Clipping of a Rebleeding Ruptured Aneurysm After Woven EndoBridge Treatment.

AIM: To present the clipping of a ruptured aneurysm in the M1 segment of the right middle cerebral artery after rebleeding, which was treated with Woven EndoBridge (WEB). CASE REPORT: A 68-year-old male patient with known hypertension, coronary artery disease and benign prostatic hypertrophy was admitted to our clinic after a ruptured aneurysm of 4.5 mm in the right middle cerebral artery M1 segment and subarachnoid hemorrhage were detected in the emergency room imaging after syncope at home. WEB device was placed into the aneurysm in the patient who was planned for endovascular treatment. After 3 days of the procedure, neurologic examination showed regression. In the brain computed tomography imaging, it was observed that there was an intraparenchymal hematoma of 4,5 cm in the right temporoparietal region and the aneurysm, which had been treated with endovascular WEB, was ruptured. The aneurysm was clipped in the patient for whom emergency surgical treatment was planned. CONCLUSION: As a conclusion, re-bleeding can be seen after aneurysm treatment with the Web device. If it is planned to re-close the aneurysm treated with the web device with a surgical clip, the pressure created by the device against the vessel can be reduced with the additional clip.

Stereotactic radiosurgery for tumors of the pineal region: A single-center experience.

Tumors of the pineal region (TPRs) are rare neoplasms that are surgically challenging to resect. Conventional treatment strategies are available, but gamma knife radiosurgery (GKRS) is an alternative approach. This study presents a single-center experience with GKRS performed for TPR with and without histopathological diagnoses. The cases of 25 patients with TPRs treated with GKRS were retrospectively analyzed. Thirteen of these 25 patients had histopathological confirmation, and 13 had elevated serum alpha-fetoprotein and beta-human chorionic gonadotropin levels. The 25 patients had a mean follow-up duration of 61 months. The total response rate to GKRS was 60%, and a 53.8% decrease in the alpha-fetoprotein and beta human chorionic gonadotropin levels was observed. The findings of this study indicate that GKRS is a safe procedure for TPRs, even in the event of insufficient histopathological findings. This treatment approach provides increased Karnofsky performance scores and an extended life expectancy.

Sagittal spinopelvic alignment in tethered cord syndrome and split cord malformation.

PURPOSE: Sagittal imbalance is common in degenerative and congenital spinal diseases. Some studies have examined spinal deformities in the spina bifida. However, sagittal spinopelvic parameters in tethered cord syndrome (TCS) and split cord malformation (SCM) have been poorly evaluated in the literature. In this study, we investigated sagittal spinopelvic differences in TCS due to fatty filum terminale and SCM patients. MATERIAL AND METHODS: A total of 78 patients with spina bifida occulta (30 SCM and 48 TCS due to fatty filum terminale) were included in the study. Radiological images of these patients were retrospectively evaluated. We evaluated the pelvic incidence, pelvic tilt, sacral slope, sagittal vertical axis (SVA), T1 pelvic angle, lumbar lordosis (LL), thoracic kyphosis, thoracolumbar alignment, and change in those parameters with age. RESULTS: Correlation coefficients between age and LL, T1 pelvic angle, and the SVA in patients with TCS due to fatty filum terminale were statistically significant. In addition, correlation coefficients between age and LL and the SVA in patients with SCM were statistically significant. Notably, LL was increased at a statistically significant level with age in patients with TCS and SCM. CONCLUSION: Improved knowledge of spinal balance parameters in patients with TCS and SCM may be helpful in understanding the clinical course of these pathologies, and provide information regarding the success of surgery at the follow-up period.

Stereotactic radiosurgery for cerebral cavernous malformation: comparison of hemorrhage rates before and after stereotactic radiosurgery.

