Çağatay Önal

Long-Term Follow-Up and Results of Thirty Pediatric Intracranial Hydatid Cysts: Half a Century of Experience in the Department of Neurosurgery of the School of Medicine at the University of Istanbul (1952–2001)

A series of 30 documented cases of intracranial hydatid cyst out of 33 pediatric and 45 total patients admitted to the Department of Neurosurgery of the School of Medicine at Istanbul University within the years 1952–1996 is presented. The pediatric population consisted of 73% of the series. Twenty patients (66%) are alive and well after a follow-up period of 8–45 years (mean 21.5 years). Six patients (20%) died and 4 (13%) were lost to follow-up. There were 3 early postoperative deaths (10%), 2 being in the pre-CT era. In 4 cases (13%), brain involvement was secondary, and 2 cases (7%) had multiple intracranial hydatid cysts. Age ranged from 4 to 16 years, with a mean of 10.4. There were 5 intraventricular (17%) and 2 (7%) intracranial extradural settlements. No children with posterior fossa hydatid cyst, primary skull hydatidosis or concomitant spinal involvement were detected. One patient (3%) presented with ‘rhinorrhea’ which in fact was a hydatid fluid leak. Preoperative pseudocerebellar syndrome, convulsion and extrapyramidal signs were seen in 6 patients each (20%). Five patients (17%) had permanent visual deficits, 3 being in pre-CT era. Out of 29 patients operated on, hydatid birth with intact cyst removal was achieved in 18 cases (62%), with no other manipulation needed. This rate has increased to 70% in the CT era. Intraoperative accidental rupture occurred in 8 cases (28%), of which 7 were localized frontally or had a frontal involvement (88% of the ruptured cases). Of the patients with intraoperative rupture, 5 are dead (63%) and they were all primary. In contrast, all 3 cases alive with intraoperative rupture are secondary. Three cases were punctured on purpose (10%). Four of the operated patients (14%) required long-term antiepileptic therapy, 3 having no preoperative seizures. Only 1 patient required a shunt (3%). Four cases had recurrence, all with intraoperative cyst rupture (14%). The long-term evaluation of the results yielded an overall mortality rate of 21%. Routine use of CT after the 80s decreased the rate to 14%. With the analysis of 50 years of data, it is strongly concluded that brain involvement in pediatric hydatid disease is a primary process if delayed diagnosis and insufficient treatment of extraneural hydatidosis are prevented.

Three Unusual Cases of Intracranial Hydatid Cyst in the Pediatric Age Group

Three unusual cases of hydatid disease with central nervous system involvement are reported in the pediatric age group: a 9-year-old boy with a total number of 12 intracranial secondary hydatid cysts; a 13-year-old girl admitted in areflexia who survived after cyst puncture and successive mass removal, and a 14-year-old boy with a huge intracranial hydatid cyst weighing 770 g which was extracted without rupture. The article discusses the surgical problems, and the related literature is reviewed.

A Serial CT Scan and MRI Verification of Diffuse Cerebrospinal Gliomatosis: A Case Report with Stereotactic Diagnosis and Radiological Confirmation

Gliomatosis cerebri is an infrequent tumor of neuroepithelial origin presenting with deterioration of cognitive functions, behavioral and mental changes, motor weakness, headache, and seizures. Laboratory data are unconclusive. MRI appears to be the imaging modality of choice and mainly reveals a bilateral and diffuse infiltration of midline adjacent brain structures whose anatomical configuration remain intact. MRI- or CT-guided stereotactic biopsy is advised as the diagnostic procedure in suspected cases. A 9-year-old girl with diffuse cerebrospinal gliomatosis, investigated with sequential cranial CT scans, and MRI-verified spinal cord involvement is reported, and the corresponding literature is reviewed.

The effect of intraventricular albumin in experimental brain oedema

SummaryTherapy for vasogenic brain oedema (VBE) is still an unsolved problem. Experimental work with the aim of establishing an oncotherapeutic option is presented.VBE is performed by focal freeze injury in rats. Using a stereotactic head holder hypo- or hyperosmolar human serum albumin is administered via the intraventricular route. The goal is to enhance the migration of oedema fluid with the aid of oncotic pressures. Early and late results are obtained for each group respectively four and twenty-four hours after the infliction of cold injury. The efficacy of therapy is evaluated by cerebrospinal fluid (CSF) osmolality, cerebral water content, tissue specific gravity, and blood-brain barrier (BBB) permeability. Posttherapeutic values for CSF osmolality are obtained by cisterna magna puncture.Hyperosmolar CSF after performance of cold injury (p < 0.05) is thought to be a result of fluid accumulation in the traumatized region partially from the intraventricular space. Posttherapeutic values after hyperosmolar albumin administration have revealed iso-osmolar CSF, increase in specific gravity (p < 0.001), and decrease in BBB permeability (p < 0.05). These results are in accordance with withdrawal of oedema fluid into the ventricles which can be interpreted as a positive therapeutic effect. Late results in hyperosmolar group have disclosed a hypo-iso-osmolar CSF, persistent increase in specific gravity, and no regression. These values have shown that hyperosmolar albumin administration does not interfere with CSF circulation. Early results of hypo-osmolar albumin application are discouraging.This preliminary work of a therapeutic trial on VBE may be a basis for future investigations with different dosages and time modalities.

