First report of surgery for anencephaly in twin pregnancies: Technical notes and postoperative management.

Anencephaly, the most severe form of neural tube defect, has no known cure, and in most cases, patients die before or shortly after birth. To date, no surgical intervention has been reported in the management of anencephaly. This study presents a case of dichorionic-diamniotic twin pregnancy in which 1 twin was anencephalic and describes the surgical management of this complex case. We aimed to share the problems experienced during the follow up of a patient who survived for a long time after surgery. We also aimed to highlight several clinical issues, including the challenges of managing anencephaly in twin pregnancies, problems experienced during the follow up process in our case, diagnosis of brain death in anencephaly cases, and ethical dilemmas related to organ donation. This case is notable because of the challenging nature of the surgical procedure and complexity of postoperative care. By highlighting the difficulties encountered during the follow up period, we hope to provide insights to health professionals that can inform the management of similar cases in the future.

Efficacy of Lumboperitoneal Shunting in Patients with Normal Pressure Hydrocephalus.

AIM: To evaluate the effectiveness of lumboperitoneal (LP) shunt procedures in the treatment of normal pressure hydrocephalus (NPH). MATERIAL AND METHODS: A medical record review was conducted to obtain demographic, clinical, laboratory data, as well as pre-, intra, -postoperative details of 65 patients who underwent LP shunt surgery for NPH between January 1, 2001 and January 1, 2014 in the Neurosurgery Clinics of Ankara Training and Research Hospital and Ankara Numune Hospital. RESULTS: At the 3rd month after LP shunt surgery, headache was resolved in almost all patients. At the end of first year, while statistically significant improvements were noted in the Modified Rankin Scale Scores and Mini-Mental State Examination Scores, gait disturbance, urinary incontinence and cognitive functions were improved by 86%, 72% and 65% of the patients, respectively. CONCLUSION: LP shunt surgery is associated with a lower rate of complication in comparison to ventriculoperitoneal shunt surgery and is an effective procedure in the treatment of NPH.

The Effects of Stereotactic Cerebroventricular Administration of Albumin, Mannitol, Hypertonic Sodium Chloride, Glycerin and Dextran in Rats with Experimental Brain Edema.

AIM: To evaluate the effects of cerebroventricular administration of hyperoncotic/hyperosmotic agents on edematous brain tissue in rats with experimental head trauma. MATERIAL AND METHODS: The study included 54 female Sprague-Dawley rats with weights ranging between 200 and 250 g. Six experimental groups were examined with each group containing 9 rats. All rats were exposed to head trauma, and treatment groups were administered 2 µl of one of the drugs (albumin, mannitol, hypertonic sodium chloride (NaCl), glycerin and dextran) 6, 12 and 24 hours after the trauma via the cerebroventricular route and using a stereotactic device. Rats were sacrificed 48 hours after the trauma, and brain tissues were extracted without damage. Biochemical analyses including reduced glutathione (GSH), nitric oxide (NO), malondialdehyde (MDA), tumor necrosis factor alpha (TNF-α), and interleukin 1 beta (IL-1ß) were performed on the injured left hemisphere. RESULTS: Compared with the control group, the albumin, mannitol, 3% NaCl and glycerin treatment groups revealed dramatic increases in GSH levels (p < 0.001). Levels of MDA, which is the end-product of brain edema and lipid peroxidation, failed to show a statistically significant decrease, but there was a decreasing trend observed in the inter-group comparisons. NO levels were also decreased in the 3% NaCl treatment group. An analysis of TNF-α and IL-1ß, two proinflammatory cytokines associated with the trauma, revealed that IL-1ß decreased significantly in all treatment groups (p=0.001), whereas no significant difference was detected in TNF-α levels. CONCLUSION: Cerebroventricular administration of hyperoncotic/hyperosmotic agents provides substantial effects on the treatment of brain edema.

Giant Parietal Encephalocele with Massive Brain Herniation and Suboccipital Encephalocele in a Neonate: An Unusual Form of Double Encephalocele.

Double encephalocele is extremely rare. We present an unusual form of double encephalocele including giant supratentorial and small infratentorial encephalocele in a neonate.

Single-Stage Posterolateral Transpedicular Approach With 360-Degree Stabilization and Vertebrectomy in Primary and Metastatic Tumors of the Spine.

