Full-Endoscopic Surgery for Hypothalamic Hamartoma Resection

Hypothalamic hamartomas (HH) are rare developmental anomalies of the inferior hypothalamus that often cause refractory epilepsy, including gelastic seizures. Surgical resection is an effective method to treat drug-resistant epilepsy and endocrinopathy in a suitable patient group. Open surgery, endoscopic surgery, ablative procedures, and stereotactic radiosurgery can be utilized. In this study, we aimed to describe the full-endoscopic approach for HH resection. The technique involves the use of an intraoperative ultrasonography (USG) system, a 30° rigid endoscope system that has an outside diameter of 2.7 mm with two working channels, a stylet that has an outer diameter of 3.8 mm, a monopolar coagulation electrode, a fiberoptic light guide, and the endovision system. Microforceps and monopolar electrocautery are the two main surgical instruments for HH removal. The protocol is easy to apply after a particular learning curve has been passed and shorter than open surgical approaches. It leads to less blood loss. Full-endoscopic surgery for HH is a minimally invasive technique that can be applied safely and effectively with good seizure and endocrinological outcomes. It provides low surgical site pain and early mobilization.

Full-Endoscopic Technique for Posterior Fossa Decompression in Chiari Malformation

BACKGROUND AND IMPORTANCE

Full-endoscopic techniques are well-described for spinal procedures. Although endoscopic-assisted techniques are reported for posterior fossa decompression (PFD) in Chiari malformation (CM), a full-endoscopic technique is yet to be reported in these patients. The aim of this study was to present and describe a full-endoscopic technique for PFD in patients with CM.

CLINICAL PRESENTATION

Two patients diagnosed with CM were operated on by the full-endoscopic PFD technique. The patients consented to the procedure and to the publication of their image. An endoscope with an oval shaft cross-section with a diameter of 9.3 mm, a working length of 177 mm, a viewing angle of 20°, and a working channel of 5.6 diameters were used. Operative videos were recorded. The surgical steps were easily applied after the clear anatomic landmarks, such as the C1 posterior tubercle and the rectus capitis posterior minor muscles. The patients were followed up for 6 months. Both patients were symptom-free with a significant decrease in Visual Analog Scale score and a good functional outcome assessed by Chicago Chiari Outcome Scale after surgery without any complications.

CONCLUSION

All the steps of the full-endoscopic technique for PFD described by the authors in their previous human cadaveric study were also feasible on patients with CM.

Intraoperative ultrasound-guided ventricular cannulation in patients with normal-sized ventricles

INTRODUCTION

Many pathologies require normal-sized ventricle cannulation, which may be technically challenging even with neuronavigation guidance. This study presents a series of ventricular cannulation of normal-sized ventricles using intraoperative ultrasound (iUS) guidance and the outcomes of patients treated by this technique, for the first time.

METHODS

The study included patients who underwent ultrasound-guided ventricular cannulation of normal-sized ventricles (either ventriculoperitoneal (VP) shunting or Ommaya reservoir) between January 2020 and June 2022. All patients underwent iUS-guided ventricular cannulation from the right Kocher's point. The inclusion criteria for normal-sized ventricles were as follows: (1) Evans index <30%, and (2) widest third ventricle diameter <6mm. Medical records and pre-, intra- and post-operative imaging were retrospectively analyzed.

RESULTS

Nine of the 18 included patients underwent VP shunt placement; 6 had idiopathic intracranial hypertension (IIH), 2 had resistant cerebrospinal fluid fistula following posterior fossa surgery, and 1 had iatrogenic intracranial pressure elevation following foramen magnum decompression. Nine patients underwent Ommaya reservoir implantation, 6 of whom had breast carcinoma and leptomeningeal metastases and 3 hematologic disease and leptomeningeal infiltration. All catheter tip positions were achieved in a single attempt, and none were placed suboptimally. Mean follow-up was 10 months. One IIH patient (5.5%) had early shunt infection which necessitated shunt removal.

CONCLUSION

iUS is a simple and safe method for accurate cannulation of normal-sized ventricles. It provides an effective real-time guidance option for challenging punctures.

Corrigendum: Full-endoscopic removal of third ventricular colloid cysts: technique, results, and limitations

[This corrects the article DOI: 10.3389/FSURG.2023.1174144.].

Full-endoscopic removal of third ventricular colloid cysts: technique, results, and limitations

Introduction

Colloid cysts (CCs) are rare benign lesions that usually arise from the roof of the third ventricle. They may present with obstructive hydrocephalus and cause sudden death. Treatment options include ventriculoperitoneal shunting, cyst aspiration, and cyst resection microscopically or endoscopically. This study aims to report and discuss the full-endoscopic technique for removing colloid cysts.

