Endoscopic Transnasal Approach for Microprolactinomas with Experience of 105 Cases in a Single Center: Paradigmal Shift for Conventional Medical Therapy.

OBJECTIVE: The classically recommended first-line therapy for microprolactinomas is medical therapy. In the presence of drug resistance and intolerance after the use of dopamine agonists or when the patients prefer surgery instead of medication, surgical treatment is considered as second-line treatment. The high hormonal remission and low complication rates after surgery for microprolactinomas suggest that the surgical outcome of endoscopic surgeries may be better than medical therapy in well-selected patients. This study reports a large series of patients with microprolactinoma treated by endoscopic transnasal approach and evaluates the efficiency of surgical treatment. METHODS: Our study is a retrospective cohort analysis of patients with microprolactinoma operated on by an endoscopic transnasal approach between August 1997 and February 2022 by an experienced pituitary surgeon in a single tertiary center. Inclusion criteria for microprolactinoma were based on increased prolactin levels, microadenoma (<10 mm in diameter) on pituitary magnetic resonance imaging, and histopathologically verified lactotroph adenoma. RESULTS: The mean follow-up was 74.90 months (range, 6-207). The postoperative day 1 remission rate was 85.7% and the long-term remission rate was 74.3%. The long-term remission rates of the patients in the preference group were significantly higher than those of the patients in the resistant or intolerance group (P = 0.002). Patients who used dopamine agonists for more than 3 years had a lower remission rate compared with patients who used dopamine agonists for a shorter period or who did not use it (P = 0.01). The surgical complication rate was 4.76%. CONCLUSIONS: According to our findings, endoscopic transnasal surgery performed by an experienced neurosurgeon in well-selected patients with microprolactinoma can be offered with cure rates superior to medical therapy and may be an alternative first-line treatment option to dopamine agonists.

Can The Fracture Line of Type II Odontoid Fractures Come to A Neutral Position After Anterior Odontoid Screw Fixation without a Manipulation?

AIM: To examine whether there was an improvement in the displaced fracture line in the follow-up, in which Anterior odontoid screw fixation (AOSF) was performed without manipulation and to determine the "displacement angle range" in which AOSF was possible. MATERIAL AND METHODS: A total of 11 patients with the diagnosis of type II odontoid fracture who underwent AOSF without manipulation were analyzed retrospectively. A control group of 30 cases was formed and odontoid related angle measurements were performed on cervical computed tomographies (CT) of the control group and the patients who were operated. RESULTS: In 6 of 7 cases in the posterior-displaced group along with all cases in the anterior-displaced group, it was determined that the displacement angles returned to the normal range in the 1st year follow-up. In 1 case having posterior displacement with posterior longitudinal ligament (PLL) damage, it was observed that the displacement angle improved to the normal range significantly, but the displacement continued. CONCLUSION: AOSF is a minimally invasive, safe and effective method in patients with displaced type II odontoid fracture, which is between the median odontoidobasal angle range of 100°-134°, whose PLL is preserved, and which cannot be manipulated.

Multiple Extraneural Metastases of Anaplastic Oligodendroglioma.

Oligodendrogliomas (ODGs) is a diffuse glial tumor that constitutes 4.2% of all brain tumors. Extraneural metastases, sometimes seen in glioblastoma multiforme, are extremely rare in ODG. In this report, we present a 63-year-old male patient who was diagnosed with Grade 3 ODG and had an intracranial mass resected in our clinic 4 years ago. The subject now presented with low back pain and was found to have widespread metastases. The prolongation of patient survival by current treatment regimens has revealed a growing number of ODG patients with metastases. We believe that back pain complaints in patients with ODG should be viewed as an indicator of metastasis.

The Effects of Proanthocyanidin on Vasospasm After Experimental Subarachnoidal Hemorrhage in Rats.

