The history of Rhoton's Lab.

The work performed in Dr. Rhoton's Lab, represented by over 500 publications on microneurosurgical anatomy, greatly contributed to improving the level of neurosurgical treatment throughout the world. The authors reviewed the development and activities of the Lab over 40 years. Dr. Albert L. Rhoton Jr., the founder of, and leader in, this field, displayed great creativity and ingenuity during his life. He devoted himself to perfecting his study methodology, employing high-definition photos and slides to enhance the quality of his published papers. He dedicated his life to the education of neurosurgeons. His "lab team," which included microneuroanatomy research fellows, medical illustrators, lab directors, and secretaries, worked together under his leadership to develop the methods and techniques of anatomical study to complete over 160 microneurosurgical anatomy projects. The medical illustrators adapted computer technologies and integrated art and science in the field of microneurosurgical anatomy. Dr. Rhoton's fellows established methods of injecting colors and pursued a series of projects to innovate surgical approaches and instruments over a 40-year period. They also continued to help Dr. Rhoton to conduct international educational activities after returning to their home countries. Rhoton's Lab became a world-renowned anatomical lab as well as a microsurgical training center and generated the knowledge necessary to perform accurate, gentle, and safe surgery for the sake of patients.

Total resection of inferiorly located sacral chordoma with posterior only approach: case report and review of the literature.

Chordoma is a primary sacral neoplasm of ectodermal origin and makes up %1- 4 of all primary bone tumors. It is usually present on the midline cerebrospinal axis and the most common locations are the spheno-clival region and the sacrum. The treatment of primary sacral tumors represents a challenge because of a large tumor mass at presentation and a hemorrhage risk in surgery. Sacral tumors may present a difficult problem to the surgeon who desires to obtain a clear margin of excision. Using the retrorectal fat tissue as a cleavage line in the posterior approach guides the neurosurgeon to resect the tumor totally and reduce the hemorrhage in sacral chordomas. In this case report, we tried to discuss the advantages of using of retrorectal fat tissue as a cleavage line in sacral chordomas under the literature.

A short history of the microsurgery training and research laboratory at Gulhane Military Medical Academy.

Microsurgical techniques have played a crucial role in the development of neurosurgery and microsurgical education has an involuting role to gain surgical competence in neurosurgery. Microsurgery laboratory at Gulhane Military Medical Academy (GMMA) was established in 1985 by Prof. Erdener Timurkaynak within the Research-Development Building. From the beginning, education of the surgeons in microsurgery has been regarded as the essential function of this center, but many experimental and anatomical researches have also taken place in this laboratory. Over the past twenty-five years, 288 courses had been held in the microsurgical laboratory and more than 1000 surgeons from different fields and specialties were trained. Many of them conducted hundreds of research projects and published scientific papers during this period. This laboratory enters in the 21st century as a dynamic research and education center committed to the continuing delivery of education, as well as ongoing research of microsurgery for the coming 100 years.

Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature.

Although the first reported surgery for lumbar disc herniation was published many years ago, there still remains little agreement for the most effective treatment protocol for symptomatic cases. Many patients with extruded lumbar disc herniation require surgical intervention due to radiculopathy of lower extremities but some neurological symptoms of intervertebral disc herniation may frequently improve with conservative treatment. In this paper, two cases of spontaneous regression of extruded lumbar herniated discs are presented. The disc regressions of two patients were correlated with clinical improvement and documented with follow up MRI studies. Additionally the clinical course of lumbar disc herniation was discussed with mechanisms, features of MRI, immunohistological pathology and treatment options of past clinical studies.

Transcavum septum pellucidum interforniceal approach for the colloid cyst of the third ventricle Operative nuance.

BACKGROUND: Despite their unfavorable locations, lesions of the third ventricle can be successfully removed via an interhemispheric, transcallosal approach. In cases with normal ventricular anatomy, this approach requires unilateral or bilateral identification of the foramen of Monro. TECHNIQUE: However, in the presence of abnormal ventricular configuration such as cavum septum pellucidum (CSP), this basic knowledge needs to be modified. After routine callosotomy, there may be a confusion while entering the CSP due to the invisualization of ventricular landmarks such as the foramen of Monro, thalamostriate vein, and choroid plexus. The floor of the CSP is formed by the fornices, and a direct approach to the interforniceal area is easier via the CSP. But the interforniceal approach is not a routine way to reach the third ventricle, which has higher risks than other modalities. CONCLUSION: This approach should be planned and used in selected cases of the CSP. Opening of the walls of CSP is recommended both to expose both the foramen of Monro and to gain safe access to the third ventricle before manipulating the interforniceal area.

116 years (1889-2005) of neurosurgical practice and education at Gulhane Military Medical Academy.

