Bulent Canbaz

Duraplasty Using Autologous Fascia Lata Reenforced by On-site Pedicled Muscle Flap: Technical Note

Objective Postoperative cerebrospinal fluid (CSF) leak is a common complication in the practice of neurosurgery, and various surgical techniques were described to overcome and manage this problem. Besides not applying watertight closure of the duraplasty, the inviability and the poor vascularization of the graft and/or the dura (eg, reoperations, multiple operations, or cranial radiotherapy) may lead to delayed healing of the suture site and resultant persistent CSF leaks. We present a simple technique that uses on-site muscle flap with pedicle to supply and vascularize the autologous fascia lata, preserving the viability of the graft and reenforcing its healing ability. Methods We applied this technique in 6 patients with postoperative CSF leaks. After harvesting a fascia lata graft with appropriate size from the patients, the graft was sutured to dural defect in watertight fashion. The suboccipital, temporal, and temporal muscles in 4 patients who had posterior fossa duraplasty, in 1 patient who had pterional craniotomy, and in 1 patient who had subtemporal craniotomy, respectively, were dissected, stretched, and sutured to the fascia graft covering the dura graft suture site and then reinforced by Tisseel fibrin glue (Baxter Healthcare Corporation, Deerfield, IL). Postoperatively, CSF lumbar drain was kept open for 72 hours with pressure wound dressing. The technical nuances are illustrated. Results Cerebrospinal fluid leaks were controlled successfully in 5 patients without recurrence. One patient with posterior fossa duraplasty had recurrence of CSF leak that required reexploration 21 days after the first surgery and a second dural repair in a site distant from the fascia lata attachment. During reexploration intraoperatively, the fascia lata graft was inspected and studied, which has shown the healing of the dura graft site and the graft neovascularization. Conclusions Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap is an effective technique to control CSF leak, especially when dura is poorly vascularized and less viable. The unfortunate recurrence of CSF leak and reexploration in the seventh patient helped us to observe the effectively healed dural defect with profound early postoperative vascularization of the graft, supporting our idea about the effectiveness of this technique.

Expression of hypoxia inducible factor-1α in tumors of patients with glioblastoma multiforme and transitional meningioma

Hypoxia-inducible factor-1 alpha (HIF-1alpha) is the major transcriptional factor involved in the adaptive response to hypoxia. The aim of this study was to assess HIF-1alpha in 22 patients with transitional meningioma (TM) and 26 patients with glioblastoma multiforme (GBM). HIF-1alpha was assessed using a commercially available enzyme-linked immunosorbent assay-based HIF-1 transcription factor assay. Levels of HIF-1alpha in TM and GBM were measured using optical density at 450nm, and median values were found to be 0.35 for TM and 0.37 OD for GBM, respectively. There was no statistically significant difference between the two types of tumor (p=0.264). These findings indicate that HIF-1alpha is elevated in both TM and GBM, suggesting that although hypoxia is one of the most important and powerful stimuli for HIF-1alpha elevation and consequently angiogenesis, other mechanisms may play roles in HIF-1alpha stimulation in benign brain tumors such as TM.

Hydrocephalus and chronically increased intracranial pressure in achondroplasia

Abstract Two achondroplastic children with ventriculomegaly are reported. The patients had no signs of increased intracranial pressure, but in one blindness had previously been detected by the parents. Neuroradiological examinations showed ventriculomegaly in both. Intracranial pressure remained at high levels (20–55 mmHg) preoperatively; ventriculo-peritoneal shunting was performed in both cases, and postoperatively levels fell to normal (5–16 mmHg). The need for the treatment of ventriculomegaly seen in achondroplastic children is analyzed on the basis of these two patients, with a brief review of literature.

Two different surgical techniques for reduction cranioplasty

Abstract Reduction cranioplasty is required in selected patients when macrocephaly interferes with head control, seating, locomotion, and social acceptance. Two different surgical techniques for reduction cranioplasty in two cases of older hydrocephalic patients are described. Emphasis is placed on the basic stages of the procedure.

Expressions of some vital molecules: glioblastoma multiforme versus normal tissues

Abstract Objective: The aim of this study was to assess plasma and/or tissue levels of adhesion and apoptotic molecules, cytokines, nitric oxide metabolites, levels of lipid peroxidation, myeloperoxidase and superoxide dismutase in patients with glioblastoma multiforme and controls. Methods: All the molecules were evaluated in 25 tumors and 30 controls: 15 were normal healthy subjects for plasma and 15 were normal brain tissues that were collected during autopsy. Commercially available kits for measurements were used. Results: Superoxide dismutase was significantly lower in tumors, while all other molecules were significantly elevated compared to the controls (p=0·0001). Superoxide dismutase negatively correlated with plasma interleukin-1beta (p=0·04) and plasma Fas (p=0·016). Plasma intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 correlated positively with plasma 3-nitrotyrosine (p=0·019) and nitrite/nitrate (p=0·019), respectively. Furthermore, plasma interleukin-1beta also positively correlated with plasma nitrite/nitrate (p=0·003). Discussion: These results suggest that there is a complex relationship between pro- and anti-apoptotic molecules in glioblastoma multiforme pathogenesis. Thus, targeting multiple pathways with advanced chemotherapeutic agents or radiotheraupetic regimens following total resections might be helpful in patients with glioblastoma multiforme since preventing a single pathway does not seem to be reasonable.