OBJECTIVE: Cerebral cavernous malformation (CM) is an angiographically occult vascular pathology. Although microsurgery is the gold standard treatment to control the symptoms of CM, resection carries high risk in some situations, especially eloquent areas. The objective was to evaluate annual hemorrhage rates (AHRs) before and after stereotactic radiosurgery (SRS) treatment of cerebral CM in different locations. METHODS: A total of 195 patients (119 women and 76 men) with CM treated at the Gazi University Gamma Knife Center between April 2005 and June 2017 were analyzed. The mean ± SD follow-up period was 67.4 ± 31.1 months (range 12 days to 170 months). AHR before SRS, AHR after SRS, morbidity associated with radiation, seizure control rate after SRS, lesion volume, coexistence with developmental venous anomaly, and SRS treatment parameters were analyzed, with evaluation of radiological data and clinical charts performed retrospectively. The seizure control rate was assessed using the Engel outcome scale. RESULTS: The AHR before SRS was 15.3%. Application of SRS to these patients significantly reduced the AHR rates to 2.6% during the first 2 years after treatment and to 1.4% thereafter. Favorable seizure control (Engel class I and II) after radiosurgery was achieved in 23 patients (88.5%) with epilepsy. Radiation-related temporary complications occurred in 15.4% of patients, and permanent morbidity occurred in 4.6%. CONCLUSIONS: SRS is a safe and effective treatment modality for reducing the hemorrhage risk of CM. The authors suggest that SRS should be considered for the treatment of patients with CM, high surgical risks, and hemorrhage history, instead of a using a wait-and-see policy.

Validity and reliability study of the Turkish version of the 'A Sport Fitness Index'.

BACKGROUND: The aim of this study was to adapt the 'Sport Fitness Index' into Turkish and to ensure its validity and reliability. METHODS: After obtaining the necessary permissions, the Sports Fitness Index was independently translated from its English original to Turkish by four different physicians specialising in sports medicine. The content validity of index v.1 was calculated using the Davis technique in sample 1 of 20 people regularly participating in sports. In sample 2 consisting of 104 athletes who had a sports-related ligament/muscle injury or applied to the sports medicine clinic for general medical examination; the validity and reliability of index v.2 were examined. ROC analysis was applied to determine the cut-off point value of the score obtained from the Turkish version of the index. RESULTS: The calculated I-CVI (lowest: 0.80, highest: 0.95) and S-CVI/Ave values (0.87) showed that the index provided content validity. Item 1 and item 10 were removed from the Turkish version of the index, as it caused a decrease in the Cronbach's alpha coefficient of the index v.2. Thus, the Cronbach's alpha coefficient of the index was calculated as 0.925. In the Turkish version of index v.2, the single-factor structure (explained variance rate 66.22%; eigenvalue 5.29) was preserved. The index provided confirmatory factor analysis model fit indices. The index provided a high level of negative correlation (r Ëƒ -.60; P = .0001) with the total score of the Physical Activity Inadequacy Scale Short Form-10 and the sub-scores of all summary components (r Ëƒ -.60; P = .0001). According to the ROC curve, the best cut-off point was 70 points with 96.6% sensitivity and 75% specificity in the Turkish version of the index. CONCLUSION: The Sports Fitness Index-TR provided its Turkish validity and reliability with its 8-item and single-factor structure. The cut-off point is accepted as 70 points.

Stereotactic Radiosurgery after Subtotal Resection of Critically-Located Grade I Meningioma: A Single-Center Experience and Review of Literature.

