Engin Gonul

Causes of infections and management results in penetrating craniocerebral injuries

From February 1992 to December 1994, 148 patients with penetrating craniocerebral injuries were treated surgically with primary and secondary debridement including repair of dural defects and removal of retained intracranial bone and metal fragments. Dural defects were closed primarily or with temporalis fascia, pericranium, and cadaver graft. Cerebrospinal fluid fistulas were observed in 11(7.3 %) patients; 7 of these were infected. Central nervous system (CNS) infection was seen in 2 patients without CSF fistula. Excluding those 11 patients with CSF fistula, CNS infection was shown in 2 of the 137 cases (1.5 %). All patients underwent CT scans periodically. In 51 (34 %) of 148 patients, bone and metal fragments were determined on control CT scans. During this time, 12 patients died (8 %). Most of deaths were caused by the direct effect of brain injury and occured within the first month after injury. Fragments retained after first debridement were followed periodically by CT scan. Surgery was not performed until infection developed. Retained fragments did not increase the infection risk, but high rates of infection did occur in cases with CSF fistula.

The antioxidant effect of β-Glucan on oxidative stress status in experimental spinal cord injury in rats

This study was performed to investigate the antioxidant effect of β-Glucan in experimental spinal cord injury (SCI). Injury was produced using weight-drop technique in rats. β-Glucan was given by intraperitoneal injection following trauma. The rats were sacrificed at the sixth day of injury. Oxidative stress status was assessed by measuring the spinal cord tissue content of Malonyldialdehyde (MDA), Superoxide Dismutase (SOD) and Gluthatione Peroxidase (GSH-Px) activities. No effect of β-Glucan on SOD and MDA activities was found but, GSH-Px levels were found to decrease to the baseline (preinjury) levels when it was compared to untreated group (U=0.000; p=0.002). According to our results, β-Glucan works like a scavenger and has an antioxidant effect on lipid peroxidation in spinal cord injury.

The evaluation of surgical treatment options in the Chiari Malformation Type I.

AIM There have been several treatment modalities to reduce the volume of the syringomyelic cavity and the pressure on the brainstem in Chiari Malformation Type I (CM-I). Foramen magnum decompression with and without duroplasty were compared in this retrospective study. MATERIAL AND METHODS From 2003 to 2006, 27 patients suffering from CMI were operated on at our institute. The following were measured: the ratio of the syringomyelic cavity to the spinal cord; pre-operative tonsillar herniation from the foramen magnum; pre- and postoperative tonsillo-dural distance; and spinoposterior fossa dural angle. RESULTS 83.3 % of the patients in the non-duroplasty and 73.3% of the patients in the duroplasty group were symptom free. The ratio of syrinx regression was 28+/-10% in the non-duroplasty and 36+/-33% in the duroplasty group. The tonsillodural distance was 3.1+/-1.8 mm in the non-duroplasty and 4.6+/-2.1 mm in the duroplasty group (p>0.05). The spino-posterior fossa dural angle was 133.6+/-9.44 degrees preoperatively and 136.7+/-9.78 degrees postoperatively in the non-duroplasty (p=0.376); 123.7+/-11.7 degrees preoperatively and 129.8+/-11.1 degrees postoperatively in the duroplasty group (p=0.885); no significant difference was found postoperatively (p=0.55, z=1.92), respectively. One patient was re-operated in the non-duroplasty group and thereafter duroplasty was performed. CONCLUSION Almost the same clinical outcomes can be achieved with and without duroplasty. There might be an option to perform duroplasty if simple procedure fails.

Retrospective analysis of spinal missile injuries.

One hundred six patients with spinal missile injury from war zones were admitted to our department from 1994 to 2000. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Sixty-five were treated surgically, of whom 55 (84%) had incomplete injuries (Frankel scores B, C, and D). In the conservative group, 28 (68%) had incomplete injuries. A total of 81 patients (53 in the surgical group, 28 in the conservative group) could be monitored for functional recovery. In the surgical group, 34 (64%) showed improvement, 15 (28%) were unchanged, and four (7%) worsened. In the conservative group, 17 (60%) improved, nine (32%) remained unchanged, and two (7%) worsened. Cerebrospinal fluid fistula was observed in ten patients, seven of them in the surgically treated group. Five of seven meningitides were seen in the surgically treated group. Surgical intervention is not essential for spinal gunshot injury; however, it may be beneficial for patients with CSF fistula, infectious and compressing foreign bodies in the injury site, instability, and rapid neurological deterioration.

