, a posterior fossa transient ischemic attack (TIA) was suspected. A large patent foramen ovale (PFO) and Chiari network (CN) were also detected on transesophageal echocardiography. His complaints were resolved following PFO closure. Our case suggests that neurosurgeons should be informed about the results of the companionship of a PFO and CN. Before deciding on CMI surgery for patients with only dizziness complaints, a detailed investigation of accompanying cardiac pathologies is paramount to ensure accurate diagnosis and treatment.

Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance.

Chondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem ( Fig. 1 ). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection ( Fig. 2 ). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors. The link to the video can be found at: https://youtu.be/WlmCP_-i57s .

Can Intracranial Vertebral Artery Hypoplasia be an Etiopathogenetic Factor for Barré-Licou Syndrome Other than Arcuate Foramen? A Retrospective Clinical Study and Review of Literature.

AIM: To investigate the co-occurrence of the arcuate foramen (AF) variation of atlas and intracranial vertebral artery (V4) hypoplasia and, therefore, to understand the pathophysiology of Barré-Licou syndrome (BLS). The AF localizes on the vertebral artery (VA) sulcus posterior to the atlas and has incomplete and complete types. Complete-type AF can exert pressure on the VA that passes through it, resulting in vertebrobasilar insufficiency finding, a BLS component. By the surgical decompression of VA at the AF level, complaints could be decreased in some cases. However, a reliable theory regarding BLS has not yet been established; therefore, the cases that do not respond to AF decompression have not been fully elucidated. We assumed that V4 hypoplasia that accompanies AF might be the main factor in the pathophysiology of BLS. MATERIAL AND METHODS: Cervical computed tomography and magnetic resonance angiography images of 139 patients aged 14?88 years with head and neck pain and dizziness were retrospectively evaluated. RESULTS: Of the patients, 19.4% exhibited complete AF and 32.4% exhibited VA hypoplasia (VAH); 10% of the patients with VAH had accompanying contralateral complete AF variation. There was no significant relationship between complete AF and contralateral and ipsilateral VAHs (right side: p=0.527 and p=0.433, respectively; left side: p=1.000 and p=0.740, respectively). CONCLUSION: Our findings indicate that V4 hypoplasia is not the main factor of BLS pathophysiology. Furthermore, the rarity of the relationship suggests why some cases do not respond to decompressive surgery.

Challenges in Using the Posterior Inferior Cerebellar Artery for Revascularization of the Anterior Inferior Cerebellar Artery: A Microsurgical Anatomic Study.

BACKGROUND: A bypass is usually required to prevent ischemia during the treatment of anterior inferior cerebellar artery (AICA) aneurysms. The intracranial (IC)-to-IC bypass provides several advantages over the extracranial-to-IC bypass in the posterior fossa. However, there are only 2 case reports about AICA revascularization with the posterior inferior cerebellar artery (PICA). We aimed to investigate the microsurgical anatomical challenges for PICA to AICA anastomosis. METHODS: Ten cadaveric heads injected with colored silicone were inspected on both sides using a lateral transcondylar approach. After the donor and recipient arteries were examined from the posterior side, neurovascular contents of the posterior fossa were excised and the origin, course, and variations of both arteries were investigated from the anterior view. The diameters of the AICA and PICA segments and the intersegment distance were measured. RESULTS: PICA variations and posteromedial origins from the vertebral artery were identified in 8 of the 20 right and 6 of the 20 left sides, and the first segment of the PICA was not present in 7 sides. Furthermore, in 18 sides, the PICA was trapped between the lower cranial nerves and dentate ligaments. Therefore the donor artery could not be brought closer than 1 cm to the recipient artery in 19 sides. Moreover, AICA variations were identified in 6 sides, and in 12 sides, the diameter of the recipient artery was <1 mm. CONCLUSIONS: The mostly PICA-related issues made PICA-to-AICA anastomosis unfeasible in all cadaveric heads included in the study.