A high-position basilar top aneurysm approached via third ventricle: case report

The authors report a subfrontal transventricular approach to a high-position basilar top aneurysm considered to be inaccessible by conventional pterional or subtemporal techniques. This special technique may be preferred in the case where a megadolichobasilar artery coexists with such an aneurysm as it has the advantage of protecting the brain from the detrimental effects of strong retraction.

Cervical Hematomyelia: A Rare Entity in a Neonate with Cesarean Section and Surgical Recovery

Spinal cord injury with or without trauma has been reported in the perinatal period. The prognosis depends primarily on diagnosis of the level, extent and nature of the lesion, established by correlations between clinical, imaging and electrophysiological data. A 25-day-old boy with normal birth weight delivered at term by cesarean section was transferred to Inönü University Turgut Özal Medical Center because of respiratory distress and brachial diplegia. A suspicious medullary lesion on cervical computerized tomography was confirmed as an intramedullary lesion extending from C3 to D1 on magnetic resonance imaging (MRI). Emergent surgery consisting of exposure of the lesion site and interlaminar direct puncture of the lesion under fluoroscopy revealed that the pathology was an intramedullary hematoma. The partial evacuation of the lesion with direct puncture, the patient’s neurological improvement and close follow-up of the patient with ultrasonography, electrophysiology and MRI are discussed in the light of recent literature.

Can the Requirement of a Diversion Procedure Be Predicted after an Uncomplicated Intracranial Hydatid Cyst Surgery

Intracranial hydatidosis is mainly a pediatric disease. Surgical evacuation of the mass in toto is the gold standard of therapy. No concise data related to the requirement of diversion procedures after uncomplicated hydatid cyst removal is encountered in the literature. The aim of this report is to focus on this idea and estimate the necessity of a diversion procedure beforehand. A 6-year-old girl both with intracranial and renal involvement of hydatidosis underwent surgery. Intact removal of the intracranial cyst harboring daughter vesicles was achieved. A persistent porencephalic cyst at the operative site required a shunt 6 months after surgery. Thick pericyst formation was blamed for this specific progress and the pathophysiology is discussed.

Gliomatosis cerebri with neurofibromatosis: an autopsy-proven case

Abstract Gliomatosis cerebri is a glial neoplastic process that is diffusely distributed through neural structures, whose anatomical configuration remains intact. Among the more than 19,000 cases hospitalized in Istanbul University Istanbul School of Medicine Department of Neurosurgery throughout the past 45 years, only 2 cases were diagnosed as gliomatosis cerebri, 1 by stereotactic ante-mortem diagnosis and the other after autopsy. In this paper, the autopsy-proven case of this rare disease with coexistent neurofibromatosis – the sixth case reported in the literature – is presented.

A new ventriculocisternal shunt technique in treatment of noncommunicating hydrocephalus: A technical note with a brief discussion of the literature

SummaryVentriculo-cisternostomy is an established procedure for the treatment of noncommunicating hydrocephalus, if the underlying pathology cannot be removed.In cases in which the foramina of Monro and the proximal part of the third ventricle are obstructed, it is not possible to make a communication between the internal and external CSF-spaces by perforation of the floor of the third ventricle, the so-called third ventriculo-cisternostomy.For such cases the authors describe a new method of drainage of both lateral ventricles to the interpeduncular cistern. This new method has been used successfully in a case with obstructive hydrocephalus of both lateral ventricles, caused by a pilocytic astrocytoma of the optic chiasma and hypothalamus with obstruction of both foramina of Monro.

Diffuse cerebrospinal gliomatosis

‘What’s in a name?’ SIR–I read the editorial in the February 2001 issue of DMCN Journal with interest.1 The continuing variable interpretation of the term ‘cerebral palsy’ could be a reflection of how different specialties, both medical and non-medical, view the term. It is possible that epidemiologists would prefer the term to denote something more specific so that they might be able to define their study populations. The clinician, and particularly the pediatric neurologist and neurodevelopmental pediatrician, who are perhaps more comfortable with uncertainty, understand that the the term only points them in a certain direction. That direction is that they are dealing with a disorder that is characterized by abnormal motor actions and postural mechanisms, and that these are due to non-progressive abnormalities of the developing brain. If the final destination for the clinician is diagnosis, differential diagnosis, etiology, prognosis, and management, the road to this destination, when dealing with pediatric neurological abnormalities characterized by motor dysfunction, starts with considering whether one is dealing with a non-progressive disorder, after deciding on anatomical localisation. The initial mental step towards the final destination may be mundane to some, but it is clearly a step that needs to be taken. I would value the opinions of my clinical and epidemiological colleagues concerning some of the statements I have read that deal with the definition of cerebral palsy. For example, the editorial suggested that if the cause of cerebral palsy syndrome is genetic then it should no longer be called a cerebral palsy syndrome. Similarly, others have suggested that the recognition of a brain malformation should not be included in the term cerebral palsy.2 I do not understand why arbitrarily chosen etiologies should be picked as exclusion criteria, unless one wishes to completely redefine the term cerebral palsy. Those of us who work with children with developmental disabilities are usually comfortable with the uncertainty that surrounds the initial understanding of a recognition of a cerebral palsy syndrome. It sets us on the road to diagnosis and differential diagnosis which, as we all know, is based on an adequate history, examination, and investigations. Those groups that diagnose, manage, and investigate the cerebral palsy syndromes may have varying perceptions of their world which limit mutual understanding. I suppose in the end, one might ask does it matter? ‘ “The question is,” said Alice, “whether you can make words mean so many different things!” ’