Materials and methods

A 25°-angled neuroendoscope with an internal working channel diameter of 3.1 mm and a length of 122 mm is used. The authors described the technique of resecting a colloid cyst by a full-endoscopic procedure and evaluated the surgical, clinical, and radiological results.

Results

Twenty-one consecutive patients underwent an operation with a transfrontal full-endoscopic approach. The swiveling technique (grasping the cyst wall and rotational movements) was used for CC resection. Of these patients, 11 were female, and ten were male (mean age, 41 years). The most frequent initial symptom was a headache. The mean cyst diameter was 13.9 mm. Thirteen patients had hydrocephalus at admission, and one needed shunting after cyst resection. Seventeen patients (81%) underwent total resection; 3 (14%), subtotal resection; and 1 (5%), partial resection. There was no mortality; one patient had permanent hemiplegia, and one had meningitis. The mean follow-up period was 14 months.

Conclusion

Even though microscopic resection of cysts has been widely used as a gold standard, successful endoscopic removal has been described recently with lower complication rates. Applying angled endoscopy with different techniques is essential for total resection. Our study is the first case series to show the outcomes of the swiveling technique with low recurrence and complication rates.

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other conventional discectomy methods, including less traumatization of the soft tissues, fewer complication rates (dural injury, bleeding), rapid rehabilitation, quick return to daily life activities, and preferable cosmetic results. FEILA is a surgery with a relatively steep learning adaptation. Endoscopic surgery is a closed tubular approach, and all surgical maneuvers are performed within a uniportal single working channel. Also, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons. Despite these, FEILA is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy. FEILA for lumbar discectomy could be considered a safe and effective alternative procedure for paracentral L5-S1 disc herniation. Here, we describe the technique of FEILA, including every cutoff step required to reach technical proficiency for surgeons who want to start applying this approach.

The effect of halofuginone use on epidural fibrosis after spinal surgery: An animal experiment

AIM

Epidural fibrosis (EF) can cause persistent low back pain after spinal surgery. Type I collagen is the main component of scar tissue formed after spinal surgery, and an antifibrotic agent is necessary for preventing fibrosis. Halofuginone is an antifibrotic agent that has an effect on type I collagen. Our study aimed to investigate the effectiveness of local halofuginone application for spinal EF after lumbar laminectomy in rats.

MATERIAL AND METHODS

Forty rats were equally divided into four groups (Groups I-IV; 10 rats in each group), and lumbar laminectomy was performed under general anesthesia. After laminectomy, Group I received saline (NaCl 0.9%) locally (control), Group II received spongostan, Group III received 0.5 mL of halofuginone-impregnated spongostan, and Group IV received 0.5 mL of halofuginone. Spongostan was used to prolong the exposure period of halofuginone. All rats were sacrificed after four weeks and evaluated according to histopathological criteria. A p-value of 0.05 was considered statistically significant.

RESULTS

Fibrosis was significantly lower in Group IV than in Group I (p 0.05). There was no significant difference in fibrosis between Group II/III and Group I. It was observed that spongostan increased fibrosis.

CONCLUSION

Halofuginone helps prevent EF after spinal surgery. However, further clinical and experimental studies are needed to assess its safety in humans.

Full-endoscopic technique for posterior fossa decompression in Chiari malformation type I: An anatomical feasibility study in human cadavers

Although endoscope-assisted techniques have been described, a full-endoscopic approach is yet to be performed for posterior fossa decompression (PFD) in Chiari malformation type I (CM-I). This study aims to describe the full-endoscopic PFD technique and evaluate its feasibility. Five fresh-frozen anonymized adult human cadavers were operated on using an endoscope with an oval shaft cross-section with a diameter of 9.3 mm, a working length of 177 mm, and a viewing angle of 20°. It also had an eccentric working channel with a diameter of 5.6 mm, a light guide, a sheath for continuous irrigation, and a rod lens system. The instruments were introduced from the working channel. Posterior craniocervical structures were dissected, and PFD was achieved. The planned steps were performed in all five cadavers. The endoscope was introduced to the posterior craniocervical region, dissecting the structures to easily expose the suboccipital bone and C1 posterior arch. Important structures, such as the C1 posterior tubercle, rectus capitis posterior minor muscles, and posterior atlantooccipital membrane, were used as landmarks. PFD was feasible even with the dural opening. Using the full-endoscopic approach, posterior craniocervical structures can be reached, and PFD can be performed successfully. The instruments used are well-defined for spinal usage; thus, this full-endoscopic technique can be widely used in the surgical treatment of patients with CM-I.

Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment

INTRODUCTION

Relatively constant surgical risks and rapid advances in endovascular treatment have caused a major shift toward endovascular management of posterior circulation aneurysms. This paper presents the results of a series of endovascularly treated posterior circulation aneurysms.

