Giant Ependymoma Removal via a Skipped Myelotomy Technique.

Intramedullary ependymomas should be treated with surgical resection. Different surgical techniques are described for these tumors, such as skipped and long-segment myelotomies. A 31-year-old male patient with a giant thoracic spinal cord ependymoma extending from the level of T5 to T10 was operated on with a skipped myelotomy technique. Although the patient had urinary incontinence and muscle weakness in both legs, the patient's complaints were nearly completely resolved in the fourth postoperative month. Operating with the smallest possible myelotomy has given us preferable results; however, more studies are needed to hypothesize the superiority of this technique over conventional myelotomy.

High-Frequency Bipolar Coagulation Limits Epidural Fibrosis in Lumbar Microdiscectomy.

BACKGROUND AND AIM: We propose a vast study to examine the effect of high-frequency bipolar coagulation used in the operating room to prevent the development of epidural fibrosis after lumbar microdiscectomy. MATERIALS AND METHODS: A total of 1004 participants were divided into two groups: no high-frequency bipolar coagulation (NC group) and high-frequency bipolar coagulation (C group). Postoperative epidural fibrosis, infection rates, reoperation status, and dural injury complications during the operation were recorded. RESULTS: Considering the epidural fibrosis rates of the two groups, epidural fibrosis was seen in 10.6% of the patients in the NC group. In contrast, it was seen in only 6.2% of the patients in the C group. CONCLUSION: The complication of epidural fibrosis that develops after lumbar microsurgery operations both impairs patient comfort and brings with it the complications of reoperation. After performing hemostasis with bipolar, coagulating the annulus may effectively reduce epidural fibrosis and prevent reoperation.

Management of Epidural Hematomas in Pediatric and Adult Population: A Hospital-Based Retrospective Study.

OBJECTIVE: We retrospectively reviewed and evaluated our treatment protocols in epidural hematoma (EDH) cases to compare surgical versus nonsurgical treatment subsections with their trauma mechanism, injury type, clinical pattern, radiological details, functional outcome, and mortality rates. METHODS: This study included 350 patients (142 females and 208 males) treated for EDH between 2010 and 2018. Two hundred seven operated and 143 observed patients for EDH were compared for demography, injury type, treatment, and outcome scores retrospectively. Glasgow Coma Scale and Glasgow Outcome Scale were used to standardize the clinical findings. Marshall and Rotterdam classifications classified radiological abnormalities. The Infinity PACS system measured hematoma volume, and volume parameters were evaluated differently in pediatric and adult groups. RESULTS: Radiological parameters showed that the observation was more favorable when the EDH volume was <30 ml in the adult and <20 ml in the pediatric group. However, close clinical follow-up with repeated computerized tomography scans suggested that when the hematoma increases in volume in the first 24 hours, it should be treated surgically. Headache, vomiting, and paresis were significant clinical symptoms in this period. Only 11% of conservatively followed cases required delayed surgical intervention. When we analyzed the findings of the 2 groups of the patient, pediatric and adult, we noticed that rebleeding after the first surgery was more common in the adult group than the pediatric group, whereas surgery due to a growing hematoma was less common in the pediatric group. CONCLUSIONS: Age, trauma severity, initial neurological statuses, and accompanying comorbidities can affect the functional outcome in acute EDH. We found that urgent surgical intervention and conservative treatment may lead to excellent results in most cases. Thus, EDH can be managed both conservatively and surgically in certain conditions. We made a comparison between pediatric and adult age groups according to treatment modalities. Both rebleeding and mortality rates are relatively lower in the pediatric operated group than in the adult operated group. In the adult observation group, rates of delayed surgery because of growing hematoma seem relatively higher than in the pediatric observation group. During radiological follow-up, we found that the progression rate of EDH in the adult observed group according to time is faster than in the pediatric observed group (P < 0.05).

Benign Intracranial Calcified Lesion or a So-Called Brain Stone: A Challenging Diagnosis.

Brain stone is an umbrella term for benign intracerebral calcifications and may be associated with various diagnoses. The surgical decision should be made on a case-by-case basis. Sometimes, conservative management should be considered, irrespective of the underlying pathology. We present a critical case with a brain stone treated conservatively. A 17-year-old female patient was admitted to our department with a headache. The neurological examination revealed no abnormal findings. Cranial CT and MRI scans showed a contrast-enhanced, highly calcified lesion located deep in the white matter at the level of the left centrum semiovale. Surgery was found unnecessary. The patient presented no neurologic deficits or symptoms during the three-year follow-up period. In this case, the differential diagnosis included arteriovenous malformations (AVMs), cavernomas, calcifying pseudoneoplasms of the neuroaxis (CAPNON), etc. The localization of the lesion, expression of the symptoms, and potential outcomes of a possible surgery should be carefully estimated before making the final decision. In summary, conservative treatment should also be considered for critically located, benign calcified lesions, irrespective of pathology, unless they cause intense neurologic symptoms or deficits.