Prevalence of Anomalously Originating Occipital Artery in a Group of Turkish Individuals: A Retrospective Study using Angiography.

AIM: To investigated the prevalence of anomalously originating occipital artery (OA) using angiography in a group of Turkish individuals. MATERIAL AND METHODS: The images recorded in the picture archiving and communication system for a total of 114 patients, in which the whole vertebral artery, as well as the external carotid artery (ECA) and its branches, were visualized, were retrospectively reviewed. Images were obtained using a Toshiba INFNX-i 8000V (Canon Medical Systems, Otawara, Tochigi, Japan) angiography device. RESULTS: We diagnosed 11 cases (12 arteries) with anomalously originating OA, representing a prevalence of 9.64%. In 7 cases, the ascending pharyngeal artery and OA originated with a common root from the ECA (8 arteries); and in 4 patients, OA originated from the distal part of the ECA (C1 vertebral level). CONCLUSION: As for many vascular structures, the prevalence of OA variations may vary according to the population under question and the examination method used. Our study has shown that in a sample from the Turkish population, the prevalence of anomalously originating OA was much higher than that stated in the literature, which used magnetic resonance angiography. To avoid complications, the high prevalence of this anomaly must be taken into account during surgeries that require the use of OA, endarterectomies, and endovascular interventions.

Familial Chiari Type 1: A Molecular Karyotyping Study in a Turkish Family and Review of the Literature.

BACKGROUND: The etiology of Chiari I malformation (CMI) has not been fully elucidated. Therefore, we performed a genetic study of a Turkish family in which 3 sisters had a diagnosis of CMI with or without syringomyelia. METHODS: In a family with 7 children, 4 daughters complained of occipital headaches. In 2 of these daughters, CMI had been diagnosed during their 30s, and CMI plus syrinx had been diagnosed in the other daughter in her 40s. Cranial magnetic resonance imaging of the fourth daughter who had developed headaches during her 30s showed normal findings. Because the other siblings in the family were asymptomatic, radiological examinations were not performed. The family had a history of distant consanguineous marriage between parents. Additionally, the father had died, and the mother was asymptomatic, with radiologically normal findings. Array comparative genome hybridization studies were performed for 12 persons from 3 generations of this family. RESULTS: None of the 12 cases examined harbored copy number variations. CONCLUSIONS: This family with 3 sisters having CMI suggested a possible autosomal recessive single-gene etiology. Cases of familial CMI are unusual but important to study because they could reveal the specific genes involved in posterior fossa/foramen magnum structure and function and provide insights into the cause of sporadic cases.

Locally Used Antibiotics for Spinal Infection Prophylaxis and Their Effects on Epidural Fibrosis: an Experimental Laminectomy Study in Rats Using Rifamycin and Gentamycin.

The study aims to assess the effects of antibiotics (ABs), which are typically used in spinal infection prophylaxis, on the formation of epidural fibrosis (EF). Specifically, we investigated the effect of rifamycin and gentamycin on EF formation in laminectomized rats. Thirty-two rats were randomly and equally divided into four groups as follows: laminectomy and physiological saline (0.9% NaCl) solution (control); laminectomy and rifamycin; laminectomy and gentamicin; and laminectomy and a mixture of rifamycin and gentamicin. Laminectomy was performed on L1 and L2 vertebrae in all rats. One month after spinal surgery, spinal tissue samples surrounding the laminectomy were cut with a microtome and stained with hematoxylin-eosin and Masson's trichrome. The histopathological analysis included examining the extent of EF, fibroblast cell density, and cartilage and bone regeneration. Statistical analysis was performed using the IBM SPSS Statistics 22 program (SPSS IBM, Turkey). A value of p < 0.05 was considered statistically significant. EF value differences between the AB treatment groups and the control group were statistically significant (p = 0.030). Specifically, binary comparisons indicated that the EF value was significantly higher in the rifamycin group than that in the control group (p = 0.003; p < 0.05). Our study suggests that locally applied ABs, especially rifamycin, should be diluted before administration to the epidural space.