METHODS

A total of 81 patients who underwent endovascular treatment of posterior circulation aneurysms performed by a single team between 2009 and 2019 were included. Demographic, clinical, radiologic, and management details were retrospectively obtained from hospital records.

RESULTS

Among the included patients, 50 (61.7%) and 31 (38.3%) were female and male, respectively. Subarachnoid hemorrhage was observed in 30 patients (37%). Moreover, 40 (49.3%) aneurysms were treated with stent-assisted coiling, 1 (1.2%) aneurysm was treated with parent artery occlusion, 2 (2.4%) aneurysms were coiled using balloon assistance, 24 (29.6%) aneurysms were coiled primarily, 1 (1.2%) patient had an unsuccessful treatment attempt, and 13 (16.0%) aneurysms were treated with flow-diverter stents or stent monotherapy. During the last follow-up, 57 (83.8%) aneurysms were completely occluded, whereas 6 (8.8%) and 2 (2.9%) aneurysms did and did not have a residual neck, respectively. Flow diversion was used to treat 13 patients, among whom 8 had total occlusion or stable residue. A total of 7 deaths (8.6%) were encountered in this series.

CONCLUSION

Endovascular treatment should be considered as the primary treatment modality for posterior circulation aneurysms. Despite the high morbidity and mortality rates, promising results can be achieved with correct patient selection. Flow diversion can be a feasible alternative for complex aneurysms that are difficult to treat.

Versatile Use of Intraoperative Ultrasound Guidance for Brain Puncture

BACKGROUND

Intraoperative ultrasound (iUS) is an effective guidance and imaging system commonly used in neuro-oncological surgery. Despite the versatility of iUS, its utility for single burr hole puncture guidance remains fairly underappreciated.

OBJECTIVE

To highlight the simplicity, versatility, and effectiveness of iUS guidance in brain puncture by presenting the current case series and technical note collection.

METHODS

We present 4 novel uses of iUS guidance for single burr hole brain puncture: cannulation of normal-sized ventricles, endoscopic third ventriculostomy (ETV) guidance, evacuation of interhemispheric empyema, and stereotactic biopsy assistance.

RESULTS

All techniques were performed successfully in a total of 16 patients. Normal-sized ventricles were cannulated in 7 patients, among whom 5 underwent Ommaya reservoir placement and 2 underwent ventriculoperitoneal shunt placement for idiopathic intracranial hypertension. No more than 1 attempt was needed for cannulation. All ventricular tip positions were optimal as shown by postoperative imaging. iUS guidance was used in 5 ETV procedures. The working cannula was successfully introduced to the lateral ventricle, providing the optimal trajectory to the third ventricular floor in these cases. Interhemispheric subdural empyema was aspirated with iUS guidance in 1 patient. Volume reduction was clearly visible, allowing near-total evacuation of the empyema. iUS guidance was used for assistive purposes during stereotactic biopsy in 3 patients. No major perioperative complications were observed throughout this series.

CONCLUSION

iUS is an effective and versatile guidance system that allows for real-time imaging and can be easily and safely employed for various brain puncture procedures.

A single-center experience of transsphenoidal endoscopic surgery for acromegaly in 73 patients: results and predictive factors for remission

BACKGROUND

Transsphenoidal endoscopic surgery is the first-line treatment for growth hormone-secreting adenomas.

OBJECTIVE

To analyse the results of the transsphenoidal endoscopic approach for acromegaly and to determine the predictive factors of remission.

METHODS

A single-centre retrospective review was performed in patients who underwent endoscopic transsphenoidal surgery for acromegaly between January 2009 and January 2019. Demographic features, clinical presentation, histopathology records, complications and pre- and postoperative radiologic and endocrinological assessments were evaluated. The factors that influenced the remission rates were investigated.

RESULTS

A total of 73 patients underwent surgery via the transsphenoidal endoscopic approach. Cavernous sinus invasion was detected in 32 patients (43.8%); and macroadenoma, in 57 (78%). The pathology specimens of the 27 patients (36.9%) showed dual-staining adenomas with prolactin. A total of 51 patients (69.8%) attained biochemical remission 1 year after surgery. A second operation was performed in 10 patients (13.6%) with residual tumours without biochemical remission in the first year. Six (60%) of the patients attained remission at the last follow-up. Transient diabetes insipidus was observed in 18 patients (24.6%); and rhinorrhoea, which was resolved with conservative treatment, in 4 (5.4%). None of the patients developed panhypopituitarism. The presence of cavernous sinus invasion and preoperative IGF-1, immediate postoperative GH and third-month IGF-1 levels were predictive of remission.