AIM: Delayed ischemic neurological deficit (DIND) and cerebral vasospasm (CV) remain the most common and debilitating neurological complications following aneurysmal subarachnoidal hemorrhage (SAH). Many reports demonstrate the importance of proanthocyanidins (PR) on the vascular system, including endothelium-dependent relaxation of blood vessels. These effects of PR on the cerebral vascular system were examined in this study. < p < MATERIAL and METHODS: Fifty-two adult Sprague-Dawley male rats were used for the experimental double hemorrhage model. They were divided to control, sham, pre- and post-interventional treatment groups. 100 mg/kg PR was administered for the treatment for respect to groups. Basilar artery diameter (BAD) and arterial wall thickness were measured and the apoptosis ratio of the endothelial cells was calculated. Arterial walls were examined electron microscopically (EM). RESULTS: There were significant differences between the groups except control and pre-SAH (p=0.37) and post-SAH and pre- SAH groups (p=0.15) with respect to BAD. According to arterial wall thickness, apoptosis ratio, and grading, there were significant differences between the groups except control and pre-SAH (p=0.85, p=0.49 and p=0.18 respectively) and SAH and post-SAH (p=0.08, p=0.21 and p=0.24 respectively) groups. EM findings revealed that pro-apoptotic and pro-necrotic degenerated endothelial cells with seldom vacuolization in post-SAH treatment group which were more serious in SAH group. CONCLUSION: Pre-SAH administration of PR induces better vasodilatation and protection of basilar artery (BA) from vasospasm (VS), which could yield neuroprotective and vasodilatator effects. In addition, PR appears to be involved in relieving oxidative damage, with an antioxidant-antiapoptotic-antinecrotic effect that may contribute to vascular dilation.

Thoracic Intramedullary Lipoma in a 3-year-old Child: Spontaneous Decrease in the Size Following Incomplete Resection.

Nondysraphic intramedullary spinal cord lipomas are even rarer. We present a thoracic intramedullary lipoma which spontaneously decreased in size following surgical debulking. A 3-year-old girl was admitted to our department with complaints of back pain since 1 year and progressive difficulty in walking since 6 months. Her magnetic resonance imaging (MRI) revealed T8-9 intramedullary mass showing increased signal intensity in both T1- and T2-weighted images. The patient was operated with a T8-9 laminoplasty and debulking, and internal decompression of the tumor was made. Histologically, the tumor was uniformly composed of mature adipose tissue revealing a lipoma. First-month control MRI revealed the rest mass almost the half volume of the preoperative mass. The 2nd year MRI revealed the size of the lipoma was spontaneously decreased to almost half of postoperative size and 3rd year was the same as the 2nd year with a mild kyphosis. Decompression and debulking with or without duraplasty is the most appropriate treatment for symptomatic patients. Dietary measures with control of fat intake and long-term follow-up are also suggested.

Brain Metastasis Of Penile Angiosarcoma.

Angiosarcoma is a rare malignancy originating from vascular endothelial cells. Brain metastasis of aniosarcomas are uncommon up to the literature. Penile angiosarcomas are also seldom among all anjiosarcomas. A case with penile angiosarcoma with confirmed brain metastasis is aimed to be reported and contribute to the literature for similar cases.

Prognostic Impact of Histologic Subtype in Non-Small Cell Lung Cancer Patients Treated with Gamma Knife Radiosurgery: Retrospective Analysis of 104 Patients.