Occipital Artery and Its Segments in Vertebral Artery Revascularization Surgery: A Microsurgical Anatomic Study.

OBJECTIVE: To study the microsurgical anatomy of the occipital artery (OA) to determine the optimal segment for use as a conduit in revascularization bypass surgery. METHODS: Twelve sides of 6 cadaveric heads that had been injected with colored silicone were exposed using C-shaped postauricular incision. The OA was dissected from its point of origin to the proximal part of the distal segment. For each segment, the diameters and length were measured, and its branches and proximity to the recipient vessel (V3) were examined. RESULTS: The mean diameters were 2.6 mm at the digastric segment, 2.04 mm at the point where it exits the mastoid sulcus, 2.0 mm, at the point just before the last descending muscular branch, and 1.8 mm and 1.5 mm after the branch and attached to the superior nuchal line, respectively. The length of the OA from the point where it exits the mastoid sulcus to the point at which it revealed the last descending muscular branch was 53 mm, and the distance of this section to the V3 was 31 mm. CONCLUSIONS: In pathologies necessitating vertebral artery revascularization surgery, it is possible to easily mobilize the OA with a C-shaped postauricular incision in the lateral suboccipital region. To reach a more appropriate segment in terms of diameter, length, and easy anastomosis, V3 sulcal and OA suboccipital segments are more suitable. Thus, if bypass surgery is indicated in cases of vertebrobasilar ischemia, the suboccipital segment of the OA may be an ideal choice and considered as an artery that can be used in "SOS" conditions.

Irreversible Footdrop as a Consequence of Neglected Knee Pain in an Adolescent with a Peroneal Intraneural Ganglion Cyst.

BACKGROUND: Peroneal intraneural ganglion cysts (IGCs) are nonneoplastic lesions. They are responsible for a small number of footdrop cases, which occur after additional nerve damage. The earliest patient symptom related to IGCs is knee pain. CASE DESCRIPTION: A 17-year-old boy developed pain in the left knee, which progressively worsened over 14 months. He did not seek any medical assistance during this time. The patient subsequently was involved in a bicycle accident, and 3 months later he was unable to raise his left foot and was referred to our clinic for footdrop. Surgery was performed, but the weakness persisted. We could not detect any functional reinnervation on electromyography 12 months after surgery. CONCLUSIONS: The most important factors in determining the prognosis of IGCs are the extent of the nerve trauma and the early diagnosis and treatment of the IGC. Detection of almost complete functional denervation on electromyography may indicate that it is too late for surgery.

Is there a relationship between blood lipids and lumbar disc herniation in young Turkish adults?

INTRODUCTION: Atherosclerosis might diminish the nutrient supply to intervertebral discs (IVD), leading to disc herniation. Therefore, there is interest in determining the possible association between the blood lipid profile and lumbar disc herniation (LDH). We aimed to evaluate the association between blood lipids and LDH in a homogeneous group of patients, controlling for age- and sex-specific effects. MATERIAL AND METHODS: This is a case-control study which consisted of 100 individuals (mean age: 41.25 ±9.09; 50 men and 50 women), classified into two groups, as follows. Group I (G-I) consisted of 50 patients who underwent surgery for symptomatic LDH, while group II (G-II) consisted of 50 patients with nonspecific complaints of a headache, but with no previous history of back and/or leg pain, recruited among patients admitted to the outpatient clinic at the time of the study, and whose age and sex were matched to the study group. Total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose, and hemoglobin A1c levels were measured. The TC/HDL-C ratio was calculated. Blood pressure, waist circumference, body mass index, and the history of smoking were included in the analysis. RESULTS: The mean values of the TC, TG, LDL-C, HDL-C levels and TC/HDL-C ratio were 198.38, 132.76, 131.9, 40.38 mg/dl and 5.09, respectively. No statistically significant relationship between the blood lipid profile and LDH was identified in this population. CONCLUSIONS: Blood lipid levels in this young adult Turkish population did not predict LDH, and may not be a leading cause of IVD ischemia and IVD degeneration.