CONCLUSION

Transsphenoidal endoscopic surgery is a safe and effective treatment for acromegaly. Reoperation should be considered in patients with residual tumours without remission.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival

BACKGROUND

In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival.

METHODS

Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated.

RESULTS

Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006).

CONCLUSIONS

Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

SURGICAL TREATMENT IN REFRACTORY EPILEPSY: SEIZURE OUTCOME RESULTS BASED ON INVASIVE EEG MONITORIZATION

AIM

Epilepsy surgery is an effective treatment in patients suffering from refractory epilepsy. In this study, the aim is to discuss seizure outcomes of patients, who had had invasive EEG monitorization (IEM), following their epilepsy surgery at our centre.

MATERIAL AND METHODS

Forty-seven patients suffering from refractory epilepsy and who were evaluated by invasive EEG were included in this retrospective study at Istanbul Faculty of Medicine from 2003 to 2017. We examined the Video EEG and invasive EEG monitorization, cranial MRI, SPECT, PET and neuropsychological tests of all patients. Moreover, postoperative seizure outcome results were evaluated according to Engel classification. The factors affecting seizure outcome were discussed.

RESULTS

Twenty-six of the patients were female (55.3%), 21 were male (44.7). The average age were 32.0 (±12.4). Forty-three patients had surgery and the average age of these patients was 26,6 (±11,15). 38.3% of the patients had hippocampal sclerosis (HS), 23.4% had focal cortical dysplasia (FCD), 8.5% had tumor, 14.9% had sequela lesion and 14.9% had unknown etiology. Postoperative seizure status according to the Engel classification showed that 81.6% of the patients were class I, 10.5% were class II, 2,6% were class III and 5,3% were class IV.

CONCLUSION

A significant relation was statistically determined between structural MRI lesion and favorable seizure outcome (p 0.05). The most frequent etiology was HS in our patients. Of the patients with Engel I, the averages of their ages, ages at onset of epilepsy and ages at surgery were lower than other groups; but the difference was not statistically significant (p 0.05). We argue that IEM is an essential examination for favorable outcome for the determination of epileptogenic zone and/or the proximity of the functional structures.

Comprehensive Anatomic and Morphometric Analyses of Triangular Working Zone for Transforaminal Endoscopic Approach in Lumbar Spine: A Fresh Cadaveric Study

OBJECTIVE

The aim of this study is to provide essential information for endoscopic transforaminal approach by performing morphometric analysis of the triangular working zone (TWZ) in fresh cadavers.

METHODS

Fifteen fresh human cadavers (9 women and 6 men) with no history of spinal surgery were used in this study. Anatomic dissection of 150 foraminal levels were performed. Significant surgical landmarks constructing TWZ were measured bilaterally from L1-2 to L5-S1 on 15 fresh cadavers. The relationship between traversing roots and intervertebral discs was defined.

RESULTS

Base, height, and hypotenuse measurements of TWZ were longer as the level lowered. Mean base height and hypotenuse of TWZ were 12.15 mm, 11.29 mm, and 16.69 mm (L1-2); 17.94 mm, 17.18 mm, and 28.03 mm (L5-S1), respectively. TWZ was triangular shaped at the upper lumbar levels (L1-2, L2-3, and L3-4), and trapezoid at the lower lumbar levels (L4-5 and L5-S1). Going down the levels, the exiting root angle was narrower, the mean exiting angle of the L5 root being 28.23°. All L2 and L3 traversing roots and nearly all L4 traversing roots (86.7%) originated from below the disc level. Forty percent of L5 traversing roots originated above the disc level, and 53.3% originated at the disc level. Most S1 traversing roots originated at the proximal margin of the disc level (80%).

CONCLUSIONS

Our study reveals a detailed morphometric analysis of TWZ. Understanding the foraminal anatomy is crucial for safely performing transforaminal endoscopic surgery. The learning curve of transforaminal surgery can be reduced by garnering knowledge of TWZ anatomy.

Clinical Study of Decompressive Craniectomy in Children

AIM

To evaluate the clinical characteristics of children who recently underwent decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) correlated to head trauma or other causes, such as ischemic insult.

MATERIAL AND METHODS

Twelve patients aged ≤17 years who underwent DC due to elevated ICP between 2013 and 2018 were included in the study. The clinical status of the participants, radiological characteristics, type and timing of surgery, and outcomes were recorded.

RESULTS

Three female and nine male patients with a mean age of 10 years were included. The initial average Glasgow Coma Scale score was 6 (3-12). All patients presented with signs of diffuse cerebral edema and subdural hematoma of various sizes along with other intracranial pathologies. Only one patient required bilateral frontal craniectomy. In the postoperative period, three patients died, and three had severe disability.