Cirsoid aneurysms of the scalp

This study reviewed the surgical management of cirsoid aneurysms of the scalp, which are rarely encountered in the neurosurgical practice, and compares the results with embolization. 21 patients with cirsoid aneurysm underwent surgery. There were 1 female and 20 male patients. Trauma was present in four patients. Selective internal and external carotid artery angiograms and cranial magnetic resonance imaging studies were performed on all patients. All angiograms were staged according to published procedures. There were 15 (71.4%) Stage 1a, 4 (19.1%) Stage 1b, and 2 (9.5%) Stage 3 patients.Total excision of the lesion was achieved in 19 patients (90.5%). We operated on only one patient for a second time, because of a residual lesion, and we resected the lesion totally. Only two patients developed necrosis of the scalp (button hole). Both scalp necroses were on the frontal area. Other patients all had good cosmetic results. Surgical resection of cirsoid aneurysms seems to be the most effective treatment with good results. There may be a tendency for the occurrence of necrosis on the frontal area. Staging of the scalp aneurysms has no effect on surgical outcome.

Monostotic craniofacial fibrous dysplasia: the Turkish experience.

Fibrous dysplasia is a benign developmental disorder of the bone. Ten percent of patients with monostotic fibrous dysplasia have craniofacial bone involvement. Twenty-six patients were followed up at the Neurosurgery and Otolaryngology, Head and Neck Surgery Departments between 1990 and 2004. The surgery was performed in 14 patients with considerable cosmetic and functional disturbance. Twelve patients who had mild pain and mass at the site of the lesion were followed up. Cosmetic and functional results, symptom analysis, and frequency of site of involvement were reviewed and compared with previous series. Cranial involvement including frontal, parietal, sphenoidal, and occipital bones was found in 13 (52%) patients. The next common site was the maxillary bone in 9 (33%) patients. Four patients had orbital decompression caused by fronto-orbital and sphenoid bone involvement. None of the patients had any major complication of surgery. Because of its benign nature and decreased growth rate after adolescence, surgical treatment should be reserved for those with functional impairment or severe cosmetic disturbance.

Facial nerve problems and hearing loss in patients with temporal bone fractures: demographic data

BACKGROUND The incidence of temporal bone fractures have increased in recent decades together with the increasing traffic and population. The aim of this study is to evaluate the cause, treatment methods, radiologic, and intraoperative findings in patients with temporal bone fractures. METHODS Thirty-five patients with temporal bone fracture who have been followed between 1992 and 2006 were retrospectively reviewed. Computerized tomography and audiometric tests were obtained. Electrophysiological evaluation of the facial nerve in patients with traumatic facial paralysis was carried by serial electromyogram (EMG). House-Brackmann grading system was used to evaluate the function of the facial nerve. Twenty-three patients underwent operation for facial paralysis or hearing loss. Results of medical and surgical therapy were documented. RESULTS Traffic crash was the most common cause (54%). Eighteen (51.4%) of patients had conductive hearing loss, 6 (17.14%) of the patients had sensorineural hearing loss, and 11 (31.42%) had normal hearing. Transient or persistent facial paralysis was detected in 24 of 35 patients (68.57%). Nineteen patients underwent partial or total facial decompression. Preoperative EMG of the majority of the operated patients revealed total axonal degeneration. The most common affected area of the facial nerve by trauma was the vertical segment (31.58%). House-Brackmann 1 and 2 grade was achieved in majority of the patients. Fourteen ossicular abnormalities were detected in 10 patients, and the abnormality was usually related to the incus. More than 10 dB air-bone gap closure was achieved in six of eight patients (75%). CONCLUSIONS Traffic crashes continue to be the main cause of temporal bone fractures. Facial paralysis caused by temporal bone trauma can be satisfactorily treated by decompression. EMG, clinical grading, and onset of the paralysis are important guides for the surgery. Restoration of the hearing can be achieved in majority of patients.