AIM: To analyze the results of stereotactic radiosurgery in 295 patients with residual Grade I meningiomas located at parasellar region, petroclival region, cerebellopontine angle and parasagittal region. MATERIAL AND METHODS: A total of 295 patients with Grade 1 residual Meningiomas (197 women, 98 men), who were treated by adjuvant radiosurgery in Gazi University Gamma Knife Center between 2004-2015 were analyzed. WHO Grade 2 and 3 meningiomas were not included in our study. Minimum radiological follow-up was 24 months. The median follow-up was 54 months. The tumor volume, location, treatment dose, morbidity, progression free survival and tumor control rate were analyzed. RESULTS: The median tumor volume was 5.2 cm3 (0.04-39.7), median age was 50 (20-80), median dose was 14 Gy and tumor control rate was 94.5% (stationary in 85.0%, volume reduction in 9.5%). Increase in tumor volume was seen in 16 patients (5.5%) and re-operation was performed in 5 of them (1.6%). Stereotactic radiosurgery was performed again for 8 patients (2.7%).The location of the tumors was as follows: 39.3% parasellar region, 20% cerebellopontine angle, 13.6% petroclival and 27.1% was parasagittal, falcine or convexity. Major morbidities were detected in 6 (2%) patients. Minor morbidities were detected in 18 (6.1%) patients. CONCLUSION: Stereotactic radiosurgery is an effective and safe treatment modality for residual Grade I meningiomas.

Intraoperative Magnetic Resonance Imaging Assisted Endoscopic Endonasal Resection of Clival Chordomas.

BACKGROUND: Cranial base chordomas are typically indolent and usually appear as encapsulated tumors. They slowly grow by infiltrating the bone, along with the lines of least resistance. Due to its relationship with important neurovascular structures, skull base chordoma surgery is challenging. OBJECTIVE: The usefulness of intraoperative magnetic resonance imaging (IO-MRI) in achieving the goal of surgery, is evaluated in this study. METHODS: Between March 2018 and March 2020, 42 patients were operated on for resection of skull base chordomas in our institution. All of them were operated on under IO-MRI. Patients were analyzed retrospectively for identifying common residue locations, complications and early post-operative outcomes. RESULTS: In 22 patients (52,4%) gross total resection was achieved according to the final IO-MRI. In 20 patients (47,6%) complete tumor removal was not possible because of extension to the petrous bone (8 patients), pontocerebellar angle (6 patients), prepontine cistern (4 patients), temporobasal (1 patient), cervical axis (1 patient). In 13 patients, the surgery was continued after the first IO-MRI control was performed, which showed a resectable residual tumor. 7 of these patients achieved total resection according to the second IO-MRI, in the other 6 patients all efforts were made to ensure maximal resection of the tumor as much as possible without morbidity. Repeated IO-MRI helped achieve gross total resection in 7 patients (53.8%). CONCLUSIONS: Our study proves that the use of IO-MRI is a safe method that provides the opportunity to show the degree of resection in skull base chordomas and to evaluate the volume and location of the residual tumor intraoperatively. Hence IO-MRI can improve the life expectancy of patients because it provides an opportunity for both gross total resection and maximal safe resection in cases where total resection is not possible.

Reduced field of view under the surgical microscope due to personal protective equipment: lessons learned during the COVID-19 pandemic.

OBJECTIVE: During the coronavirus disease 2019 (COVID-19) pandemic, neurosurgeons all around the globe continue to operate in emergency cases using new self-protective measures. Personal protective equipment (PPE) use is recommended in all surgeries. The authors have experienced varying degrees of field of view (FOV) loss under the surgical microscope with different PPE. Herein, they aimed to investigate the effects of different PPE on FOV while using the surgical microscope. METHODS: Fifteen neurosurgeons and neurosurgery residents participated in this study. Three kinds of PPE (safety spectacles, blast goggles, and face shields) were tested while using a surgical microscope. FOV was measured using a 12 × 12-cm checkered sheet of paper on which every square had an area of 25 mm2 under the microscope. The surgical microscope was positioned perpendicular to the test paper, and the zoom was fixed. Each participant marked on the test sheet the peripheral borders of their FOV while using different PPE and without wearing any PPE. A one-way repeated-measures ANOVA was performed to determine if there was a significant difference in FOV values with the different PPE. RESULTS: FOV was significantly different between each PPE (F[3, 42] = 6339.845, p < 0.0005). Post hoc analysis revealed a significant decrease in the FOV from the naked eye (9305.33 ± 406.1 mm2) to blast goggles (2501.91 ± 176.5 mm2) and face shields (92.33 ± 6.4 mm2). There were no significant FOV changes with the safety spectacles (9267.45 ± 410.5 mm2). CONCLUSIONS: While operating under a surgical microscope safety spectacles provide favorable FOVs. Face shields increase the eye piece-pupil distance, which causes a severe reduction in FOV.