AIM: In this study, factors affecting survival, local failure, distant brain failure, whole brain failure and whole-brain radiation therapy (WBRT) free survival according to histological subtypes were investigated in patients with brain metastases from non-small cell lung cancer (NSCLC). MATERIAL AND METHODS: Patients with positive pathology reports for adenocarcinoma (ACA) and squamous cell carcinoma (SCC) were included in the study. Seventy-eight ACA and 26 SCC patients were included in the study. Patients with previous history of cerebral metastasis surgery and WBRT were excluded from the study. RESULTS: The median survival was calculated as 12.6 months for patients with ACA and 5.9 months for patients with SCC. One-year distant brain failure was calculated as 65.1% in ACA patients and 39.6% in SCC patients. One-year whole brain failure was calculated as 58.1% in ACA patients and 39.6% in SCC patients. The one-year freedom from WBRT rate was calculated as 72.8% in ACA patients and 56.3% in SCC patients. SCC histology was considered as a significant factor in deterioration of overall survival in multivariate analysis. SCC histology, the increase in the number of metastases and RPA class were factors that caused an increase in distant brain failure. Also, SCC histology, the increase in the number of metastases and RPA class were factors that caused an increase in whole brain failure. CONCLUSION: SCC histology may be an important prognostic factor for overall survival. Also, due to high distant brain failure rate in SCC histology, WBRT can be added to treatment early.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

BACKGROUND AND PURPOSE: Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. MATERIALS AND METHODS: Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. RESULTS: 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3-51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. CONCLUSIONS: Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.

Massive Calcified Cerebellar Pilocytic Astrocytoma with Rapid Recurrence : A Rare Case.

Pilocytic astrocytomas (PAs) are World Heath Organization Grade I tumors and are most common in children. PA calcification is not a common finding and has been reported more frequently in the optic nerve, hypothalamic/thalamus and superficially located cerebral tumors. We present a cerebellar PA in a 3-year-old male patient with cystic components and massive calcification areas. The residual tumor grew rapidly after the first operation, and the patient was operated on again. A histopathological examination revealed polar spongioblastoma-like cells. Massive calcification is not a common feature in PAs and can lead to difficulties in radiological and pathological differential diagnoses.

Rapid Spontaneous Resolution of Acute Epidural Hematoma: A Case Report and Review of the Literature.

BACKGROUND: Epidural hematomas (EDH) are pathologies in which the early diagnosis and treatment are important. Resolution under 24 hours is very rare. CASE REPORT: An 11-month-old male patient was brought to the emergency department with head trauma from falling out of bed onto his back. There were no neurological deficits, except for the patient being somnolent. Computed tomography (CT) of the patient revealed subgaleal edema in the right parietal region, linear fracture and image consistent with EDH with a thickness of about 9 mm underneath fracture. A control CT was performed after 3 hours as somnolence continued in follow-up of the patient. Hematoma in the epidural region was observed to completely resolve and edema in the subgaleal region was observed to gain hemorrhagic characteristics. CONCLUSION: In total, 15 cases have been reported, including our case, in the literature with resolution less than 24 hours. Our case has the fourth fastest resolution ever reported in the English literature. We think that the most important factor in the rapid spontaneous resolution is the presence of a connection between the epidural and epicranial space, either through a fracture or cranial sutures.

The Relationship of the Vertebral Artery with Anatomical Landmarks in the Posterior Craniovertebral Junction of Fresh Human Cadavers in the Turkish Population.

AIM: Surgical anatomy concerning the posterior craniovertebral region in fresh human cadavers was studied to provide most accurate information for the surgical approach. MATERIAL AND METHODS: In thirty-two fresh human cadavers, the distance from the posterior tubercle to the sulcus of vertebral artery (VA), the thickness and length of the third segment of VA (V3), the distance of C1/C2 facet to V3, the length, height and shape of the C2 ganglion to the neighboring structures, the distance from medial border of C1 lateral mass to dura mater, the distance of the transverse process of atlas to mastoid tip, the thickness of C1 posterior arcus were measured. RESULTS: There were variations of sulcus of VA in 14 of 32 cadavers (43.7%), the right VA was larger in 23 cadavers (71.8%). The ganglion was found over the C1 lateral mass screw entry point in 45 of 64 ganglions (70.31%) and below the screw entry point in 19 of 64 ganglions (29.69%). The distance of the medial border of the C1 lateral mass to dural tube was 3.81±0.55 mm at the right side and 3.91±0.59 mm at the left. The thickness of C1 posterior arch was 3.73±0.75 mm at the right side and 3.75±0.77 mm at the left. The mean distance from the transverse process of C1 to the mastoid tip was 15.82±4.49 mm at the right side and 15.46±4.38 mm at the left. CONCLUSION: This is the most comprehensive and only fresh cadaver study about this region in the literature.