OBJECTIVE: Currently, anterior, posterior, or combined approaches are used in various spinal disorders; however, a single-stage posterolateral transpedicular approach with 360° stabilization and vertebrectomy provides better results for spinal tumors. METHODS: We evaluated the age, sex distribution, presenting symptoms, neurologic examination findings according to the pre- and postoperative Frankel classification, pre- and postoperative VAS pain scores, preoperatively administered medical therapies, pre- and postoperative corset use, level of the lesion, levels of previous surgical interventions, root ligation (if performed), results of the primary disease, hospitalization duration (after the operation), postoperative complications (if any), postoperative follow-up duration, and postoperative survival duration of 22 patients. RESULTS: We observed that primary bone tumors were localized in the lumbar (75%) and thoracic regions (25%) and that metastatic tumors were localized in the thoracic (77.78%) and lumbar regions (22.22%). The VAS and Frankel scores of the 22 patients who were included in the study revealed that this surgical treatment modality was associated with statistically significant improvements in test scores (P < 0.001). No ribcage dislocation was observed. In 1 patient (4.54%), a neurologic deficit developed. Two patients (9.09%) required revision because of screw malposition. CONCLUSIONS: In spinal tumors, 360° fusion performed via a posterolateral approach is a less risky, relatively safe, and less invasive method. This method, which reduces the risks of anesthesia and internal problems and decreases cost, is an essential technique for decreasing hospitalization duration, improving pain levels, and achieving faster mobilization and faster initiation of radiotherapy and chemotherapy.

The sulci of the inferior surface of the temporal lobe: An anatomical study.

Understanding the anatomy of temporal lobe sulci and their variations can allow for safer neurosurgical approaches. Although the inferior temporal sulci and their relations to each other has been described by several authors, the nomenclature used has not been universal. The aim of this study was to investigate the anatomic features of the three main sulci of the inferior temporal lobe and provide a simple description of complex patterns among these sulci. Sulcal variations and their relations were examined in seventy formalin-fixed, adult cadaveric cerebral hemispheres. We recommend a simple but modified classification specifically for anatomic variations of the rhinal and collateral sulci. Furthermore, we describe the frequency of occipitotemporal sulci that contain 5 and 6 segments, not previously mentioned. The length and depth of all sulci were measured in all samples. Additionally, more detailed results regarding the patterns, courses, connections, relationships and measurements were given. Understanding of the complex anatomy of this clinically important region is of benefit to neurosurgeons, providing necessary guidance for neurosurgical approaches to the inferior surface of the temporal lobe. Clin. Anat. 29:932-942, 2016. © 2016 Wiley Periodicals, Inc.

The Biochemical, Histopathological and Clinical Comparison of the Neuroprotective Effects of Subcutaneous Adalimumab and Intravenous Methylprednisolone in an Experimental Compressive Spinal Cord Trauma Model.

AIM: To evaluate the neuroprotective effects of adalimumab in an experimental spinal cord injury model and compare them with those of the widely-used methylprednisolone. MATERIAL AND METHODS: Forty male Wistar rats were divided into 5 as the sham, trauma, adalimumab, methylprednisolone, and adalimumab+methylprednisolone groups. Only laminectomy was performed in the sham group. Laminectomy and trauma was performed to the trauma group but no treatment was given. A single dose of 40 mg/kg subcutaneous adalimumab was administered after the laminectomy and trauma to group 3. A single dose of intravenous 30 mg/kg methylprednisolone was administered right after laminectomy and trauma to group 4. Single doses of 40 mg/kg adalimumab and 30 mg/kg methylprednisolone were administered together after laminectomy and trauma to group 5. Serum malondialdehyde (MDA), TNF-α, IL-1ß and IL-6 levels were measured and sections were obtained for histopathological study at the end of the 7 < sup > th < /sup > day. RESULTS: MDA, TNF-α, IL-1ß and IL-6 levels in serum were significantly decreased in the adalimumab group with clinical and histopathological improvement not less than the methylprednisolone group. The serum MDA levels were similar when the two drugs were given together or separately but there was a statistically quite significant decrease in TNF-α, IL-1ß and IL-6 levels with concurrent use. Statistically significantly better results were obtained on histopathological evaluation with the use of both drugs together. CONCLUSION: This study revealed that adalimumab is as effective as methylprednisolone in compressive spinal cord injury in rats.

Neuroprotective effects of adalimumab on rats with experimental peripheral nerve injury: An electron microscopic and biochemical study.