Women in Neurosurgery: Gender Differences in Authorship in High-Impact Neurosurgery Journals through the Last Two Decades.

OBJECTIVE: Despite common gender disparities in authorship across the vast majority of specialties, the presence of a similar lack of equality in neurosurgery literature is not published yet. Therefore the authors examined the changes in representation of women among the first and senior (last) authors of original articles in high-impact neurosurgical journals between 2003 and 2018. METHODS: Data regarding women proportions among the first and senior authors were collected from the issues of Neurosurgery and Journal of Neurosurgery published in 2003, 2008, 2013, and 2018. RESULTS: According to the analysis of 3247 original articles, compared with male authors, female authors have published fewer articles as the first (518 of women, 2729 of men) and senior authors (352 of women, 2884 of men). Nonetheless, the proportion of women in the first authorship represented a significant increase from 2003 to 2018 (from 12% to 16.5%, respectively; P < 0.01), but not in senior authorship (11.7% in 2003 vs. 10.5% in 2018; P > 0.05). Overall, women wrote more research articles than case reports as both first and senior authors (451 and 301 vs. 67 and 51, respectively). In addition, women demonstrated a higher percentage of first authors on female senior author articles (30.4%) than male senior author articles (14.1%). CONCLUSIONS: Although a rising trend in female authorship of neurosurgical literature has been going on through the last 2 decades, this advancement could not be regarded as satisfactory, as the gender gap in authorship is still excessive. Strikingly, female first authors had a tendency of coauthoring with female senior authors.

Hyperbaric oxygen therapy in the treatment of malign edema complication after arteriovenous malformation radiosurgery.

A 16-year-old female patient with headache was admitted to our hospital. Radiological examination showed a Spetzler-Martin Grade III arteriovenous malformation (AVM) located at the left frontal lobe. Volume-staged stereotactic radiosurgery (SRS) treatment performed in two fractions at three-month intervals and post-procedural period were uneventful. Eight months later the patient was admitted to our hospital with headache, vomiting, right-sided facial palsy and right upper extremity paresthesia. Radiological examination demonstrated severe vasogenic edema in the left centrum semiovale and temporal region. Due to severe and steroid-resistant malign edema, hyperbaric oxygen (HBO2) therapy was performed as an alternative treatment option. Neurological symptoms resolved completely after HBO2. Radiological examination demonstrated serious improvement of brain edema and mass effect.

Management of Neonatal Facial Paralysis due to Cerebellopontine Angle Arachnoid Cyst: A Case Report.

Arachnoid cysts are benign, cerebrospinal fluid-filled collections that can be located in the brain or spinal cord. Arachnoid cysts form approximately 1% of all intracranial lesions. They are accepted as arachnoid developmental anomaly and arise from membrane splitting or duplication. Generally, lesion growth causes symptoms because of mass effect or obstruction. Arachnoid cyst growing mechanisms are a largely controversial issue. We report the case of a neonatal female patient who presented with congenital facial paralysis. Magnetic resonance imaging showed a right cerebellopontine angle arachnoid cyst causing severe mass effect on the brain stem. Cyst fenestration and cystocisternal shunt was performed through retrosigmoid suboccipital craniotomy.

Can the Etiopathogenesis of Chiari Malformation Be Craniocervical Junction Stabilization Difference? Morphometric Analysis of Craniocervical Junction Ligaments.