A Rare Case of Concomitant Intramedullary Gangliocytoma at the Cervicomedullary Junction in Patient with Neuroendocrine Tumor of Lung.

Ganglion cell tumors (GCT) are divided into two subtypes : gangliocytoma and ganglioglioma. Intramedullary gangliocytomas are extremely rare. A 20-year-old male patient with pain of neck, who also had a previously known neuroendocrine tumor of lung, was operated for mass found in the cervicomedullary junction with a presumptive diagnosis of metastases. Only partial resection could be performed. Pathological diagnosis had been reported as gangliocytoma. Only ten cases of intramedullary gangliocytoma have been reported in the literature. Although association with scoliosis and Von Recklinghausen's disease were previously reported in the literature, no gangliocytoma case concomitant with endocrine tumor of lung have been published. Pathological study is the most important diagnostic method for gangliocytomas. Surgical excision is the primary treatment, but difficulty in total surgical tumor resection is the most important problem.

The retrospective analysis of the effect of balloon kyphoplasty to the adjacent-segment fracture in 171 patients.

STUDY DESIGN: Analysis of the adjacent-segment fractures in 171 balloon kyphoplasty (BK)-performed patients. OBJECTIVE: The purpose of this study was to investigate the risk factors for new symptomatic vertebral compression fractures (VCF) after BK. SUMMARY OF BACKGROUND DATA: Although there are many studies about the incidence and possible risk factors for occurrence of adjacent-level fractures, there is no consensus on the increased risk of adjacent-level fractures after BK. METHODS: We performed a retrospective analysis of 171 patients treated with percutaneous kyphoplasty. The follow-up period was 41.04±21.78 months. The occurrence of new symptomatic VCF was recorded after the procedure. We evaluated the variables of patient age and sex, the amount of injected cement, the initial kyphotic angle (KA) of VCF, the change of the KA after BK, the severity of osteoporosis, and the percentage of height restoration of the vertebral body. Furthermore, possible risk factors were reported for new symptomatic VCFs. RESULTS: The only 2 factors identified as being significantly associated with adjacent-level fractures were the sex (P=0.001) of the patient and the preoperative KA (P=0.013). The patients with new symptomatic compression fracture had higher initial KA than those without fractures. The female group had higher risk than the male group in occurrence of the new vertebra fractures. The severity of the osteoporosis (low bone mineral density) was not a determinant in occurrence of the new VCF after BK. CONCLUSIONS: If the patients experience severe or mild back pain with higher preoperative KA, especially in the first 2 months, then they deserve detailed radiologic examination. To avoid subsequent fracture in the same or adjacent level, vertebral body should be filled adequately and sagittal balance should be obtained with KA correction. BK alone did not influence the incidence of subsequent VCF.

A extremely rare case of cervical intramedullary granuloma due to Brucella accompanied by Chiari Type-1 malformation.

Chiari Type-1 malformation is displacement of the cerebellar tonsils through the foramen magnum into the cervical spine and usually does not exceed the level of C2. It is 50-70% associated with syringomyelia. Nervous system involvement due to brucellosis is called neurobrucellosis, and neurological involvement rate has been reported an average of 3-5%, ranging between 3% and 25% at different series. Intramedullary abscess or granuloma due to Brucella is extremely rare. Hence far, six cases have been reported in the literature and only two of these cases were reported as intramedullary granuloma. This case is presented in order to remind the importance of the cervical cord granuloma which was presented once before in the literature and to emphasize the importance of evaluation of patient history, clinical and radiological findings together in the evaluation of a patient.

A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears.