Transsphenoidal approaches to the pituitary: a progression in experience in a single centre

BackgroundEvolving of a single centre by means of different transsphenoidal approaches during the survey of methodological advances in pituitary surgery is presented.Materials and methodsNinety-three consecutive patients with pituitary adenomas underwent transphenoidal pituitary operations at Gulhane Military Medical Academy from January 1996 to October 2007. Retrospective chart-based analysis of the surgical methods of transsphenoidal pituitary adenoma operations were done. Surgical methods were described. Outcomes and complications were presented. Attention is focused on the methodology of different surgical techniques of pituitary surgery.FindingsDuring the evaluation period, 12 Sublabial approaches (1996–1998), 13 transseptal transsphenoidal approaches (1999–2000), 15 endonasal transsphenoidal approaches (2000–2004), 25 endoscopy assisted endonasal approaches (2002–2006) and 28 pure endoscopic endonasal approaches (2006–2007) were performed.ConclusionsTechnologic advancements in endoscopy and gaining experience in pituitary surgery drives neurosurgeons toward less invasive approaches.

Initial experience with silver-impregnated polyurethane ventricular catheter for shunting of cerebrospinal fluid in patients with infected hydrocephalus

Abstract Objective: Infection is a major complication and risk factor of cerebrospinal fluid (CSF) shunting procedures. Recently, antibiotic-impregnated shunt systems have been developed in an attempt to prevent or reduce the CSF infection. The aim of this study was to determine the efficacy of silver-impregnated polyurethane ventricular catheter for shunting of CSF in patients with infected hydrocephalus. Methods: Seven patients who had hydrocephalus with high protein level and positive CSF culture underwent implantation of ventriculoperitoneal shunt with silver-impregnated polyurethane ventricular catheter. All of them experienced shunt failure previously due to infection. The Silverline ventricular catheter, which was connected to the Miethke gravity-assisted valve system and peritoneal catheter, was used in all patients. The mean follow-up period after operation was 14 months. Cerebrospinal fluid samples from the reservoir of the shunts were obtained at the end of the third month after operation in all patients. Results: The CSF protein level of the patients was reduced significantly, and the CSF culture became negative after shunt placement with silver-impregnated polyurethane ventricular catheters. The mean CSF silver (Ag) level was 0.51 ng/ml [parts per billion (ppb)], and blood Ag level was 3.65 ng/ml (ppb) at the first month after operation. No shunt obstruction or infection was observed in the follow-up period. Conclusion: Silver-impregnated polyurethane ventricular catheters appear to be safe and well tolerated in patients who sustained infected hydrocephalus. Preliminary results suggest a complete improvement of infection. Longer follow-up and large number of patients are needed to more accurately assess the efficacy of these catheters.

Imaging of posterior fossa epidermoid tumors

OBJECTIVE Epidermoid tumors have similar radiologic characteristics with arachnoid cysts on routine imaging techniques. Since they warrant different therapeutic interventions, it is essential to differentiate the two pathologies and to assess operative results. PURPOSE The purpose of this study is to define the MR characteristics of epidermoid tumors in posterior fossa particularly on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI). PATIENTS AND METHODS During a 10-year period, we operated 19 cases with epidermoid tumor of posterior fossa. The localization of the epidermoids was cerebellopontine angle in 16 patients, within the fourth ventricle in 2 patients and pineal region in 1 patient. Neuroimaging included CT in all patients, conventional MR in 14 patients and FLAIR and DWI in the last 6 patients. RESULTS In the first 13 cases, diagnosis of epidermoid tumor was difficult on CT and conventional MR. Epidermoids appeared as heterogeneous hyperintense lesions on FLAIR and homogenous hyperintense lesions on DWI in the last 6 patients. While total resection of the tumor was achieved in 17 patients, subtotal resection was performed in 2 patients. Histopathological examinations of the specimens revealed epidermoid tumor in all cases. CONCLUSION Advances in neuroradiology provide us advantages for planning the treatment modalities in epidermoid tumors of the posterior fossa. The difficulties in preoperative differential diagnosis and judgment for reoperation in the postoperative course have been decreased particularly via FLAIR and DWI.