CONCLUSION

With the increasing use and success of DC in adults, this procedure can also be effective in children. Considering brain differences in children, large and well-structured clinical trials must be conducted to prevent complications and to identify the best technique, timing, and benefits of DC for children.

Gray-to-white matter ratio predicts long-term recovery potential of patients with aneurysmal subarachnoid hemorrhage

Predicting recovery potential of patients with aneurysmal subarachnoid hemorrhage (aSAH) is challenging. We investigated whether the gray-to-white matter ratio (GWR) predicts recovery of cognitive function (CF) and quality of life (QOL) of these patients. We analyzed data of 69 patients with aSAH. Patients' demographics, comorbidities, and neurological status were recorded. One year after aSAH, Montreal Cognitive Assessment (MoCA) and Short Form-36 (SF-36) tests were administered to the patients, and brain volumes of patients were examined using MRI. Three years after aSAH, MoCA and SF-36 tests were conducted again. Differences between the test scores 1 and 3 years after aSAH were evaluated (ΔMoCA and ΔSF-36). Patients with ΔMoCA ≥ 4 points and those with ΔSF-36 ≥ 8 points were referred to as good MoCA and SF-36 recovery, respectively. ΔMoCA correlated with GWR in male and female patients (females: p < 0.001, R² = 0.581; males: p < 0.001, R² = 0.481). In female patients, GWR > 1.34 predicted good MoCA recovery with 82.3% sensitivity and 80% specificity, and in male patients, GWR > 1.36 predicted good MoCA recovery with 80% sensitivity and 95% specificity. ΔSF-36 correlated with GWR in male and female patients (females: p < 0.001, R² = 0.479; males: p < 0.001, R² = 0.627). In female patients, GWR > 1.35 predicted good SF-36 recovery with 74% sensitivity and 84% specificity, and in male patients, GWR > 1.38 predicted good SF-36 recovery with 72% sensitivity and 92% specificity. GWR is a good predictor of the recovery of CF and QOL in patients with aSAH and, thus, can help physicians to better organize rehabilitation of patients.

Characterization of Hand Clenching in Human Sensorimotor Cortex Using High-, and Ultra-High Frequency Band Modulations of Electrocorticogram

Functional mapping of eloquent cortex before the resection of a tumor is a critical procedure for optimizing survival and quality of life. In order to locate the hand area of the motor cortex in two patients with low-grade gliomas (LGG), we recorded electrocorticogram (ECoG) from a 113 channel hybrid high-density grid (64 large contacts with diameter of 2.7 mm and 49 small contacts with diameter of 1 mm) while they executed hand clenching movements. We investigated the spatio-spectral characteristics of the neural oscillatory activity and observed that, in both patients, the hand movements were consistently associated with a wide spread power decrease in the low frequency band (LFB: 8–32 Hz) and a more localized power increase in the high frequency band (HFB: 60–280 Hz) within the sensorimotor region. Importantly, we observed significant power increase in the ultra-high frequency band (UFB: 300–800 Hz) during hand movements of both patients within a restricted cortical region close to the central sulcus, and the motor cortical “hand knob.” Among all frequency bands we studied, the UFB modulations were closest to the central sulcus and direct cortical stimulation (DCS) positive site. Both HFB and UFB modulations exhibited different timing characteristics at different locations. Power increase in HFB and UFB starting before movement onset was observed mostly at the anterior part of the activated cortical region. In addition, the spatial patterns in HFB and UFB indicated a probable postcentral shift of the hand motor function in one of the patients. We also compared the task related subband modulations captured by the small and large contacts in our hybrid grid. We did not find any significant difference in terms of band power changes. This study shows initial evidence that event-driven neural oscillatory activity recorded from ECoG can reach up to 800 Hz. The spatial distribution of UFB oscillations was found to be more focalized and closer to the central sulcus compared to LFB and HFB. More studies are needed to characterize further the functional significance of UFB relative to LFB and HFB.

Memantine and Q-VD-OPh Treatments in Experimental Spinal Cord Injury: Combined Inhibition of Necrosis and Apoptosis

AIM

To evaluate the effects of NMDA receptor antagonist memantine and pancaspase inhibitor Q-VD-Oph in combination or alone in experimental spinal cord injury.

MATERIAL AND METHODS

45 male Sprague-Dawley rats were divided into five groups. Spinal cord injury was created with the clip compression technique. The drugs were administered either alone of in combination to the subjects according to their groups. Motor function was assessed with Tarlov's motor grading scale and the inclined plane technique. The subjects were sacrificed at the fifth postoperative day. Histopathological examination was done with the use of hematoxylin eosin and TUNEL staining.

RESULTS

The results for TUNEL staining and apoptotic cell counts revealed statistically significant differences in Q-VD-Oph and combined treatment groups. Tarlov motor grading scale and inclined plane test results were also found significantly better in these two groups.

