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.

Protection from spinal cord ischemia-reperfusion damage with alpha-lipoic acid preconditioning in an animal model.

BACKGROUND: This study aims to investigate whether preconditioning with alpha-lipoic acid has any protective effect in neuronal damage in an experimental spinal cord ischemia-reperfusion injury model. METHODS: Eighteen adult male New Zealand rabbits (2.4-3.5 kg) were equally divided into sham, control and treatment groups. The abdominal aorta was occluded for 30 min proximally 1 cm below the renal artery and distally 1 cm above the bifurcation using aneurysm clips in control and treatment groups. Treatment group received intraperitoneal 100 mg/kg lipoic acid 20 min before aortic cross-clamping. The animals were sacrificed 48 hours after the operation and spinal cord segments between L2 and L5 were removed for biochemical and histopathological analysis. Levels of glutathione, malondialdehyde, total nitrate/nitrite, advanced oxidation protein products, catalase, superoxide dismutase, and glutathione peroxidase were examined in spinal cord. RESULTS: Preconditioning with alpha-lipoic acid demonstrated significantly favorable effects in all measured parameters of oxidative stress. Histopathological evaluation of the tissues also demonstrated significantly decreased neuronal degeneration, axonal damage, and microglial and astrocytic infiltration in the treatment group compared to the control group. CONCLUSION: The results of this study indicate that alpha-lipoic acid administration before aortic cross-clamping has significant neuroprotective effect on spinal cord injury in rabbits.

The Effect of Quetiapine on Treatment of Experimental Acute Spinal Cord Injury.

AIM: It is well known that treatment modalities against secondary damage due to spinal cord injury (SCI) are very important. This phase has been researched in many experimental studies. Apoptosis is one of the major mechanisms of secondary damage on spinal cord. The present study was undertaken to determine if quetiapine, a 5-HT2 receptor blocker atypical antipsychotic agent can rescue neuronal cells from apoptosis in a SCI model. MATERIAL AND METHODS: Thirty-two female Wistar rats were separated to 4 equal groups. Total laminectomy was performed at T5-7 level and spinal cord injury was produced by using the clip compression technique. Each rat from groups "1 day" (D-I) and "7 days" (D-II) was daily injected intraperitoneally with Quetiapine (10 mg/kg/day). No treatment was administered to the control groups "1 day" (K-I) and "7 days" (K-II). At the end of follow-up periods, all animals were sacrificed and spinal cords were removed. Apoptotic cells were evaluated by using immunohistochemical technique (TUNEL) in injured spinal cord specimens. RESULTS: There was a statistically significant difference while counting ApopTag positive cells, both at 1 day groups of K-I and D-I (p=0.00000008) and at 7 day groups of K-II and D-II (p=0.000005). Unlike the 1-day period, a statistically significant difference was found between grey and white matter ApopTag positive cells at the 7 < sup > th < /sup > day (p=0.0001). CONCLUSION: Quetiapine has a protective effect on secondary damage caused by SCI, while also can be used in post-traumatic stress disorder, depression and agitation as a versatile agent.

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.

Spine Tango in Turkish: Development of a Local Registry System.

AIM: Successfully established registry systems, rather than personal efforts to collect data, are required to record, analyze, compare and secure patient related data. Unfortunately, our country does not have such patient registry systems for spinal pathologies and surgeries at this time. In order to fill this gap in patient management in Turkey, the authors adopted already established Spine Tango registry system in a unique way answering the requirements of our health system. This article aims to present the adaptation process of Spine Tango forms for use in Turkish and describe the first implementation with 50 patients treated for spinal pathologies in a tertiary referral center. MATERIAL AND METHODS: In 2011, an effort was initiated by the first author to translate the original Spine Tango forms into Turkish. Funding for this project was provided by authors themselves. With the assistance of a Spine Tango team, the translation process was completed. The Turkish forms were then used in an academic institution with a high spinal workload. A local solution was developed by the authors using commercially available software and mobile instruments. This system was tested with 50 spine patients from June 2012 to January 2013. RESULTS: The analysis of the data gathered using the new Turkey Spine Tango registry system was successful. CONCLUSION: In an environment of exponentially increasing medical data, successfully established registry systems have the potential to facilitate patient management. The authors recommend the use of Turkish Spine Tango forms for clinics performing spinal interventions.