Lateral sublabial endoscopic approach to foramen ovale: a novel endoscopic technique to access infratemporal fossa.

Objective: Our aim was to define a novel endoscopic approach to selectively access the foramen ovale through the lateral sublabial route. Methods: Lateral sublabial endoscopic approach to the foramen ovale was studied in 3 fresh cadavers. A 2.5-cm sublabial submucosal incision gained access to the foramen ovale through the corridor under the zygomatic process of maxilla and lateral to the pterygoid plate. To display the anatomic principles of the lateral sublabial endoscopic approach, the surgical anatomy of the endoscopic corridor and the neurovascular structures around the foramen ovale were studied and documented. Results: Lateral sublabial endoscopic approach provided access to the foramen ovale and related neurovascular structures at the posterolateral part of the sphenoid bone without any bone resection. The branches of the pterygoid segment of the maxillary artery superficial to the lower and upper heads of the pterygoid muscles were exposed initially through the endoscopic corridor under the zygoma and lateral to the pterygoid plate. The buccal nerve, passing in between the 2 heads of the lateral pterygoid muscle and the lingual and inferior alveolar branches of the V3 segment of the trigeminal nerve, emerging from under the cover of the lower head of the lateral pterygoid muscle were exposed deep to the branches of the maxillary artery. Following the inferior alveolar nerve backward proximally under the lower head of the pterygoid muscle exposes the foramen ovale. Conclusions: Lateral sublabial endoscopic approach, a minimally invasive route to the foramen ovale, requires no bone removal and provides adequate exposure to a hard-to-reach area in the infratemporal fossa. With the advantage of visualizing the distal segment of the maxillary artery and the segments of the mandibular nerve, early in the procedure, the approach can provide a controlled endoscopic manipulation for accessing this region.

Tissue and plasma thioredoxin reductase expressions in patients with glioblastoma multiforme.

BACKGROUND AND STUDY AIMS Thioredoxin reductase (TrxR) is a redox protein that is considered to play a role in tumor progression. The purpose of this study was to assess the expression of TrxR in blood and tumor samples of glioblastoma multiforme (GBM) patients. PATIENTS TrxR levels were evaluated in blood and GBM tissues extracted from 27 patients, in normal brain tissues of 12 autopsy cases, and in blood samples of 12 healthy subjects. The results were compared between tumor and control groups. RESULTS The mean level of TrxR in GBM tissues (74.5 ± 14.9 U/g wet tissue) was remarkably higher than in normal brain tissues (14.8 ± 3.4 U/g wet tissue). The mean TrxR levels in blood were significantly higher in GBM patients (296.3 ± 43.6 U/mL) than in the controls (203.0 ± 11.3 U/mL). CONCLUSIONS These findings suggest that high levels of TrxR may be related to progression of GBM.

Double benefit of long-acting somatostatin analogs in a patient with coexistence of acromegaly and ulcerative colitis

Somatostatin analogs control GH/IGF‐1 excess in acromegaly. Somatostatin receptors also mediate the complex effects of somatostatin on the gastrointestinal tract and may be defensive in inflammatory bowel diseases, such as ulcerative colitis. We present a patient who showed good response to long‐acting octreotide (OCT‐LAR) treatment in terms of both acromegaly and ulcerative colitis (UC).

Management and follow-up results of an incidental thyroid carcinoma in a young woman with ovarian teratoma

Abstract Thyroid cancer in ovarian teratoma is reported to be rare and experiences are limited. A 26-year-old woman had undergone bilateral cystectomy and omentectomy for bilateral cystic adnexial masses. Pathological examination showed 1.5 cm follicular variant papillary thyroid carcinoma on the basis of unilateral mature cystic teratoma. Increased CA-125 and CA19-9 levels decreased to normal reference ranges after surgery, but postoperative magnetic resonance imaging indicated multiple abdominal cystic loci. After total thyroidectomy, high dose I-131 was administered to ablate thyroid tissue. Thereafter, levothyroxine was started to achieve subclinical hyperthyroidism. No iodine uptake was detected in post-therapeutic whole body scan (WBS) other than thyroid bed. This finding supported that tumor did not show dissemination to abdomen. No uptake on the first-year evaluation with low-dose I-131 WBS suggested the complete ablation of the thyroid gland. It is recommended that thyroid carcinoma arising from ectopic thyroid tissue in a teratoma should be managed as thyroid carcinoma in thyroid. However, direct dissemination to contiguous regions in abdomen and hematogenous dissemination to distant organs should be in mind. Radical surgery including total abdominal hysterectomy, bilateral salphingo-oopherectomy, pelvic and paraaortic lymph node excision and thyroidectomy is recommended. Fertility preserving surgery may be the surgical procedure as in the present case.

Endolymphatic Sac Tumor: A Rare Differential Diagnosis in Cerebellopontine Angle Lesions

Endolymphatic sac tumors (ELSTs) extending to the cerebellopontine angle (CPA) are extremely rare and generally misdiagnosed as meningioma or neurinoma. Recognition of such a tumor is of paramount importance, because preoperative strategies may help the surgeon to excise the tumor completely. A case of a CPA tumor that was diagnosed radiologically as meningioma or neurinoma before surgery is reported here. Histopathologically, however, the lesion proved to be an ELST. Any lesion with an unusual appearance on magnetic resonance imaging in the CPA may be an ELST, and the diagnosis should be considered in the differential diagnosis.