CONCLUSION

Combined use of memantine and Q-VD-OPh provides better histological and clinical results. The combined inhibition of the two major pathways, necrosis and apoptosis, needs to be further assessed with in-vivo or in-vitro studies.

Surgery for Pyogenic Brain Abscess over 30 Years: Evaluation of the Roles of Aspiration and Craniotomy

AIM

To evaluate the roles of craniotomy and aspiration in the treatment of pyogenic brain abscess throughout 30 years of computerized tomography.

MATERIAL AND METHODS

A retrospective study of 224 patients who were surgically treated at Istanbul Medical Faculty, Department of Neurosurgery between 1982 and 2012 was undertaken. The records were analyzed for demographic, clinical and radiological findings, surgical interventions (resection, free-hand aspiration and image-guided aspiration), data regarding abscesses (etiological factors, site, size, number, localization and identified microorganism), corticosteroid and antibiotic usage and complications, and the outcomes were reviewed.

RESULTS

The male-to-female ratio was 2.2, and the mean age was 26.2±1.25 years. The most common presenting symptom was headache (56.7%), followed by nausea and vomiting (28.5%). Otitis media and mastoiditis were the most common causes of abscess (41.9%), and 44 patients had multiple abscesses. Aerobic gram-positive microorganisms were the most frequently isolated pathogens in culture (51.5%). Primary surgical interventions were as follows: craniotomy and resection (38.8%), free-hand aspiration (49.1%) and image-guided aspiration (12.1%). The aspiration-to-resection ratio was 1.36 (64/47) in the first decade, 2.94 (50/17) in the second decade and 1 (23/23) in the last decade. Age, level of consciousness at the time of admission and potent corticosteroid usage were found to be significantly associated with mortality (p=0.001, p≤0.001 and p=0,038, respectively). The total morbidity and mortality ratios were 4.9% and 9.8%, respectively. Seizures were more common in patients of craniotomy group (p=0.023).

CONCLUSION

Treatment of pyogenic brain abscess remains challenging, despite advances in surgical and imaging technology, and craniotomy retains a significant role in surgical treatment.

Metabolic changes and factors influencing base deficit in infants undergoing craniosynostosis surgery: a retrospective study

BACKGROUND

Corrective craniosynostosis surgery is often associated with a large amount of blood loss and metabolic disturbances. In the present study, we investigated the severity, duration of metabolic disturbances, and causal risk factors in infants.

METHODS

A retrospective analysis was performed of 36 infants who underwent craniosynostosis surgery. We analyzed the following: demographics, duration of surgery, intraoperative blood loss, RBC, FFP and fluids transfused, urine output, hemodynamic parameters, and electrolyte and base deficit (BD) values. The lowest intraoperative BD value and time required (period I: <6 h; period II: 6-12 h; period III: >12 h) for BD values to return to normal (-4 to +2) in the postoperative period were determined. In addition, we recorded the postoperative length of stay in the ICU and hospital, postoperative blood loss, and early complications.

RESULTS

We detected that 88% of the patients had subnormal BD levels and 22% had metabolic acidosis. The lowest average BD measured during the operation was -8.4 ± 2.6 mmol/l. We carried out a multiple regression analysis, which revealed that lower BD values were associated with a longer duration of hypotension (p = 0.002, R(2) = 0.453) and greater intraoperative blood loss (p = 0.002, R(2) = 0.674). We examined the amount of intraoperative blood loss and found that that there were fewer blood product transfusions in period I patients and longer hypotensive episodes in period III patients. Also, a negative correlation was detected between the lowest intraoperative BD value with ICU duration (p = 0.004, r = -0.466) and hospital stay (p < 0.001, r = -0.764).

CONCLUSION

Almost all patients developed intraoperative negative BD, which was prolonged in the postoperative period. The most important risk factors for developing negative BD are the amount of blood loss and duration of hypotension.

Neuronavigation-assisted percutaneous balloon compression for the treatment of trigeminal neuralgia: The technique and short-term clinical results

BACKGROUND

Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia. However, this technique has a steep learning curve and significant complications were reported that were related to foramen ovale puncturing. The aim of this study was to evaluate the clinical results of a small patient group who underwent neuronavigation-assisted PBC.

METHODS

An intraoperative computed tomography (CT) device (CereTom, Neurologica, Danvers, MA/USA) was used to obtain CT scans with 2-mm slice thicknesses. The data were transferred to a neuronavigation system planning station (BrainLab, Feldkirchen, Germany). A soft touch registration system was used for image registration. With the image guidance, a trajectory was defined and the foramen ovale was cannulated using neuronavigation and Hartel's landmarks.