A Huge Calcified Supratentorial Ependymoma: A Case Report.

Tanycytic ependymoma has been marked as Grade II by the World Health Organization (WHO), requiring considerable treatment. However, according to the fifth edition of the WHO Classification of Tumors of the Central Nervous System published in 2021, tanycytic ependymoma is no longer identified as a subtype of ependymoma. Herein, we offer an unusual case of a supratentorial ependymoma, previously tanycytic ependymoma. Which radiologically mimic pineal region tumors; however, they pathologically mimic meningiomas, schwannomas, medulloblastomas, or astroblastomas. A three-year-old girl presented to our neurosurgery department with sudden onset gait disturbance and balance impairment; we detected no additional neurologic deficit. Magnetic Resonance Imaging (MRI) revealed a giant, multilobulated, well-circumscribed right pineal mass, approximately 4.5 x 4.5 x 4.5 cm in size, crossing the midline and extending posteriorly, invading the pineal region. The initial diagnosis was a pineal region tumor. Following gross-total resection of the tumor, pathology reports showed tanycytic ependymoma. Postoperatively the patient's gait disturbance was improved, and there was no balance impairment. Follow-ups at three and six months, no sign of recurrence has been encountered. Our case demonstrates that supratentorial ependymomas may also occur in the pineal region and requires an accurate neuropathologic diagnosis. Early accurate diagnosis is essential; since those tumors may be related to a wide range of prognoses and necessitate different treatment modalities.

Anterior communicating artery aneurysm in a young patient with Fahr's disease: case presentation.

BACKGROUND AND IMPORTANCE: Fahr disease is an uncommon disorder defined as prominent calcification in basal ganglia, dentate nuclei of cerebellum, pulvinar thalami and subcortical white matter and it has been shown that calcium is the major factor that causes the hyperdensity on computer tomography (CT). Spontaneous subarachnoid hemorrhage from an aneurysm in a patient with Fahr disease was first reported by Al-Jehani et al. in 2012 in a 54-year-old female patient with calcification of basal ganglia and deep cerebellar nuclei and a subarachnoid hemorrhage from a right posterior communicating artery aneurysm. CLINICAL PRESENTATION: We present a 17 years old patient with Fahr disease with an anterior communicating artery aneurysm rupture. CONCLUSION: There are few reports of intracranial hemorrhage with Fahr's disease. It may be suggested that excessive calcium accumulation contributes to aneurysm formation or rupture.

Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas.

In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.

Silent Pulmonary Thromboembolism in Patients Undergoing Craniotomy for Brain Tumor.

AIM: To detect the silent pulmonary thromboembolism (SPTE) frequency in patients who underwent craniotomy for a brain tumor, and to examine the correlation based on the data obtained from patients. MATERIAL AND METHODS: Overall, 100 patients with brain tumors were included in the study. The mean age was 54.29 years (±12.5 years), with the youngest patient being 19 years old and the oldest 73 years. All patients underwent craniotomy, and a pulmonary ventilation-perfusion scintigraphy was performed 48 h after surgery to detect SPTE. The frequency of SPTE and the conditions related to it were investigated. RESULTS: The incidence of SPTE was 26% in patients with a brain tumor who underwent craniotomy. Statistically, no correlation was observed between SPTE and data obtained from patients (tumor histopathology, tumor localization, perilesional edema, midline shift, bleeding time, surgical positioning, smoking history, age, duration of surgery, etc.). CONCLUSION: Our study revealed a high rate of SPTE in patients with a brain tumor who underwent craniotomy. Although most articles suggest using anticoagulant therapy in these patients, the literature lacks definite evidence for the same.

Late recovery of stereotactic radiosurgery induced perilesional edema of an arteriovenous malformation after bevacizumab treatment.

MATERIALS AND METHODS: We present a 41-year old male patient who was admitted to our clinic with epileptic seizures, headaches and hemiparesis 14 months after SRS treatment for a left fronto-parietal Spetzler-Martin Grade III arteriovenous malformation (AVM). On his first-year follow-up perilesional edema was observed for which the patient received steroid treatment, but the patient did not show any benefit from it. In the cases of steroid resistant perilesional edemas, bevacizumab can be used for reducing symptoms and even radiological perilesional edema as well. RESULTS: In our case, we have seen the effect of bevacizumab for symptomatic perilesional edema in a AVM patient after SRS treatment after radiological / neurological recovery. Our patient's headaches decreased rapidly after 2 days after treatment and was able to mobilize himself after 2 months but total resolution of symptoms and radiological findings observed after 1,5 years. CONCLUSIONS: The duration and optimum dose of bevacizumab therapy needed to further investigation. Our study showed that bevacizumab was a long-term and effective treatment option for the cases with peritumoral edema resistant to glucocorticoid treatment, where the patient had conditions such as severe headache and neurological deficits.