BACKGROUND: Adalimumab, a new-generation anti-inflammatory agent, exerts its effect through tumor necrosis factor α (TNF-α), secreted from immune response cells such as macrophages and lymphocytes. TNF-α has been shown to play an important role in the processes of apoptosis and demyelination, and blockage of its activity may improve neural healing. Investigated in the present study is the probable neuroprotective influence of adalimumab in rats using a peripheral nerve injury model with biochemical and electron microscopic methods. METHODS: Forty adult Wistar albino rats were randomly divided into control, sciatic nerve trauma, low-dose adalimumab, and high-dose adalimumab groups. Six rats from each group were assigned biochemical microscopy, and 4 were assigned electron microscopy. Neural injury was induced with clip compression following dissection of sciatic nerves. Adalimumab was simultaneously injected. The rats were sacrificed after 2 weeks of adalimumab treatment. RESULTS: Nerve tissue lipid peroxidation values were found to be significantly decreased in both the low- and high-dose adalimumab treatment groups, compared to the group subjected only to sciatic nerve trauma. CONCLUSION: Results demonstrate that adalimumab is an effective neuroprotective agent for neural healing, particularly in the early phase.

The Outcomes of Late Term Surgical Treatment of Penetrating Peripheral Nerve Injuries.

AIM: The aim of this retrospective study was to evaluate the follow-up results of patients who received late-term surgical treatment for peripheral nerve lesions caused by penetrating injuries. MATERIAL AND METHODS: The study included 25 patients who underwent surgery for peripheral nerve injuries in our clinic between 2007 and 2013. The patients were evaluated with respect to age, gender, etiology of the trauma, the affected nerve, clinical examinations, electrophysiological findings, surgical techniques and functional outcomes. RESULTS: The study included 30 nerves of 25 patients (19 male, 6 female; mean age 30.1 years). The mean time between the initial injury and admission to our clinic was 11.5 months (range, 3 to 30 months). Cuts caused by glass were the most common cause of injury (68.5%). The most commonly injured nerves in our patients were the median nerve (43.4%) and ulnar nerve (26.6%). External neurolysis and decompression were performed in eleven patients, epineurotomy and internal neurolysis were performed in eight patients, epineural repair was performed in fourteen patients, fascicular repair was performed in three patients, and interfascicular anastomosis using sural nerve grafting was performed in five patients. Postoperative motor strength and electrophysiological analyses showed significant improvements. Better outcomes were obtained in cases with median nerve injuries rather than other nerve injuries. Additionally, patients undergoing external neurolysis and decompression exhibited better outcomes than those undergoing other surgical approaches. CONCLUSION: Although surgical treatment is recommended as early as possible for peripheral nerve injuries, late-term surgical treatments may provide positive outcomes.

Fatal cerebellar hemorrhage as an initial presentation of medulloblastoma in a child.

Children with medulloblastomas most commonly present with signs and symptoms of elevated intracranial pressure due to obstructive hydrocephalus, especially headaches and vomiting. However, some pediatric patients present with sudden neurological deterioration due to intracerebellar hemorrhage associated with medulloblastoma, although very few reports exist that document this phenomenon. An 8-year-old girl was admitted to our emergency department who presented with sudden loss of consciousness, vomiting, and bradycardia. The neuroradiological evaluation revealed a hemorrhagic mass lesion in the posterior fossa. Urgent evacuation of the hematoma was performed. The postoperative course was uneventful, and the postoperative histopathological examination revealed the lesion to be a medulloblastoma. This report presents an unusual case of a medulloblastoma presenting with fatal intracranial hemorrhage in a child. The clinical features and intraoperative and pathologic findings of the case are discussed.

Placento-Cranial Adhesions in Amniotic Band Syndrome and the Role of Surgery in Their Management: An Unusual Case Presentation and Systematic Literature Review.

Amniotic band syndrome is a group of sporadic congenital anomalies that involve the limbs, craniofacial regions and trunk, ranging from simple digital band constriction to complex craniofacial and central nervous system abnormalities. Placento-cranial adhesions in amniotic band syndrome are extremely rare, and severe conditions are associated with high morbidity and mortality rates. In this study, we pooled placento-cranial adhesion case reports that were published in the medical literature and added an unpublished case from our institution. The purpose of this article was to review and discuss the clinical features and outcomes of placento-cranial adhesions in amniotic band syndrome.

Evaluation of the Time-dependent Contamination of Spinal Implants: Prospective Randomized Trial.