OBJECTIVES: This study aims to compare the clinical outcome and possible complications of augmentation technique and standard reconstruction for the treatment of partial anterior cruciate ligament (ACL) tears. PATIENTS AND METHODS: Forty patients (36 males, 4 females; mean age 30 years; range 19 to 40 years) who underwent surgery due to ACL tear were included in this prospective randomized study. The patients were randomly divided into two groups, including 20 patients in each group. The patients in the group 1 underwent standard single bundle ACL reconstruction with hamstring tendon autografts, while those in the group 2 underwent augmentation where the remaining remnant ACL was not sacrificed, but instead augmented with hamstring tendon autograft as in the standard reconstruction technique. The mean follow-up was 24.3 months (range; 21-28 months). Clinical outcomes were evaluated using International Knee Documentation Committee (IKDC), Lysholm scores, physical instability tests and patient satisfaction questionnaires. The complication rates of both groups were compared. Tibial and femoral tunnel widening were assessed using lateral and anteroposterior radiographs. RESULTS: No significant differences were found between the groups in terms of IKDC, Lysholm scores, physical instability tests, patient satisfaction questionnaires and incidences of Cyclops lesions and arthrofibrosis. Tibial and femoral tunnel widening was less in the augmentation group. This difference was more significant on the tibial side. CONCLUSION: In the repair of partial ACL tears, augmentation technique is as effective as the standard technique, leading to, less tunnel widening evidently in the tibial tunnel, particularly.

Identification of promoter region methylation patterns of MGMT, CDKN2A, GSTP1, and THBS1 genes in intracranial meningioma patients.

BACKGROUND: Cytogenetic, molecular and epigenetic changes are all known to take place in the pathogenesis of meningiomas. In this study, we aimed at investing methylation of MGMT (DNA repair), CDKN2A (cell cycle control), GSTP1 (detoxification), and THBS1 (angiogenesis inhibitor) genes, which are known to be unmethylated in normal tissue, in meningioma samples. MATERIALS AND METHODS: Methylation specific polymerase chain reaction was used to study promoter regions methylation of genes in 36 patient samples. RESULTS: Methylation in promoter regions of MGMT, CDKN2A, GSTP1, and THBS1 genes were found in 11.1%, 8.3%, 2.8%, and 0% of the cases, respectively. About 19.4% of cases revealed promoter methylation of at least a single gene, whereas only 2.8% of cases revealed methylation of more than one gene. Based on their World Health Organization 2007 grade; 6.3% of grade I cases, 35.3% of grade II cases, and 33.3% of grade III cases showed hypermethylation in the promoter regions of the genes studied. No statistically significant relation was found between promoter zone methylation and factors such as age, sex, histopathology, grade, or recurrence. CONCLUSIONS: Further research on promoter zone methylation will help expose the methylation profile and pathogenesis of meningiomas, which will consequently guide to a deeper understanding of the pathogenesis of the disease, thus ensuring a better understanding of the prognosis and considering novel treatment options.

Incidence of meniscal and osteochondral lesions in patients undergoing delayed anterior cruciate ligament reconstruction.

OBJECTIVE: Unreconstructed anterior cruciate ligament (ACL) tears cause repeated incidences of giving-way and rotational-translational instability. The aim of this study was to test our hypothesis that delayed surgical treatment of patients with ACL tears, especially those with high Tegner activity levels, results in more severe and complicated meniscal and osteochondral lesions with potential affect on the outcome. METHODS: This study included 385 patients who underwent arthroscopic ACL reconstruction between 2001 and 2009. Patients arthroscopic video records or MRI scans and patient files at the time of surgery were analyzed. We defined severe meniscal and osteochondral lesions which could negatively affect the outcome and labeled them meniscal lesions affecting outcome (MLAO) and osteochondral lesions affecting outcome (OLAO). The relation between MLAO, OLAO, time since injury and Tegner activity levels were statistically analyzed. RESULTS: The incidences of MLAO and OLAO grew statistically higher as time elapsed between the injury and surgery increased (p=0.001, p<0.05; p=0.001, p<0.05). The relation between the Tegner activity score, MLAO and OLAO risk were found to be statistically insignificant (p=0.317, p=0.184, p>0.05). CONCLUSION: Delays in ACL reconstruction surgery result in an increase in the incidence of meniscal and osteochondral lesions which have the potential to negatively affect the surgical outcome.