Foraminal Stenosis as a Cause of Postdiscectomy Syndrome.

AIM: To reveal the relation between postdiscectomy syndrome and foraminal stenosis due to height loss of disc level in patients operated for one-sided L5-S1 disc herniation. MATERIAL AND METHODS: 100 operated patients due to L5-S1 one-sided disc herniation were included. Mean age was 46.60 years (±10.52 years). Foraminal height, width, and intervertebral disc height were measured via CT. The diameters were compared preoperatively and postoperatively. The relation between the measurements and clinic findings was investigated. RESULTS: Six months after discectomy, for the operated side, the mean foraminal height decreased from 16.78 ± 1.75 mm to 14.43 ± 1.62 mm (p 0.05) and the mean foraminal width decreased from 6.30 ± 1.43 mm to 5.34 ± 1.56 mm (p 0.05). According to the correlation test, for the operated side, a statistically significant relationship was observed between the decrease in foramen height and leg pain visual analog scale (VAS) score. Moreover, a statistically significant relationship was observed between the decrease in the posterior side height of the disc level and the leg pain VAS score. CONCLUSION: Overall, after microdiscectomy, as the height of the foramen decreased, leg pain also increased. Moreover, the decrease in the posterior side height of the disc level was associated with an increase in leg pain. Therefore, over time, the collapse of the disc distance decreases the foramen height, which causes leg pain. After microdiscectomy, in patients whose leg pain was relieved at first but started again after a time, the foramen and disc level diameters should be checked.

Traumatic Retroclival Epidural Hematoma.

Retroclival epidural hematomas are particularly rare conditions that are frequently the result of high-energy, hyperflexion-hyperextension injuries in pediatric patients. We present the case of a 7-year-old previously healthy girl with traumatic retroclival epidural hematoma after a fall from a swing. She presented with a Glasgow Coma Scale score of 15 with severe neck pain and limitation of cervical movements in all directions. Radiological examination revealed retroclival epidural hematoma, and the patient was managed conservatively with good recovery. Although conservative management leads to good recovery in most cases, retroclival epidural hematomas should always be kept in mind regardless of the severity of trauma.

Late-onset Metastasis of Intracranial Papillary Thyroid Carcinoma.

BACKGROUND: Papillary thyroid carcinoma is the most common subtype of thyroid cancers, accounting for >90% of all thyroid carcinomas. Despite a favorable long-term survival rate of 94.4%, people with distant metastases show worse outcome. Cerebral metastases are slightly uncommon and stand for only 1%-3% of all metastases. CASE DESCRIPTION: We present a 56-year-old male patient complaining of serious headaches for >20 days. He underwent thyroidectomy surgery 13 years ago due to papillary thyroid carcinoma and was reported "tumor free" on his follow-ups without any complaints. On his cranial magnetic resonance imaging scan a right temporal mass lesion was detected. During surgery, the tumor was removed and reported as papillary thyroid carcinoma metastasis. CONCLUSION: A case in which a patient with papillary thyroid carcinoma developed brain metastasis after such a long time was not reported in the literature before.

Transorbital penetrating head trauma leading to serious cerebral edema - A case report.

Penetrating transorbital head injuries are rarely seen. We present a 6-year old male patient who was referred to our department after a wooden stick penetrated his right eye. On admission his general condition was well and he showed no neurologic deficits. On his cranial computed tomography (CT) there was a fracture on his right orbital wall and minimal subarachnoid hemorrhage in his right frontal lobe. On later follow-ups the patient's condition worsened and his control CT showed diffuse cerebral edema. The patient underwent emergent decompressive surgery. Due to this immediate intervention the patient was released from the hospital with no major deficits later. Up to our knowledge, there are no cases in the literature reported in which decompressive craniectomy was necessary after a transorbital penetrating head trauma.

Microsurgical Experience with Pedicle-Sparing Transfacet Approach for Thoracic Disk Herniation.