Modern medical education in the Ottoman Empire began with the founding of the School of Medicine and Surgery in 1827. This was a military school established to provide military physicians for the army. The first neurosurgical interventions at this school were initiated by Cemil Pasha in 1889. This school has gradually expanded since its opening, and was reorganized and renamed "Gulhane Military Medical Academy" in 1898 as the result of efforts to establish modern medical education and practice in the Ottoman Empire. Neurosurgical operations have been continued by the different surgeons in the Department of Surgery at Gulhane Military Medical Academy. In 1957, the Department of Neurosurgery became an independent department through the work of Professor Zinnur Rollas. Today, neurosurgery is a dynamic and constantly changing department at Gulhane Military Medical Academy with work still in progress on technological, diagnostic, and surgical innovations that permit the treatment of highly complex cases.

Imaging of posterior fossa epidermoid tumors.

OBJECTIVE: Epidermoid tumors have similar radiologic characteristics with arachnoid cysts on routine imaging techniques. Since they warrant different therapeutic interventions, it is essential to differentiate the two pathologies and to assess operative results. PURPOSE: The purpose of this study is to define the MR characteristics of epidermoid tumors in posterior fossa particularly on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI). PATIENTS AND METHODS: During a 10-year period, we operated 19 cases with epidermoid tumor of posterior fossa. The localization of the epidermoids was cerebellopontine angle in 16 patients, within the fourth ventricle in 2 patients and pineal region in 1 patient. Neuroimaging included CT in all patients, conventional MR in 14 patients and FLAIR and DWI in the last 6 patients. RESULTS: In the first 13 cases, diagnosis of epidermoid tumor was difficult on CT and conventional MR. Epidermoids appeared as heterogeneous hyperintense lesions on FLAIR and homogenous hyperintense lesions on DWI in the last 6 patients. While total resection of the tumor was achieved in 17 patients, subtotal resection was performed in 2 patients. Histopathological examinations of the specimens revealed epidermoid tumor in all cases. CONCLUSION: Advances in neuroradiology provide us advantages for planning the treatment modalities in epidermoid tumors of the posterior fossa. The difficulties in preoperative differential diagnosis and judgment for reoperation in the postoperative course have been decreased particularly via FLAIR and DWI.

Composite type of split cord malformation: two different types at three different levels: case report.

The authors report on a child with a composite type of split cord malformation (SCM). The patient presented with symptoms of a common cold. The diagnosis of SCM was made based on computerized tomography and magnetic resonance (MR) imaging of whole spinal axis. The SCM was Type I at T-4 and T-5 and Type II at T-12, according to the classification developed by Pang. The child underwent resection of the splitting lesions and terminal filum release. No case of composite-type SCM reported to date contains documentation of such a malformation. Because of the possible neurological and urological problems, the authors recommend MR imaging of the whole spine be performed during/an evaluation for SCM.

The antioxidant effect of beta-Glucan on oxidative stress status in experimental spinal cord injury in rats.

This study was performed to investigate the antioxidant effect of beta-Glucan in experimental spinal cord injury (SCI). Injury was produced using weight-drop technique in rats. beta-Glucan was given by intraperitoneal injection following trauma. The rats were sacrificed at the sixth day of injury. Oxidative stress status was assessed by measuring the spinal cord tissue content of Malonyldialdehyde (MDA), Superoxide Dismutase (SOD) and Gluthatione Peroxidase (GSH-Px) activities. No effect of beta-Glucan on SOD and MDA activities was found but, GSH-Px levels were found to decrease to the baseline (preinjury) levels when it was compared to untreated group (U=0.000; p=0.002). According to our results, beta-Glucan works like a scavenger and has an antioxidant effect on lipid peroxidation in spinal cord injury.

Penetrating orbitocranial gunshot injuries.

BACKGROUND: The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries. METHODS: Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured. RESULTS: The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect-negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect-positive injuries. CONCLUSION: The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.

Ventricular injury following cranial gunshot wounds: clinical study.

Gunshot wounds to the head are usually fatal injuries, despite all medical and surgical interventions. Ventricular injury is a poor prognostic factor-for penetrating cranial gunshot wounds. Intraventricular hemorrhage and ventricular lacerations are the main components of such injuries. The incidence, management, and outcomes of cases of ventricular injury secondary to cranial gunshot wounds that were treated during a 9-year period at Gülhane Military Medical Academy were examined. The study group consisted of 67 consecutive patients who were admitted to the Department of Neurosurgery with the diagnosis of ventricular injury, with different penetration sites. The patients had been injured by either bullets or shrapnel. Surgical treatment was performed for all patients with ventricular injuries and 22 (32.8%) died. Ventricular injury in cranial gunshot wounds is a complex severe type of trauma that requires serious treatment. Early radiological diagnosis and accurate treatment frequently had lifesaving roles for these patients.

The clinical and surgical aspects of spinal tumors in children.

A series of 20 pediatric patients underwent surgery for spinal tumor at the Department of Neurosurgery, Gulhane Military Medical Academy between 1995 and 2003. Motor weakness and reflex changes were the main initial signs in these patients. Epidural tumors and intradural-extramedullary tumors were in equal number, and total tumor removal was achieved in most of the patients without adjuvant treatment. Laminotomy was the main surgical method in 60% of the patients with spinal tumor, especially in children younger than 3 years of age.

Surgical outcomes of ulnar nerve lesions in children. A retrospective clinical study.