Effect of bone mineral density on lumbar discs in young adults: A case-control study.

Bone mineral density (BMD) might be a risk factor for lumbar disc herniation (LDH) in young adults, but there is not enough data concerning this effect. Several studies have been performed on elderly and osteoporotic patients. Thus, we aimed to investigate the effect of BMD on the etiopathogenesis of LDH in young adults.One hundred patients (mean age: 38.45 ±â€Š8.92 years; 50 men and 50 women) were enrolled this case-control study and classified into 2 groups, as follows. The case group (G-I) included 50 patients with symptomatic LDH who were hospitalized in the Physical Medicine and Rehabilitation Clinic, and the control group (G-II) included 50 patients with lower back pain but no finding of LDH detected using magnetic resonance imaging. Patients in the G-II were recruited among those admitted to the outpatient clinic at the time of the study, and whose age and sex were matched to those of the study group. Women in menopause were excluded from the study. BMD analysis by dual energy x-ray absorptiometry was performed in both groups.The mean values of the femur neck and lumbar spine BMD were 1.02 ±â€Š0.13 and 1.19 ±â€Š0.14 g/cm, respectively. There was no statistically significant relationship between BMD and LDH in this population.This result may mean that in a normal range, BMD does not exert a compressive load on the lumbar discs in young adults and therefore may not lead to LDH by this mechanism and the load.

Semivertical Incision: An Aesthetically and Electrophysiologically Effective Mini-Incision Technique for Carpal Tunnel Decompression.

BACKGROUND The purpose of this study was to present the clinical results of our retrospective series of carpal tunnel release (CTR) operations. For these operations we used a unique type of incision, for the first time, for treatment of carpal tunnel syndrome (CTS) consisting of a 1-cm semi-vertical (SV) incision made into the wrist crease for macroscopic open CTR. MATERIAL AND METHODS This retrospective study included 114 patients (101 females and 13 males) with CTR who were operated upon in our neurosurgery clinic between December 2010 and June 2015. Patient ages ranged from 35 to 83 years (mean 55.05±12.04 years). In total, 127 hands (73 right and 54 left) were operated upon using the SV skin incision technique. After an average follow-up of 18 months (ranging from 6 to 30 months), clinical and electrophysiological (EP) evaluations were performed. RESULTS A review of the English language literature published since 1957, when Phalen first popularised the diagnosis and treatment of this disease, determined that no previous reports of the mini-open incision technique as described in our study have been published. In our retrospective patient case review, we found that after operations using the SV incision technique, statistically significant differences were detected in electromyography (EMG) improvements (p<0.01). In addition, patients who showed improvement in EMG studies (n=90) were satisfied with the result of their surgery. CONCLUSIONS Our study demonstrated that 1-cm skin SV incision was a cosmetically satisfying, fast, and safe approach to CTR that was not only clinically effective but also electrophysiologically effective.

The outcome of a pregnant woman with a minor head injury: an ossified subdural hematoma (OSDH).

We experienced an ossified subdural hematoma (OSDH), which is an extremely rare form of chronic subdural hematoma (SDH), in the dominant hemisphere of a 35-year-old woman. She presented to our outpatient clinic with a complaint of a headache; she had previously experienced a head injury while she was pregnant. We performed surgery with extreme caution because the lesion was attached to the surrounding tissue. Since an OSDH is an extremely rare form of chronic SDH, neurosurgeons might not experienced them during their daily practice. Additionally, head injuries received during pregnancy should be taken seriously, and after delivery, the patient should undergo cranial computed tomography, even if she is asymptomatic.

Microsurgical resection of tumors of the lateral and third ventricles: operative corridors for difficult-to-reach lesions.

Tumors of the lateral and third ventricles are cradled on all sides by vital vascular and eloquent neural structures. Microsurgical resection, which always requires attentive planning, plays a critical role in the contemporary management of these lesions. This article provides an overview of the open microsurgical approaches to the region highlighting key clinical perspectives.