OBJECTIVE: The craniocervical junction permits a certain amount of mobility for the cervical spine. The biomechanical properties of occipital bone-atlas joint mainly depend on the bony structure, and atlas-axis joint biomechanical properties mainly depend on ligamentous structure. The underlying etiologic factor of Chiari malformation (CM) is debatable. Nowadays, some researchers argue that stabilization difference is one of the suspicious factors for etiopathogenesis. We aim to analyze the ligamentous morphometric differences of CM. METHODS: Magnetic resonance images of 93 adult healthy subjects (n = 93) without any craniocervical junction development abnormalities and 25 (n = 25) adult patients with craniocervical junction development abnormalities (Arnold CM) were evaluated. Length, width, and length-width ratios of ligaments were evaluated. RESULTS: Length of transverse ligament (mean: 23 ± 3.6 [range: 12.1-31.4]) in the normal population was significantly longer than transverse ligament length in CM patients (mean: 21.3 ± 2.5 [range: 17.2-24.9]). Length of alar ligament (mean: 10.7 ± 2 [range: 5.1-15.4]) in the normal population was significantly longer than alar ligament length in CM patients (mean: 8.8 ± 3.8 [range: 1.1-16.6]) (P = 0.007). CONCLUSIONS: Craniocervical ligaments play an important role in maintaining stability and motion capacity of this region. This study promoted better understanding of craniocervical junction anomalies and provided data that facilitate performing more precise surgical treatment.

Retrospective Analysis of 449 Intracranial Meningioma Patients Operated Between 2007 and 2013 at a Single Institute.

AIM: Meningioma literature has many large surgical case series, which have been references of text books and neurosurgical practice. Many of those series were published when stereotactic radiosurgery (SRS) was not so common or these series were in terms of World Health Organization (WHO) 2000 classification. In this study, we aimed to make an update to the current literature using WHO 2007 classification system. MATERIAL AND METHODS: Four hundred eighty-eight intracranial meningioma patients underwent open surgery in 2007-2013 and 449 of them were included in this study. All pathological specimens were re-evaluated in terms of WHO 2007 classification. All demographical and follow-up records and imaging archives were investigated by using our center"s central automation system and National Central Population Management System. If records were not available or not adequate, investigators made phone calls to patients. Pediatric patients were excluded. RESULTS: Three hundred twenty-six female (76.2%) and 123 male (27.4%) patients were analyzed. Their ages ranged from 18 to 84 years (mean=51.6±11.9 years). The most common subtype of meningioma was meningothelial meningioma (51.7%), followed by atypical meningioma (20.3%). WHO Grade I meningiomas had statistically random localization distribution, but WHO Grade II meningiomas were more common in the convexity, parasagittal and middle fossa. Younger age was found to be significantly related with tumor recurrence or progression. Seventy-three (16.2%) patients underwent SRS and 64 (14.2%) patients underwent adjuvant radiotherapy (ART) after surgery. Convexity localization was found to be associated with recurrence, mortality and higher WHO 2007 grade. CONCLUSION: Convexity meningiomas are associated with recurrence, mortality and higher WHO 2007 grade. Convexity meningiomas should be totally resected in order to achieve maximum benefit from surgery.

Clinical and surgical outcomes of upper lumbar disc herniations: a retrospective study

Background/aim: Upper lumbar disc herniation (LDH), generally involving L1?L2 and L2?L3 level herniation, is less common than lower LDH and, in this retrospective study, the clinical and radiological findings of patients who suffered from upper LDH and were operated on due to this pathology were reviewed. Materials and methods: Data regarding neurological and radiological findings of patients operated on between January 2005 and December 2013 were retrospectively collected. During this period, 3494 patients had surgery for LDH, and 129 of these patients had disc herniation at the upper levels. Seventy-eight patients with proper follow-up and data were included in the study. Results: There were 39 males and 39 females enrolled in the study. Twenty-one patients (0.6%) were operated on due to L1?L2 disc herniation and 45 (1.2%) had L2?L3 disc herniation. Twelve (0.3%) patients had disc pathologies at both levels. The mean age of the population was 59.9 years old, and this was significantly higher than lower LDH averages previously described in the literature (42 years old). Cauda equina signs and urinary disturbances were frequently seen, in addition to symptoms related to back and leg pain, neurologic claudication, and weakness in lower extremities. Conclusion: Upper LDHs requiring surgical therapy are extremely rare, more so than other LDHs. They are more frequent among older patients and are often present along with signs of cauda equina and urinary dysfunction.