RESULTS

Sixteen procedures were performed on 13 patients (4 female and 9 male) without complications. The total length of the procedure was not more than 57 min in all instances.

CONCLUSIONS

We believe that image-guided neuronavigation is useful for neurosurgeons who are at the beginning of their PBC learning curve. It may also be an alternative for particular patients with significant anatomic variations that result in an unsuccessful foramen ovale puncture.

Unilateral endoscopic optic nerve decompression for idiopathic intracranial hypertension: a series of 10 patients

OBJECTIVE

Several surgical treatment modalities, including lumboperitoneal or ventriculoperitoneal shunt surgery, subtemporal decompression, endovascular venous sinus stenting, optic nerve decompression (OND), were used in the management of idiopathic intracranial hypertension (IIH). Each surgical technique has different advantages and disadvantages. Endoscopic OND is rarely used in the management of IIH. There are only four reported cases. The aim of this study is to describe the surgical results of patients treated with this less invasive surgical technique.

METHODS

A series of 10 consecutive cases of unilateral OND was reviewed. Between December 2008 and December 2012 these patients underwent the endoscopic approach without nerve sheath opening. Presenting symptoms, neurological examination findings, magnetic resonance venography imaging results, fundoscopic and visual acuity examination findings, and automated perimetry test results were recorded. Perioperative results, including complications and length of hospital stay, were evaluated. Findings at follow-up evaluations were also recorded.

RESULTS

This report is the first series of unilateral OND performed using the endoscopic approach. The mean patient age was 34.1 years (range, 9-49 years); there were nine female and one male patients. Visual impairment was the main symptom in this patient group, whereas headache was a secondary complaint. The patients were first managed with medical treatment for at least 3 months. Unilateral endoscopic OND was performed on the side with the most visual failure. Mean follow-up was 28.4 months (range, 8-55 months). The visual field defects and visual acuity improved in eight of nine patients, whereas papilloedema improved in seven of nine patients. Also headaches resolved in four of seven patients. There were no complications in this relatively small series.

CONCLUSIONS

The surgical treatment of IIH by using the unilateral endoscopic OND technique is a safe and effective method in the hands of experienced surgeons with advanced endoscopic skills. A collaboration with the ophthalmology team is needed for the follow-up. Further studies with larger patient numbers is needed to compare unilateral endoscopic OND technique with the current techniques used in the surgical management of IIH.

Effects of sodium hyaluronate and methylprednisolone alone or in combination in preventing epidural fibrosis

OBJECTIVE

Epidural fibrosis and leptomeningeal adhesion formation are common causes of failed back surgery syndrome (FBSS). We employed a rat model of lumbar laminectomy to evaluate the histopathological effects of sodium hyaluronate (HA) and methylprednisolone (MP) alone or in combination on post-laminectomy epidural fibrosis.

METHODS

Thirty-two male Sprague-Dawley rats were divided into four groups. All rats underwent three-level lumbar laminectomy. In the treatment groups, HA solution, MP, or a combination of both was applied locally to the epidural spaces of the laminectomy fields. No neurological deficits or pathological wound site changes were observed in any of the groups. At the end of the sixth week, all rats were sacrificed, and the laminectomy vertebral column areas were removed en-bloc. Specimens were evaluated by an expert neuropathologist according to histopathological criteria.

RESULTS

The results of the three treatment groups were separately compared with the control group to assess epidural fibrosis. Minimal reduction in the rate of epidural fibrosis was observed in the groups treated with HA or MP compared with the control group. However, no significant difference in epidural fibrosis was noted between the combined treatment group and the control group.

CONCLUSIONS

Our study showed that MP and HA, given separately, significantly reduce post-laminectomy epidural fibrosis; however, the combination of these drugs is not effective. Further investigation is needed to address the causative drug interactions.

Factors influencing blood loss and postoperative morbidity in children undergoing craniosynostosis surgery: a retrospective study

BACKGROUND

Craniosynostosis is a condition resulting from the premature fusion of cranial sutures. Corrective surgery is often associated with a large amount of blood loss, with transfusion of red blood cells (RBC) and fresh frozen plasma (FFP). The aims of this study were to determine the variables associated with increased blood loss and postoperative complications.

METHODS

A retrospective analysis was performed of 42 pediatric patients who underwent craniosynostosis surgery. We analyzed the following: demographic parameters, duration of surgery, intraoperative blood loss, RBC, FFP and fluid transfusion, urine output, and hemodynamic parameters. In addition, we recorded the postoperative length of stay in the intensive care unit and hospital, postoperative blood loss and early complications.