The ulnar nerve provides the major motor innervation of the interosseous muscles of the hand and the flexor muscles of the wrist and the fourth and fifth digits. Injury is most common at the wrist, forearm or elbow, secondary to trauma or entrapment. Pediatric ulnar nerve lesions differ from adult lesions by their quicker axonal regeneration. Neural plasticity is also greater in children. We analyzed 21 pediatric patients with ulnar nerve lesion who underwent surgical treatment between 1995 and 2002 to determine if there were differences in the neurological outcome in terms of the type of lesion and surgery. Data showed that excellent results were found in 100% of the lesions treated by simple decompression and nearly 58% of the lesions treated by neurolysis. Good results were obtained in 33% of lesions treated by neurolysis. There were fair results for surgery performed in discontinuous lesions.

Association of paranasal sinus osteoma and intracranial mucocele--two case reports.

Two young adult males presented with paranasal sinus osteoma associated with mucocele. A 20-year-old man presented with headache and seizure, and another 20-year-old man presented with headache, frontal deformity, and visual disturbances. Both patients underwent surgery and satisfactory results were obtained. Isolated paranasal sinus osteomas are benign and slow-growing tumors, but may become more aggressive in association with mucoceles. The higher aggressiveness of the lesions may be due to the presence of the mucocele. Calcification and ossification of the mucocele probably contributes to the unexpected enlargement of the osteoma.

Surgical outcomes of cerebellar tumors in children.

Cerebellar tumors in childhood are generally associated with a favorable outcome if they are managed appropriately. 27 cases of pediatric cerebellar tumors, operated over a 7-year period, are presented. Histopathological diagnoses were as follows: pilocytic astrocytoma (48.2%); medulloblastoma (22.2%); ependymoma (18.5%); fibrillary astrocytoma grade III (3.7%); cystic oligodendroglioma (3.7%), and hemangioblastoma (3.7%). Microscopic gross total resection was achieved in 16 (59.3%) of 27 cases. The total removal of pediatric cerebellar tumors without neurological deficit is possible with appropriate microsurgical techniques excluding brain stem invasion. The follow-up periods must be shorter if brain stem invasion exists. Radiotherapy and chemotherapy are the adjuvant therapies according to the pathological diagnosis and the patient's age.

Split cord malformation in adults.

Although split cord malformations have been well documented in children, there is no consensus about their surgical indications and clinical course in adults because of their rarity. Medical records of nine young adult patients with split cord malformations were reviewed retrospectively. The most common complaint was radicular low back pain persisting more than 1 year, and the most common finding was hypertrichosis. Adult split cord malformation patients in our series had neither scoliosis nor foot deformities. Radiologically, all had low-situated conus medullaris. Eight of them underwent surgery. The radicular low back pain decreased in all the surgically treated patients at short-term follow-up but had not disappeared. Although pain originating from split cord malformations seems to be the most common surgical indication in adult patients and shows good short-term results, in our opinion long-term pain improvement is necessary for confirmation. According to our results, it seems that symptomatic young adults with split cord malformations are good candidates for complaint and deficit stabilization surgery.

Retrospective analysis of spinal missile injuries.

One hundred six patients with spinal missile injury from war zones were admitted to our department from 1994 to 2000. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Sixty-five were treated surgically, of whom 55 (84%) had incomplete injuries (Frankel scores B, C, and D). In the conservative group, 28 (68%) had incomplete injuries. A total of 81 patients (53 in the surgical group, 28 in the conservative group) could be monitored for functional recovery. In the surgical group, 34 (64%) showed improvement, 15 (28%) were unchanged, and four (7%) worsened. In the conservative group, 17 (60%) improved, nine (32%) remained unchanged, and two (7%) worsened. Cerebrospinal fluid fistula was observed in ten patients, seven of them in the surgically treated group. Five of seven meningitides were seen in the surgically treated group. Surgical intervention is not essential for spinal gunshot injury; however, it may be beneficial for patients with CSF fistula, infectious and compressing foreign bodies in the injury site, instability, and rapid neurological deterioration.

Transmaxillary approach to the orbit: an anatomic study.

OBJECTIVE: Various approaches to expose the orbit have been used, such as cranial, lateral, and medial approaches. In an effort to gain exposure to the orbit without necessitating a craniotomy, we have developed a transmaxillary approach to the orbit. METHODS: An approach was developed that uses data obtained by performing 24 orbit dissections in 12 cadaveric heads. After sublabial incision to expose the maxilla, maxillotomy is performed and the course of the infraorbital nerve is identified. The orbital floor is opened, and the orbit is accessed. RESULTS: This technique offers access to the inferomedial and inferolateral orbit and to the inferior aspect of the optic nerve. CONCLUSION: The transmaxillary approach provides an entirely extradural approach to the orbit. This technique combines the benefits of a cosmetically acceptable approach with orbitotomy and avoids the use of craniotomy and brain retraction to access the deep medial, lateral, and inferior orbit. We advocate the transmaxillary approach to the orbit in cases of inferomedial posterior intraconal and inferolateral lesions as an alternative and adjunct to the standard techniques of orbital surgery.