Primary Intracerebral Alveolar Soft Part Sarcoma in an 11-Year-Old Girl: Case Report and Review of the Literature.

Alveolar soft part sarcoma (ASPS), a rarely observed tumor, is a soft tissue sarcoma with an unidentified cell origin. It constitutes 0.5-1.0% of all soft tissue sarcomas. It may appear in various parts of the body, but mostly observed in the trunk and the extremities. It has a high metastasis potential. To the best of our knowledge, only three cases of primary intracranial ASPS without a demonstrable lesion elsewhere is encountered. An 11-year-old girl was operated because of fronto-parietal mass lesion by craniotomy. Pathological examination revealed ASPS and no primary focus was detected. In spite of radiotherapy and chemotherapy as an adjuvant therapy, after 45 months she had a second operation for recurrence of the tumor. Since it is possible to observe metastases in late phases, up to 30 years, the patients must be followed up for a long period. Although radiotherapy and chemotherapy followed by surgery is the most accepted treatment strategy, the prognosis is still poor.

Accuracy of pedicle screw placement in thoracolumbar spine with conventional open technique.

AIM: To demonstrate the incidence of screw misplacement and revision rates in a group of 72 patients that underwent pedicle screw fixation for spinal pathologies using the conventional, fluoroscopy-guided open technique. MATERIAL AND METHODS: Data from 72 consecutive patients with spinal instability that received 472 screws between April 2011 and May 2013 were reviewed and pedicle wall breach was graded as mild ( < 3 mm), moderate (3-6 mm) and severe ( > 6 mm). Direction of misplacement was also assessed in reformatted images as medial, lateral, superior and inferior (or in combinations). RESULTS: The indications for pedicle screw placement were as follows: degenerative (59.7%), trauma (13%) and tumor (9.7%). Pedicle screws were inserted between T9 and S1. In this series of the 472 screws, 29 (6.1%) screws were implanted with minimal pedicle wall violation (≤ 3 mm) and 16 screws (3.4%) were implanted with moderate (3-6 mm) violations. There were no severe violations (more than 6 mm) in this series. Pedicle violations were significantly higher in thoracic pedicles and in trauma patients when compared to other groups. Only two patients required pedicle screw repositioning after their index surgery. CONCLUSION: Conventional open technique in pedicle screw placement is a safe and sound method with its low and acceptable complication rates.

Neuroprotective effects of quetiapine on neuronal apoptosis following experimental transient focal cerebral ischemia in rats.

OBJECTIVE: This study was undertaken in the belief that the atypical antipsychotic drug quetiapine could prevent apoptosis in the penumbra region following ischemia, taking into account findings that show 5-hydroxytryptamine-2 receptor blockers can prevent apoptosis. METHODS: We created 5 groups, each containing 6 animals. Nothing was done on the K-I group used for comparisons with the other groups to make sure adequate ischemia had been achieved. The K-II group was sacrificed on the 1st day after transient focal cerebral ischemia and the K-III group on the 3rd day. The D-I group was administered quetiapine following ischemia and sacrificed on the 1st day while the D-II group was administered quetiapine every day following the ischemia and sacrificed on the 3rd day. The samples were stained with the immunochemical TUNEL method and the number of apoptotic cells were counted. RESULTS: There was a significant difference between the first and third day control groups (K-II/K-III : p=0.004) and this indicates that apoptotic cell death increases with time. This increase was not encountered in the drug groups (D-I/D-II : p=1.00). Statistical analysis of immunohistochemical data revealed that quetiapine decreased the apoptotic cell death that normally increased with time. CONCLUSION: Quetiapine is already in clinical use and is a safe drug, in contrast to many substances that are used to prevent ischemia and are not normally used clinically. Our results and the literature data indicate that quetiapine could help both as a neuronal protector and to resolve neuropsychiatric problems caused by the ischemia in cerebral ischemia cases.

Transoral protrusion of a peritoneal catheter due to gastric perforation 10 years after a ventriculoperitoneal shunting: case report and review of the literature.

Various complications following ventriculoperitoneal (VP) shunting have been reported but transoral protrusion of peritoneal catheter is a very rare situation. This case is the first adult with a transoral VP shunt protrusion in available literature. A 47-year-old female with pseudotumor cerebri admitted after the peritoneal catheter protruded from her mouth during retching. Endoscopic examination showed a catheter inside stomach entered through the anterior surface. The patient was treated via VP shunt extraction and remained stable. Extrusion of peritoneal catheter through vagina, anus, scrotal skin or gastrostomy wound is well-known. However transoral protrusion should be considered as a very rare complication of VP shunting, especially in an adult. We present a rare case of transoral protrusion of a peritoneal catheter 10 years after ventriculo-peritoneal shunting procedure and review of the literature through this article.