Simplest radiological measurement related to clinical success in endoscopic third ventriculostomy.

OBJECTIVE: Radiologic criteria for a successful endoscopic third ventriculostomy are not clearly defined and there is an ongoing need for determining simplest and strongest radiological criteria for this purpose. This paper aims to determine the easiest radiological parameter related to surgical outcome METHODS: Between January 2012 and December 2015 all patients receiving endoscopic third ventriculostomy with various indications were reviewed and 29 patients whose preoperative and early postoperative 3D-CISS images were available were studied. There were 13 males and 16 females, and there were 11 pediatric cases (mean age: 9.90±5.2; range: 2-18). The mean age of the entire population was 26.58±18.32 (range: 2-68 years). Measurements were performed using the ruler tool of a freely distributed medical imaging software. Simple ruler measurements of ventricular floor depression, lamina terminalis bowing, anterior commissure to tuber cinereum distance, mamillary body to lamina terminalis distance, third ventricular width, frontal horn width and occipital horn width were recorded and compared between successful and failed interventions. RESULTS: Of the ventriculostomies, 22 (75.9%) were considered successful and 7 (24.1%) as failed at the last follow-up visit. Of the measurements performed, only those related to the third ventricle itself were significantly higher in the failed group. There were no association with lateral ventricular measurements. CONCLUSION: Simple ruler measurements of the suggested distances significantly correlate with clinical success. After validating our results with higher number of patients, complex measurements and calculations to determine the link between clinical success and radiological success of ventriculostomy procedures may not be needed.

Intramedullary dermoid cyst infection mimicking holocord tumor: should radical resection be mandatory?-a case report.

BACKGROUND: Dermoid cysts are benign lesions which contain epidermal and dermal elements. Dermoid cysts usually contain a dermal sinus tract but this is not mandatory. Dermoid cysts can manifest by spinal cord infection without a dermal sinus tract. An infected spinal dermoid cyst associated with a holocord spinal abscess poses diagnostic and surgical challenges. Although radical surgical drainage is considered as the main treatment modality for spinal abscess, less extensive surgery for microbiological sampling and appropriate antibiotic treatment can be another alternative modality. CASE DESCRIPTION: A 1-year-old boy patient was admitted to our hospital with progressive paraplegia, bladder dysfunction, and neck rigidity. Medical history of the patient included recurrent urinary tract infection and cephalosporin treatments several times. Initial neurological examination revealed confusion, fever, neck rigidity, paraplegia (also, the motor power of the right upper extremity was three fifths that of the upper extremities). He had urinary and gastrointestinal retention. Conservative surgery was performed to take pathological and microbiological samples. With appropriate antibiotic regimen, the nuchal rigidity and fever improved dramatically. Infectious parameters in blood biochemistry significantly decreased after the antibiotic regimen. DISCUSSION AND CONCLUSION: Holocord spinal abscesses are a rare entity. The source of the disease can be hemopoietic spread or contagious spread. The dermal sinus tract is major risk factor for contagious spread. The major hemopoietic sources are urogenital infection, endocarditis, and infective lung diseases. The hemopoietic spread is a more common source for pediatric patients. The thoracolumbar region is the most common site of involvement. Spinal infection has a tendency to extend longitudinally throughout spinal fibers. The pathogenesis of the holocord edema or syrinx is uncertain. The underlying etiology may be inflammation, infection, and associated venous congestion within the spinal canal. Also, CSF circulation alteration due to arachnoiditis may be another etiological factor. The most important entities on outcome are appropriate surgical treatment and antibiotic administration.