Her-2/neu gene amplification in paraffin-embedded tissue sections of meningioma patients.

AIM: Meningiomas arise from the meningoendothelial cells and are one of the most common tumors of the central nervous system. The HER-2/neu gene is located on the 17q11.2-q12 chromosome region and encodes an epidermal growth factor receptor. HER- 2/neu gene amplification and/or over expression have been studied most widely in breast carcinomas. Previous studies have shown the importance of HER-2/neu gene amplification on the prognosis of meningioma cases. In this study, we aimed to detect HER-2/neu gene copy number in archive materials of 55 meningioma patients by fluorescent in situ hybridization (FISH). MATERIAL AND METHODS: The patients included in the study had undergone surgery in the neurosurgery department of our hospital between 1999 and 2002. Tissue samples were classified histologically according to WHO 2007 guidelines. Interphase FISH was performed on 3 to 4microm thick paraffin embedded tissue sections for the detection of HER- 2/neu gene amplification status. RESULTS: We found HER-2/neu gene amplification in 7 (12.73%) patients. Another 2 patients had only one signal for the HER-2/neu region. We confirmed this finding by a second hybridization with the chromosome 17p13.1 (p53) probe. CONCLUSION: According to our results, HER-2/neu amplification could be regarded as an additional genetic factor playing role in meningioma pathogenesis together with known chromosomal abnormalities.

Prognostic significance of third ventricle dilation in spontaneous intracerebral hemorrhage: a preliminary clinical study.

OBJECTIVE: Although numerous factors have been described that predict outcome after spontaneous intracerebral hemorrhage (ICH), very little is know about the role of hemorrhagic dilation of the third ventricle in development of hydrocephalus and prognosis. The objective of this study was to investigate whether the presence of hemorrhagic third ventricle dilation after ICH would predict development of hydrocephalus and outcome. METHODS: We identified the patients with spontaneous ICH treated with external ventricular drainage (EVD) in this retrospective study. Computerized tomography (CT) was performed at admission within 24 hours of onset and retrospectively analysed to determine lesion size and location, status of third and fourth ventricle and frontal horn index (FHI). Glasgow coma scale (GCS) score, mean arterial pressure (MAP), etiology and demographic data were obtained from medical records. Outcome was determined using modified Rankin score at month 3. Patients with and without third ventricle dilation were compared in terms of hydrocephalus (FHI > 0.38), initial GCS score, age and MAP, and analyses were performed to determine whether third ventricle dilation was a predictor of poor outcome. RESULTS: Of the 22 patients studied, all had thalamic or basal ganglia hemorrhage with intraventricular hemorrhage (IVH) and all are treated with external ventricular drainage (EVD). Of the 22 patients, 12 had third ventricle dilation (width > or = 10 mm) and ten patients had non-dilated third ventricle (width < 10 mm). Patients with third ventricle dilation had lower GCS scores (7.4 +/- 1.8 versus 9.7 +/- 2.1, p < 0.005) and had higher FHI (0.46 +/- 0.06 versus 0.38 +/- 0.02, p < 0.005) as compared to patients with non-dilated third ventricle. The differences in age (59.5 +/- 9.4 versus 59.2 +/- 11.2) and MAP (128.3 +/- 16.0 versus 130.5 +/- 13.6) of the patients were not significant statistically. Sixty-six percent of patients (8/12) with third ventricle dilation and 60% of patients (6/10) with normal third ventricle were dead 6 months post-operation and mortality rate did not differ significantly. DISCUSSION: Although the roles of various factors are well described in the prognosis of spontaneous ICH, little is known about the role of third ventricle dilation. Based on our results, we concluded that third ventricle dilation is a poor prognostic factor.