Funda Batay

Risky anatomic variations of sphenoid sinus for surgery

We searched for the surgically risky anatomic variations of sphenoid sinus and aimed to compare axial and coronal tomography in detection of these variations. Fifty-six paranasal tomography images (112 sides) were evaluated for coronal, axial and both coronal and axial images. Tomographic findings including bony septum extending to optic canal or internal carotid artery; protrusions and dehiscences of the walls of internal carotid artery, optic nerve, maxillary nerve and vidian nerve; extreme medial course of internal carotid artery; patterns of aeration of the anterior clinoid process; and Onodi cells were evaluated. The results were classified as “present, absent, suspicious-thin (only for dehiscence) or no-consensus”. The results of each plane were compared with that of the result of the both planes together. Kappa coefficient and Chi-square tests were used to compare both planes. Twelve cadaveric dissections were performed to reveal the proximity of sphenoid sinus to surgically risky anatomic structures. Endoscopy was applied to five cadavers. 18 evaluations were classified as ‘no-consensus’. We detected 34, 35, 34 and 40 protrusions of internal carotid artery, optic nerve, maxillary nerve, vidian nerve, respectively. Dehiscences were present in 6, 9, 4 and 8, and suspicious-thin in 8, 10, 16 and 25 in canals of internal carotid artery, optic nerve, maxillary nerve and vidian nerve, respectively. Bony septum to internal carotid artery and optic nerve was observed in 30 and 22 cases. We observed 9 extreme medial courses of internal carotid artery, 27 aerated clinoid process and 9 Onodi cells. Axial images were superior in detection of bony septum to internal carotid artery and Onodi cells; while the coronal images were more successful in detection of protrusion of optic nerve and vidian nerve, and dehiscense of maxillary nerve and vidian nerve (P<0.05). In cadaveric dissections, the septa were inserted into the bony covering of the carotid arteries in two sinuses (8.3%). Detailed preoperative analysis of the anatomy of the sphenoid sinus and its boundaries is crucial in facilitating entry to the pituitary fossa and reducing intraoperative complications. Coronal tomography more successfully detects the sphenoid sinus anatomic variations.

Meckel's Cave

OBJECTIVE To review the microsurgical anatomy of Meckels cave, a detailed knowledge of which is a prerequisite to devising an appropriate surgical strategy and performing successful surgery. METHODS The microsurgical anatomy of Meckels cave was studied under an operating microscope in 15 human cadaver heads (30 sides). To understand the meningeal architecture and the cross-sectional anatomy of Meckels cave, serial histologic sections were made in an additional adult human cadaver specimen. RESULTS Meckels cave is a natural mouth-shaped aperture connecting with the posterior fossa that is located in the medial portion of the middle cranial fossa. The cave extends forward similar to an open-ended three-fingered glove and provides a channel for the rootlets of the trigeminal nerve; the trigeminal ganglion; and the ophthalmic (cranial nerve V(1)), maxillary (cranial nerve V(2)), and mandibular (cranial nerve V(3)) divisions until they reach their respective foramina. The average height of this oval mouth was found to be 4.2 mm (range 3-5 mm) and the average width was 7.6 mm (range 6-8 mm). The mouth of Meckels cave was located 12 mm (range 10-15 mm) superior and medial to the internal acoustic meatus and 6.5 mm (range 5-8 mm) superior and medial to the dural point of entrance of the nervus abducens and 20 mm (range 18-23 mm) medial to the arcuate eminence. CONCLUSIONS Detailed and sound knowledge of the microsurgical anatomy of Meckels cave, which borders on surgically important structures, such as the internal carotid artery and cavernous sinus, is essential to performing precise microneurosurgery in this region. This study describes the complex anatomy of Meckels cave and surrounding structures to provide the knowledge needed to devise a more complete surgical strategy and establish accurate orientation during the surgical procedure.

Prevalence of Primary Tethered Cord Syndrome Associated with Occult Spinal Dysraphism in Primary School Children in Turkey

The prevalence and associated factors of primary tethered cord syndrome (PTCS) in primary school children were investigated. A cross-sectional study was performed in four demographically different primary schools in Turkey. Demographic, familial and physical data were collected from 5,499 children based on enuresis as a predominant symptom and dermatologic and orthopedic signs as clues of occult spinal dysraphism. Statistical analysis and input of the data were carried out with the SPSS package program 10.00, and logistic regression analysis was used to identify discriminating factors between enuretic children with or without neurologic signs. Of 5,499 analyzed children, 422 (7.7%) had enuresis nocturna, and 19.9% of 422 children had also daytime incontinence. Sixteen of these 422 enuretic children (3.8%) had several dermatologic signs. Five of them had spina bifida on plain radiographies, and 4 of them had cord tethering on lumbar MRI. Fifteen of 422 enuretic children (3.7%) had gait disturbances and orthopedic anomalies without cutaneous manifestations. Six of 15 children had spina bifida on plain graphies and 2 of them had tethered cord syndrome on MRI. The general prevalence of PTCS was found to be 0.1% of 5,499 analyzed children and 1.4% of enuretic children. A good outcome after untethering was found in 83.0% in this series. Practitioners should be aware of these clues of occult spinal dysraphism and resort to further radiologic and neurosurgical assessment. Early surgical intervention may halt the progression of the neurologic deficits and stabilize or reverse symptoms.