Effectiveness of single posterior decompressive laminectomy in symptomatic lumbar spinal stenosis: a retrospective study.

AIM: The best method for surgical intervention in symptomatic lumbar stenosis is not clear. The present study aims to assess first year outcomes and complication rates of patients treated with single posterior decompressive laminectomy. MATERIAL AND METHODS: Patients requiring surgery for severe, symptomatic, lumbar spinal stenosis were evaluated retrospectively. Oswestry disability index scores as well as the complications attributable to surgery were recorded before, at the sixth month and at the twelfth month of the surgery. RESULTS: Eighty patients were enrolled to the study. The mean age of the population was 63,14 ± 11,57. Neurogenic claudication was the most common finding (65%). Of the patients, 67.5% had severe spinal stenosis. The mean ODI score at the baseline was relatively high than in the literature and was measured as 74.30 ± 5.38. At the end of the 6 months follow-up period, all patients' ODI scores significantly improved. Moreover, this improvement continued till the end of the 12 month. The mean change in ODI at the end of the first year was 41.80% ± 12.73. CONCLUSION: In selected cases of symptomatic lumbar spinal stenosis, single posterior decompression using laminectomy is safe and effective.

Intraventricular dysembryoplastic neuroepithelial tumour: case report.

Dysembryoplastic neuroepithelial tumour (DNT) is located in the cerebral cortex with very few exceptions. In this article, an extremely rare case of intraventricular DNT originating from the septum pellucidum is reported. A 25-year-old woman presented with 5-month history of headache. Cranial magnetic resonance imaging (MRI) scans revealed a mass in the right lateral and third ventricle which was hypointense on T1-weighted image, and hyperintense on T2-weighted images. No contrast enhancement was detected. The lesion was excised totally using a transcallosal-transventricular approach. Immunohistochemical examination revealed DNT. The patient was discharged without any neurological deficits. Intraventricular DNT presents with symptoms of increased intracranial pressure rather than seizures. Distinguishing DNT from other intraventricular tumours is essential as DNT is characterized by benign clinical course and does not require adjuvant therapy.

Immunomodulatory effectiveness of azithromycin in prevention of postlaminectomy epidural fibrosis.

OBJECTIVE: One of the important causes of failed back surgery is the extensive peridural fibrosis collecting in the surgical field after spinal surgeries. Today we know that inflammatory mechanisms mediated by the immune system of the body plays an important role in generation of fibrosis. Azithromycin, a macrolide antibiotic, has proven immunomodulatory effects in various diseases. This study aims to investigate the effects of azithromycin on peridural fibrosis. METHODS: Twenty-four Wistar rats received laminectomies before dividing them into three groups randomly. Animals of the control group received normal saline intraperitoneally while animals in the treatment groups received low (20 mg/kg) and high (80 mg/kg) doses of azithromycin intraperitoneally after surgical interventions. The amount of fibrosis, fibroblast density and inflammatory cell density were analyzed histologically. RESULTS: Analysis demonstrated significantly reduced fibrosis, fibroblast density and inflammatory cell density in treatment groups compared to the control group. There was no difference between the treatment groups. CONCLUSION: Immune system plays critical roles in tissue repair and fibrogenesis. Results of our study demonstrated that azithromycin application reduced formation of peridural fibrosis in experimental laminectomy model in rats. Further studies with different dose regimes and different application routes are required to carry these results to an advanced level.

Neuroprotective effects of gabapentin in experimental spinal cord injury.