STUDY DESIGN: Prospective study OBJECTIVE.: To evaluate contamination in spinal implants using a liquid culture medium and the effect of covering an implant set on contamination. SUMMARY OF BACKGROUND DATA: Postoperative infection rates increase with the use of spinal implants. Because implant contamination may be an important origin for postoperative infections, investigation, evaluation, and taking required precautions to prevent these contaminations are critical. METHODS: Patients operated on for various spinal pathologies were randomized. The patients were divided into groups of covered and uncovered implant sets. The screw samples were placed in liquid culture medium immediately after opening the implant set. The implant set in the covered group was immediately covered with a sterile surgical towel. A new screw was taken from the implant set and cultured in the liquid culture medium every 30 minutes. At the end of 24 hours, swabs with samples from the liquid culture medium were used to culture blood agar. At the end of 48 hours, the samples with growth were considered contaminated. RESULTS: Growth started after 30 minutes in the uncovered group, whereas only a single growth was noted after 60 minutes in the covered group. Contamination increased with time in both groups, but more so in the open group. A statistically significant difference in contamination was found between the groups at and after 30 minutes. CONCLUSION: Contamination increases with time in all implant materials. Contamination rates can be reduced by using simple precautions, such as covering the implant set. Culturing the entire implant samples in liquid culture medium is accepted as a safe and more effective method in evaluating contamination. LEVEL OF EVIDENCE: 2.

Results of treatment of unstable thoracolumbar burst fractures using pedicle instrumentation with and without fracture-level screws.

BACKGROUND: Two different techniques of short-segment instrumentation, with and without a pedicle screw at the fracture level, were compared in thoracolumbar burst fractures in neurologically intact (ASIA-E) patients. The sagittal index, kyphosis angle (Cobb), canal compromise ratio, and compression ratio of the anterior vertebral height were analyzed. METHODS: Seventy patients who underwent short-segment stabilization for thoracolumbar (T11-L2) burst fractures in our clinic between 2008 and 2012 were included in this retrospective study. In 35 patients (group 1), a pedicle screw was placed only one level down and one level up from the fracture level. In another 35 patients (group 2), a screw was placed at the fracture level in addition to the short segment. Only neurologically intact patients with burst fractures according to the Denis classification were included. The patients were evaluated according to their age/gender, trauma etiology, and fracture level. Their preoperative and most recent postoperative follow-up radiographs and CTs were evaluated in terms of the sagittal index, kyphosis angle (Cobb), ratio of canal compromise, and anterior vertebral height. RESULTS: The two groups were similar in their ages, follow-up periods, and severity of the deformity and fracture. When the pedicle screw was placed at the fracture level in addition to short-segment stabilization, statistically significant improvements in the sagittal index (p < 0.001), local kyphosis (Cobb) angle (p = 0.006), and compression ratio of the anterior vertebral height (p = 0.002) were observed. Concerning the ratio of canal compromise according to the CT findings (p = 0.189), moderate differences were found. CONCLUSIONS: Short-segment stabilization in thoracolumbar burst fractures with additional screws at the level of the fracture results in an improved kyphosis correction, sagittal index, and compression ratio of the anterior vertebral height. However, long-term follow-up is needed to determine the clinical significance of these findings.

Familial perimesencephalic subarachnoid hemorrhage: two case reports.

INTRODUCTION: Non-aneurysmal spontaneous subarachnoid hemorrhage is characterized by an accumulation of a limited amount of subarachnoid hemorrhage, predominantly around the midbrain, and a lack of blood in the brain parenchyma or ventricular system. It represents 5% of all spontaneous subarachnoid hemorrhage cases. In spite of extensive investigation, understanding of the mechanisms leading to perimesencephalic non-aneurysmal subarachnoid hemorrhage remains incompletely defined. A growing body of evidence has supported a familial predisposition for non-aneurysmal spontaneous subarachnoid hemorrhage. CASE PRESENTATION: A 39-year-old Caucasian man presented with sudden onset headache associated with diplopia. His computed tomography scan revealed perimesencephalic subarachnoid hemorrhage. A cerebral angiogram showed no apparent source of bleeding. He was treated conservatively and discharged after 1 week without any neurological deficits. The older brother of the first case, a 44-year-old Caucasian man, presented 1.5 years later with acute onset of headache and his computed tomography scan also showed perimesencephalic non-aneurysmal subarachnoid hemorrhage. He was discharged home with normal neurological examination 1 week later. Follow-up angiograms did not reveal any source of bleeding in either patient. CONCLUSIONS: We report the cases of two siblings with perimesencephalic non-aneurysmal subarachnoid hemorrhage, which may further suggest a familial predisposition of non-aneurysmal spontaneous subarachnoid hemorrhage and may also point out the possible higher risk of perimesencephalic non-aneurysmal subarachnoid hemorrhage in the first-degree relatives of patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage.

Systemic administration of atorvastatin improves locomotor functions and hyperacute-acute response after experimental spinal cord injury: an ultrastructural and biochemical analysis.