Bilateral Optic Pathway Ganglioglioma: The Fifth Case in the Literature.

Gangliogliomas are mixed tumors which contain both glial and neuronal elements. The optic pathway is a very rare location for gangliogliomas, with less than 23 cases reported in the literature. Bilateral involvement of the entire optic pathway was reported in only 4 cases before. Because of similar radiological appearance of other pathological entities such as gliomas and craniopharyngiomas, histopathological diagnosis is essential. We report a ganglioglioma case that involved both optic pathways. A 12-year-old patient suffering from visual deterioration for 6 months was evaluated. After a visual field test and radiological examinations, a microsurgical biopsy procedure was performed. Pathological examination revealed dysplastic/neoplastic ganglion cells and neoplastic glial cells, and the diagnosis was a World Health Organization (WHO) grade 1 ganglioglioma. The patient is scheduled for adjuvant radiotherapy with the hope of prevention of progression.

Direct venous spinal reabsorption of cerebrospinal fluid: a new concept with serial magnetic resonance cisternography in rabbits.

OBJECT: For nearly 100 years it has been believed that the main reabsorption of CSF occurs in arachnoid projections into the superior sagittal sinus, but a significant number of experiments and cases conflict with this hypothesis. According to recently published studies, CSF is permanently produced and absorbed in the whole CSF system. Clusters of arachnoidal villi, which are speculated to have a role in the reabsorption of CSF, have recently been revealed in the dorsal root of the spinal nerves. Huge absorptive surface areas of microvessels have been suggested to serve a putative role in reabsorption. The authors' aim was to observe direct venous connections between the subarachnoid space and the perispinal veins. METHODS: Eleven adult (6 months old) New Zealand white male rabbits weighing approximately 3.0 kg each were used in this experiment. After obtaining precontrast MR cisternography images, subarachnoid access was gained percutaneously via a cisternal approach by using a 20-gauge intravenous indwelling cannula. One rabbit died as a result of brainstem trauma during percutaneous cannulation before contrast administration, but contrast agent was still injected to see the possible MR imaging results of spinal CSF reabsorption after death. Magnetic resonance imaging was performed at 15, 60, 120, and 180 minutes after the administration of contrast agent. After intramuscular injections of anesthetic, 2 rabbits died 120 and 150 minutes after contrast injection, but the MR imaging study at 180 minutes after contrast injection was still performed. RESULTS: Direct connections between the subarachnoid space and the perispinal veins were observed in all rabbits during serial MR cisternography. The enhancement power was not affected by the amount of injected contrast agent or by cervical or lumbar penetration but was increased at higher contrast concentrations or upon seizure (physical activity). CONCLUSIONS: Extracranial reabsorption of CSF has been finally proved with direct radiological confirmation of spinal venous reabsorption of CSF using serial MR cisternography. The authors believe that this study can help to develop a more accurate model of CSF dynamics, which will allow understanding of many CSF-related diseases, as well as the development of new strategies for treatment.

Trigeminal neuralgia associated with cerebellopontine angle lipoma in childhood.

Cerebellopontine angle lipomas are rare and more rarely associated with trigeminal neuralgia especially in childhood. Medical treatment provides relief from the pain; however, the effect may not be permanent. Surgical treatment is associated with a high morbidity rate; therefore, surgery should be considered only in intractable cases. In this article we describe the clinical course and radiological features of a 6-year-old girl with a cerebellopontine angle lipoma who presented with a 4-year history of left-side trigeminal neuralgia, especially in the mandibular area. Magnetic resonance imaging revealed an extra-axial fatty mass at the level of the 'dorsal-entry zone' of the trigeminal nerve. The pain improved with carbamazepine therapy.