BACKGROUND: Extensive research has focused on neuroprotection after spinal cord trauma to alleviate the effects of secondary injury. This study aims to investigate the neuroprotective effects of gabapentin in experimental spinal cord injury. METHODS: Thirty-six adult, male Wistar rats received spinal cord injury using the clip compression method. Animals were divided into five groups. High (200 mg/kg) and low doses (30 mg/kg) of gabapentin were administered to the animals in the treatment groups after spinal cord trauma and ultrastructural findings and lipid peroxidation levels of these two groups were compared with the animals that received only laminectomy, only trauma, and trauma and 30 mg/kg methylprednisolone. RESULTS: Regarding tissue lipid peroxidation levels after trauma, animals in gabapentin groups demonstrated better results than the trauma group. However, these results were no better than the methylprednisolone group. The results regarding the ultrastructural findings were similar. Treatment groups demonstrated better ultrastructural findings than the trauma group. In addition, the results of the high dose gabapentin group were significantly better than the low dose gabapentin group. CONCLUSIONS: Gabapentin demonstrated similar neuroprotective effects as methylprednisolone in early phase of spinal cord injury. Further studies with different experimental settings including neurological outcome are required to achieve conclusive results.

A survey on application of quantitative methods on analysis of brain parameters changing with temperature.

Brain temperature fluctuations occur in consequence of physiological and pathophysiological conditions and indicate changes in brain metabolism, cerebral blood flow (CBF), brain functions and neural damage. Lowering the brain temperature of patients with traumatic brain injuries achieves considerable improvements. When the human brain is cooled down to 30°C, it switches to a sub functional regime where it can live longer with less oxygen, glucose and other supplies. Fluctuations in brain temperature cause changes in brain parameters which can be measured by electroencephalogram (EEG) and transcranial Doppler (TCD). It is very important to understand the temperature dependencies of brain's electrical activity and blood flow and their interrelations considering the good clinical results achieved by lowering the brain temperature of neurologically injured patients. Since protecting the patient's brain is of primary importance in many fields including cardiology, neurology, traumatology and anesthesia it can be clearly seen that this subject is very important. In this study, we survey the "state-of-the-art" in analysis of EEG and TCD brain parameters changing with temperature and present further research opportunities.

Comparison of collagen biomatrix and omentum effectiveness on peripheral nerve regeneration.

Despite the presence of various nerve coaptation materials and techniques, achievement of the functional nerve regeneration is still inadequate. This study was aimed to compare the effectiveness of conduit composed of collagen biomatrix and omentum graft on peripheral nerve regeneration. Thirty-five male Wistar rats were divided into four groups. In the control group, the right sciatic nerve was skeletonized from the sciatic notch till the point of bifurcation. In the primary epineural repair group, the nerve was transected 1 cm proximal to the bifurcation with a sharp pair of micro scissors and then repaired with four epineural sutures. In the collagen biomatrix group, the epineural repaired nerve was wrapped with collagen biomatrix. In the collagen group, the epineural repaired nerve was wrapped with the nonpediculated omentum. Assessment of the nerve regeneration was based on functional (Walking Track Analysis, Electrophysiological Measurements), histological, and morphometric criteria. Light and electron microscopic examinations showed that collagen-biomatrix-wrapped specimens have the best regeneration. The electrophysiological study confirmed the recovery of electrical activity in the regenerated axons.

Malignant intracerebral giant nerve sheath tumor in a 14-month-old girl with neurofibromatosis type 1: a case report.

INTRODUCTION: Malignant intracerebral nerve sheath tumor (MINST) is extremely rare and the origin is still unclear. The authors present the clinical, radiological, and pathological features of a malignant intracerebral giant nerve sheath tumor. CASE REPORT: A giant tumor in the right frontotemporoparietal lobes causing a midline shift was detected in a 14-month-old girl who presented with developmental delay, vomiting, and lethargy. The physical examination was consistent with neurofibromatosis type 1 (NF-1). Subtotal resection was performed and the histopathological examination revealed the diagnosis of MINST. DISCUSSION: There are only six cases of malignant intracerebral nerve sheath tumor in the literature. The presented case is the youngest and the occurrence of MINST in a 14-month-old girl may support the hypothesis of multipotent mesenchymal stem cell origin; however, the tumors which arise from multipotent mesenchymal stem cells may be seen in later stages of life. Another important feature of the presented case is the occurrence of MINST in NF-1. CONCLUSION: MINSTs are extremely rare tumors with unknown origin. The location, the degree, and the size of the tumor and the general condition of the patient are prognostic factors in MINSTs, like in other malignant tumors.

Frontal sinus osteoma associated with pneumocephalus.

The most common causes of intracranial air are head trauma and neurosurgical procedures. Less common etiologies include infection due to gas-forming organisms, mucoceles, tumours, congenital neuroenteric cysts, and dural defects. Here, we present a case of a frontal sinus osteoma associated with longstanding pneumocephalus.