Glabellar Frown Lines as a Reliable Landmark for the Supratrochlear Artery

OBJECTIVE: Preservation of the supratrochlear vascular pedicle (SVP) during use of the paramedian forehead flap can be accomplished by the aid of Doppler imaging; however, a reliable surface landmark may be invaluable in cases where Doppler examination fails. Our observations showed that the most prominent glabellar frown lines (GFLs) are very close to the SVP; however, the actual relationship of these structures remains unclear. STUDY DESIGN: The relationship between GFLs and the SVP was investigated in 19 volunteers by the aid of Doppler imaging and in 8 cadaver heads by dissection. The distance between the GFLs and the SVP was measured. SETTING: The study took place at an academic tertiary-care facility. RESULTS: The SVP was located just at the GFLs in almost 50% of the cases and an average of 3.2 mm lateral to GFLs in the remaining cases. CONCLUSION: GFLs may serve as reliable surface landmarks in the use of the paramedian forehead flap where Doppler imaging was not helpful.

Growth dynamics of meningiomas in patients with multiple sclerosis treated with interferon: report of two cases.

Summary.Summary. Background: Although multiple sclerosis (MS) is a common disease of the central nervous system, the association of intraparenchymal tumour has been rarely reported and the potential relationship between intracranial meningioma and MS has not been seriously analysed. This report addresses the association of multiple sclerosis and intracranial meningioma and discusses the effect of interferon treatment on tumour progression. Clinical Presentation: We report two cases with multiple sclerosis, who developed meningioma four and twenty years after the diagnosis of MS was made. Neither patient had a history of meningioma initially and both were being treated interferon when the meningioma was progressed. Findings: Histological examination of two cases revealed meningothelial meningioma. The first patients KI67 level was 2.5% and was positive for the progesterone and estrogen receptor. Chromosomal analysis showed some abnormalities. In the second case, mild atypical change by presence of nuclear enlargement and rare mitotic figures were noted and PCNA, KI67 levels were less than 2%. Conclusions: We reported the association of multiple sclerosis and intracranial meningioma and observed the progression of the meningiomas during interferon treatment. Although, we cannot exclude the coincidence between the two diseases we discussed suspicious relationship between the interferon treatment and the tumour progression.

The microsurgical anatomy of the hypoglossal canal

BackgroundThe hypoglossal canal (HC) is a region of the skull base whose involvement in many pathological entities is often ignored. Adequate knowledge of the anatomy of the HC and its related bony, neural, and vascular structures is essential for surgery of lesions involving this area.MethodsTen adult human cadaver heads from a US source fixed by formalin (20 sides) and 20 dry human skulls from Indian sources (40 sides) were used in this study. Various aspects of the anatomy of this region including the size, course and variation of the hypoglossal nerve and its relationship to the adjacent and canalicular course were recorded.ResultsThe left HC was located at 10 o’clock and the right HC at the 2 o’clock position with respect to the foramen magnum. The canal was surrounded superiorly by the jugular tubercle, superolaterally by the jugular foramen, laterally by the sigmoid sinus and inferiorly by the occipital condyle. All dry skulls were drilled in the horizontal plane at an axis of about 45° and directed slightly upwards.ConclusionsDetailed knowledge of the microsurgical anatomy of the region of the HC is crucial when performing surgery for lesions of the condylar region, the lower clivus, and ventral brain stem. This study provides the knowledge required to achieve accurate orientation and effective maneuvers during surgical procedures for treatment of the patient without injuring the vital neural and bony structures.

First detailed description of axial traction techniques by serefeddin sabuncuoglu in the 15th century

Serefeddin Sabuncuoglu was a famous Turkish surgeon who lived in Amasya, Central Anatolia in 1385–1470. He is the author of the first illustrated surgical textbook in the Turkish-Islamic literature, namely, ‘Cerrahiyyetu’l Haniyye’ [23]. There are three known handwritten copies of the book; two in Istanbul [18, 19] and one in Paris [20]. His marvellous book, ‘Cerrahiyyetu’l Haniyye’ was re-discovered in 1939 by Suheyl Unver [22]. In, 1992 Ilter Uzel, a Turkish medical historian, examined three copies of the book and published them in Turkish, English and Arabic [23]. The book consists of three chapters (cauterization treatments, surgical procedures and fractures and dislocations), 193 topics and 206 pages dealing with many fields of surgery [4–8, 11, 24]. The book includes the author’s own coloured miniature drawings of the operative procedures. Sections of this book regarding spinal disorders are reviewed. He describes the management of spinal dislocations in the third chapter, 30th section (17, 22, 23). We focus on the interesting axial traction techniques which were described and used by Sabuncuoglu in the 15th century.

Microsurgical Anatomical Landmarks Associated with High Bifurcation Carotid Artery Surgery and Related to Hypoglossal Nerve

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