AIM: Spinal cord injury (SCI) is characterized by posttraumatic inflammatory cascades including excitotoxicity, oxidative stress, and apoptosis. Agents against neuroinflammation are the current scope of studies on experimental SCI with promising results. MATERIAL AND METHODS: Thirty-two male Sprague-Dawley rats weighing 250-320 gram were used. They were randomized and divided into four groups with eight animals in each as sham, control, SCI+PEG (polyethylene glycol) and SCI+atorvastatin group. Rats were anesthetized with intraperitoneal ketamine (80 mg/kg) and xylazine (10 mg/kg) and SCI was induced by the weight-drop model. A single level laminectomy was performed at T10 and the spinal column was immobilized with a stereotactic device. Rats in the treatment group received ip atorvastatin at 0.2 mg/kg. Neurological impairments were examined through Modified Tarlov's and inclined angle scores. The SCI section was resected for electron-microscopic analysis, IL-1ß and IL-6 level. All data were analyzed using one-way ANOVA and Dunnet T3 test. RESULTS: Atorvastatin improved locomotor recovery after rat SCI. The results were further confirmed with a statistically significant decrease of IL-1ß, IL-6 and lipid peroxide levels. This finding revealed the anti-inflammatory and beneficial effect of atorvastatin on rat SCI. CONCLUSION: The present study focused on both B and T cell mediated immunity and confirmed the beneficial effect of atorvastatin with decreased expressions of IL-1ß and IL-6.

The neuroprotective effects of rituximab in rat spinal cord injury model: an immunohistochemical study.

AIM: In the present study, we investigate the neuroprotective effects of rituximab, a monoclonal antibody directed towards B cell mediated humoral immunity, on a rat spinal cord injury (SCI) model with immunohistochemical methods. MATERIAL AND METHODS: Twenty-four rats were used for the study. Rats were divided as control, SCI, and rituximab-treated SCI groups. Intraperitoneal rituximab administration was performed on days 0, 3 and 5 in the third group. Rats were sacrificed 7 days after trauma. Antibodies against IL-1ß, IL-6, TNF-α and CD20 were studied with the ELISA method together with electron microscopic analysis. RESULTS: It was found that rituximab suppressed oligodendrocytes at the phagocytic stage but was still inefficient for the regenerative phase. TNF-α expression was markedly increased in rats subjected to SCI and suppressed after rituximab treatment. Decreased CD20 expression was another prominent finding in rats under rituximab therapy. However, expressions of IL-1ß and IL-6 were both increased in glial cells without significant change after rituximab administration. CONCLUSION: TNF-α expression was augmented at the level of SCI both in neuronal and glial cells, particularly in oligodendrocytes. All were suppressed after rituximab administration and rituximab reduced CD20 expression both in neuronal and supportive glial cells which may be related to neural healing.

Dyke-davidoff-masson syndrome associated with epidermoid tumour and arachnoid cyst: a case report.

BACKGROUND: Dyke-Davidoff-Masson Syndrome (DDMS) is a rarely seen clinical entity which is characterised by cerebral hemiatrophy, contralateral hemiparesis and epilepsy. Radiological features are typical, such as unilateral atrophy of the cerebral hemisphere and associated compensatory bone changes in the skull, like thickening, enlargement of the paranasal sinuses and mastoid air cells. CASE REPORT: In this article, we report the first case of DDMS associated with epidermoid tumour and arachnoid cyst, who underwent operation for an epidermoid tumour in the inter-hemispheric region. To our knowledge, this is the first report of DDMS associated with multiple intracranial pathologies and this association has not been previously described in the literature. CONCLUSION: Any patient who receives DDMS in the light of clinical and radiological findings should be investigated for concomitant pathologies. Different sequences of MRI may be useful in the diagnosis of other intracranial lesions.

Intracranial arachnoid cyst family with autosomal recessive trait mapped to chromosome 6q22.31-23.2.

BACKGROUND: Arachnoid cysts are congenital fluid-filled compartments within the cerebrospinal fluid cisterns and cerebral fissures. They most commonly occur sporadically, and familial occurrence has rarely been reported. In this study, we showed the first genetic linkage in the literature in a pure intracranial arachnoid cyst family with autosomal recessive trait. METHODS: We identified an intracranial arachnoid cyst family in southern Turkey whose six of seven offspring had intracranial arachnoid cysts in different localizations, and collected venous blood from seven offspring of the family. Whole-genome linkage analysis was performed in all offspring. RESULTS: A theorical maximum logarithm of the odds score of 4.6 was identified at chromosome 6q22.31-23.2. This result shows strong genetic linkage to this locus. CONCLUSIONS: We present the first genetic linkage analysis result in a pure intracranial arachnoid cyst family in literature. Further investigation of this linkage area can reveal a causative gene causing the intracranial arachnoid cyst phenotype and can illuminate the pathogenesis of this disease.