PURPOSE: Thoracic disk herniation (TDH) is relatively uncommon. The surgical approach differs from lumbar or cervical disk herniations because serious complications are associated with the posterior approach in TDH. Various different approaches have been tried for the surgical removal of TDH, but most of them are cumbersome surgeries such as thoracotomy or thoracoscopic or anterior approaches with or without instrumentation. The requirement for a simplified, familiar, and less morbid surgery has motivated some new approaches. A pedicle-sparing transfacet approach (PSTA) was first described in 1995, but to date no sufficient clinical series has been presented in the literature to report on its feasibility and applicability along with complication and morbidity rates. Our objective was to assess the feasibility of the PSTA under microscopic visualization in a cumulative clinical series. METHODS: Twenty-eight consecutive patients with no response to medical/physical treatment with and without motor weakness of their lower extremities underwent the surgery for TDH via the PSTA under microscopic visualization by a senior neurosurgeon. Preoperative and postoperative low extremity muscle strength, sensation, reflex status, and visual analog scores (VAS), Nurick grades, and complications were recorded. Postoperative MRI within 24 hours was performed. The median follow-up period was 33 months. RESULTS: The patients consisted of 16 men and 12 women. The disk levels ranged from T8 to T12-L1. All but one patient received one-level surgery. One patient was operated on two levels. A total of 21 patients had paracentral disk herniations; the other 7 had central disk herniations. Postoperative MRI showed satisfactory removal of disk herniation in all but one patient. There was no infection, wrong level surgery, or incidental durotomy. Median VAS levels significantly improved after the operation from 7.4 to 2.3. The Nuric grades decreased from 2.7 to 1.6 after surgery. CONCLUSIONS: The microsurgical PSTA is a safe and feasible technique with a significantly shorter surgeon's learning curve. The approach offers a wide surgical window; moreover, it can by increased by tilting the surgical table allowing satisfactory decompression of TDH. After PSTA, segmental instrumentation is not required.

Matrix metalloprotease-9 expresssion in meningioma: Correlation with growth fraction and role of gender. A pilot immunohistochemical study.

OBJECTIVE: Matrix metalloproteases (MMPs), particularly MMP2 and MMP9 increase tumor invasion and edema in meningiomas. Although lesser recognized, MMPs may also enhance cell growth via liberating growth factors or via cleaving inactive growth factors into active isoforms. However, there exist very few studies, which investigated correlation of MMPs with growth fraction in meningiomas. Meningiomas are seen more frequently in women and their growth accelarate during pregnancy. However, no study examined whether MMP-expressions in meningioma differ with gender. PATIENTS AND METHODS: In a pilot immunohistochemical study, we analyzed the correlation of MMP9 expression with Ki67 index and whether gender influences MMP9 expression. We retrospectively selected 24 meningioma cases including 10 cases with WHO Grade-1 tumors and 7 cases each with WHO Grade-2 and 3 tumors, respectively. RESULTS: We separately determined the intensity and area of MMP9 staining and also calculated an expression index by multiplying these two parameters. Spearman correlation analyses revealed that MMP9 staining intensity, staining area and expression index significantly correlated with Ki67 proliferation index. MMP9 staining indices were significantly higher in women specimens. CONCLUSION: If these findings will be confirmed in larger series, MMP-inhibitors and female hormone receptor-antagonists may be combined to augment chemotherapy efficacy and to attenuate invasion in high-grade meningiomas.

Primary Ewing Sarcoma of Frontotemporal Bone in Geriatric Patient.

BACKGROUND: Ewing sarcoma is a rare primary malignant bone tumor, which mainly affects children and adolescents. Calvarial bone involvement and its appearance in elderly patients are extremely rare. CASE DESCRIPTION: We presented a 68-year-old female patient with headache and right frontotemporal swelling. Imaging studies showed a right frontotemporal mass expanding to the Sylvian fissure. The patient underwent total resection of the mass, and pathologic evaluation ensured the diagnosis of primary Ewing sarcoma. The patient had adjuvant radiotherapy and chemotherapy after surgery. CONCLUSIONS: Prognosis and efficiency of treatment for primary Ewing sarcoma of skull are unclear in elderly patients because of the sarcoma's rare appearance. Therefore more clinical evaluation is necessary. This case is the oldest patient presented in the literature.

Intracerebral Hemorrhage with Multiple Intracranial Arterial Stenoses in a Synthetic Cannabinoid "Spice" User.

Synthetic cannabinoids (spice), which are used frequently worldwide, are more potent than herbal compounds and also have more side effects in comparison. A 23-year-old male was admitted to the emergency unit with altered consciousness. There was no sign of trauma, and his medical history did not reveal any chronic illness. Computed tomography revealed a large frontal hematoma extending to the ventricular system. The outcomes of cerebral angiography were consistent with multiple intracranial arterial stenoses (MIAS) which can also be seen after cannabis usage. The patient made a good recovery with treatment, and during the follow-up, his medical condition was stable. In addition to the psychological symptoms, encephalopathy, ischemia, and seizures have also been described as side effects of synthetic cannabinoids. This paper reports an intracerebral hematoma due to synthetic cannabinoids and its association with MIAS.