RESULTS

The mean age, weight and surgical duration were 9.2 ± 3.2 months, 9.3 ± 2.0 kg and 255.8 ± 46.7 min, respectively. Intraoperative blood loss was 61.2 ± 15.3 ml/kg and RBC, FFP and fluid transfusion were 27.3 ± 7.1 ml/kg, 16.5 ± 4.7 ml/kg and 21.7 ± 4.6 ml/kg/h, respectively. Greater intraoperative blood loss was associated with longer surgical duration (p = 0.001, correlation coefficient = 0.495, R2 = 0.245) and lower patient weight (p < 0.001, correlation coefficient = -0.557, R2 = 0.311). Longer hospital stay was associated with greater intraoperative blood loss (p < 0.001, correlation coefficient = 0.754, R2 = 0.568) and greater intraoperative RBC transfusion (p < 0.001, correlation coefficient = 0.795, R2 = 0.632).

CONCLUSION

Severe blood loss occurred in all children who underwent craniosynostotic corrections. Furthermore, the duration of surgery, patient weight and certain surgical procedures correlated with greater blood loss. Careful hemodynamic monitoring and evaluation of a patient's hematocrit value and volume status together may be helpful in maintaining the balance between insufficient and excessive blood product transfusion.

Effect of lumbar puncture in patients with aneurysmal subarachnoid hemorrhage treated microsurgically or endovascularly

OBJECTIVE

The aim of this study was to evaluate the effect of treatment modality (surgical clipping vs. endovascular coiling) and lumbar puncture (LP) in patients with aneurysmal subarachnoid hemorrhage (SAH) based on neurologic status on admission and clinical outcome.

PATIENTS AND METHODS

One hundred forty-eight consecutive patients with ruptured intracranial aneurysms treated via endovascular or surgical methods were included in our study. Patients who refused further therapy or received only supportive therapy because of bad neurologic status were excluded. Severity of SAH was evaluated using the Fisher score. World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess (H&H) scores were used for evaluation of neurologic status. Glasgow Outcome Scale scores and modified Rankin scores were used for outcome evaluation.

RESULTS

We found that modified Rankin scores were significantly lower in the surgical clipping group (1.1 ± 1.4) than in the endovascular coiling group (1.7 ± 1.8) (p: 0.04). The positive lumbar puncture [LP(+)] group had similar outcome scores as the negative lumbar puncture [LP(-)] group, although the LP(+) group had worse initial SAH evaluation scores (WFNS 1.64 ± 0.95-1.23 ± 0.61, p: 0.0004 and H&H 2.18 ± 1.07-1.65 ± 0.88, p: 0.001).

CONCLUSION

Surgical clipping might improve clinical outcome better than endovascular coiling, although a more confident conclusion requires absolute randomization of patients for both treatments. LP could also improve clinical outcome in patients with high initial SAH evaluation scores.

Ascending transaqueductal cystoventriculoperitoneal shunting in Dandy-Walker malformation: technical note

The optimal treatment for Dandy-Walker malformation is still controversial. Ventriculoperitoneal shunting, cystoperitoneal shunting or combinations are the most common surgical options in the management of this clinical entity. Endoscopic procedures like ventriculocystostomy, 3rd ventriculostomy or endoscopy-assisted shunt surgeries have become the focus of recent publications. We describe a new transcystic endoscopic technique, with the usage of a single ascending transaqueductal shunt catheter with additional holes, whereby both the posterior fossa cyst and supratentorial ventricular compartments are drained effectively. By using this new technique complications associated with combined shunting can be avoided. In addition, by equalizing the pressure within the supra- and infratentorial compartments, the upward or downward herniations associated with single-catheter shunting can be prevented.

Clinical, pathological and radiological features of paraspinal textiloma: report of two cases and review of the literature

Textiloma is a term used for retained cottonoid or surgical sponge in the operation field. Although they occur mostly after thoracic or abdominal operation, they can also be encountered after surgery of extremities or the spine. There are few reports of spinal cases in which MR and CT imaging findings of textilomas have been described. In this report, two additional cases with MR, CT and pathological features of paraspinal textilomas are described. CT image demonstrated a paraspinal mass simulating a malignant tumour. While T1-weighted MR images showed the masses with low signal intensity, T2-weighted MR images showed heterogeneous masses with low and high signal intensities.

The redundant nerve root syndrome of the Cauda equina

The redundant nerve root syndrome is defined as the association of high-grade extradural lumbar spinal stenosis with large, elongated and tortuous nerve roots. Acquired elongation of nerve roots due to the mechanical trapping at the level of lumbar spinal stenosis is assumed to be the possible mechanism. It is believed that the cause is a squeezing force due to the chronic compression. The most common clinical symptoms are low back pain and leg pain. Although lumbar spinal canal stenosis is common, the entity has rarely been discussed in the literature. Here we present the MR imaging and intraoperative appearance of the condition with a brief discussion in a 71-year-old woman.