Low Back Pain and Internet: Infopollution.

AIM: An increasing number of patients engage in health information seeking via the internet. We aimed to determine the quality of information on the internet for treatment of three common neurosurgical conditions associated with low back pain using the DISCERN® instrument. MATERIAL AND METHODS: The search phrases "lumbar disc herniation (LDH) treatment", "lumbar spinal stenosis (LSS) treatment" and "lumbar spondylolisthesis (LSL) treatment" were searched in the Google® search engine using the simple searching method. The first 30 websites were evaluated for website authors (healthcare, news, personal, physician, and unidentified), and DISCERN® scores using 15 key questions representing a separate quality criterion plus an overall quality rating. Each site was scored independently by two observers. RESULTS: Of 90 links retrieved, a total of 83 websites were used for analysis. The physician authors were ranked first (39.3%) in the search results. Only 3.6% of the websites had clear aims, and the information was relevant in 6%. Seventy-two (86.7%) websites had no sources of evidence for the information mentioned. The information was completely balanced and unbiased in only 8 (9.6%) websites. Fifty-one (61.5%) websites had no described benefits for any of the treatments and only 2 (2.4%) websites described a risk for each treatment. Only 6 (7.2%) websites were found to be useful and appropriate sources of information about treatment choices. The DISCERN® scores were not significantly different between all author groups (p=0.713). CONCLUSION: The information on the treatment options of LDH, LSS and LSL on the internet is not useful or appropriate regarding treatment choices. Neurosurgeons should be aware of this inconsistency.

Evaluation of median nerve T2 signal changes in patients with surgically treated carpal tunnel syndrome.

OBJECTIVE: To determine the accuracy of median nerve T2 evaluation and its relation with Boston Questionnaire (BQ) and nerve conduction studies (NCSs) in pre-operative and post-operative carpal tunnel syndrome (CTS) patients in comparison with healthy volunteers. METHODS: Twenty-three CTS patients and 24 healthy volunteers underwent NCSs, median nerve T2 evaluation and self-administered BQ. Pre-operative and 1st year post-operative median nerve T2 values and cross-sectional areas (CSAs) were compared both within pre-operative and post-operative CTS groups, and with healthy volunteers. The relationship between MRI findings and BQ and NCSs was analyzed. The ROC curve analysis was used for determining the accuracy. RESULTS: The comparison of pre-operative and post-operative T2 values and CSAs revealed statistically significant improvements in the post-operative patient group (p<0.001 for all parameters). There were positive correlations between T2 values at all levels and BQ values, and positive and negative correlations were also found regarding T2 values and NCS findings in CTS patients. The receiver operating characteristic curve analysis for defined cut-off levels of median nerve T2 values in hands with severe CTS yielded excellent accuracy at all levels. However, this accuracy could not be demonstrated in hands with mild CTS. CONCLUSION: This study is the first to analyze T2 values in both pre-operative and post-operative CTS patients. The presence of increased T2 values in CTS patients compared to controls and excellent accuracy in hands with severe CTS indicates T2 signal changes related to CTS pathophysiology and possible utilization of T2 signal evaluation in hands with severe CTS.

Malignant Transformation of Grade II Ependymoma in a 2-Year-Old Child: Case Report.

Ependymomas are central nervous system neoplasms that account for a third of all posterior fossa tumors in children. The most common location for infratentorial ependymoma is within the fourth ventricle. We present a case report of malignant transformation of an infratentorial grade II ependymoma in a 2-year-old child who presented with vomiting and visual disturbance. An infratentorial brain tumor in the left cerebellar area was totally removed, and the initial pathologic diagnosis was grade II ependymoma. The tumor recurred aggressively 1 year later; subtotal removal and adjuvant chemotherapy were performed. After a second operation, a histopathologic study was performed. The second specimen was defined as a grade III anaplastic ependymoma. Transformation to grade III anaplastic ependymoma is possible for a grade II ependymoma but very rare. The diagnosis of the anaplastic variant of intracranial ependymomas is difficult. Surgical treatment remains the mainstay of the treatment for all cases. Ependymomas in young infants have a worse prognosis than older children, so we need individual clinical evaluation and close follow-up of such cases. This article highlights the requirement of a close follow-up for grade II ependymomas for anaplastic transformation.