Kaya Aksoy

Unilateral Blindness due to Patient Positioning During Cervical Syringomyelia Surgery: Unilateral Blindness After Prone Position

During spinal surgery using a horseshoe headrest with the patient in the prone position, the possibility of central retinal artery occlusion (CRAO) increases, and its cause can be attributed primarily to excessive extraocular pressure, a very rare complication. This report describes a case of CRAO, occurring in an adult, after cervical syringomyelia surgery in which a horseshoe headrest was used.

Complications of brain tissue pressure monitoring with a fiberoptic device.

Seventy-five patients with intracranial hypertension whose Glasgow Coma Score (GCS) was 8 or below and in whom intracranial pressure (ICP) was monitored were examined for complications of this procedure. In 20 of the 75 patients we used only an intraparenchymal fiberoptic ICP monitoring transducer, while, in the remaining 55 patients, who required CSF drainage, a ventricular drainage set (VDS) was used in addition to ICP monitoring. The duration of monitoring with the ICP transducer alone was approximately 5.1 ± 2.6 das (min. 1, max. 13) and that of ICP monitoring with VDS was 6.2 ± 3.1 days (min. 1, max. 13). In 8 cases a total of 9 complications were experienced (12 %). These complications were infection in 3 cases (4 %), epidural hematoma in 2 cases (2.7 %), disconnection in 2 cases (2.7 %) and contusion in 2 cases (2.7 %). Although none of the 44 patients who were monitored for less than 5 days experienced infection, 3 of the 31 patients monitored for longer than 5 days did experience infection (9.7 %) (p < 0.05). None of the 20 patients who underwent ICP monitoring only experienced infection. However, 3 of the 55 patients in whom the ventricular drainage set was implanted in addition to the transducer for ICP monitoring experienced infection (p < 0.05).Owing to its minimally invasive nature, low complication rate, and accuracy in monitoring the parenchyma pressure, the Camino fiberoptic intraparenchymal monitor has become the system of choice in our clinic.

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

SummaryBackground. The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre.Method. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2).Findings. The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploë (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 ± 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4–5) and 8 (26.7%) had poor results (GOS 1–3).Conclusions. Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.

Preservation of craniotomy bone flaps under the scalp.

Bone flaps are occasionally not replaced because of brain swelling or for other reasons. Various methods for preserving the free bone flaps have been described. Reimplantation of a free bone flap after a period of preservation outside the body, however, may be complicated by infection, and facilities for proper preservation under sterile conditions may not be available. We present a new technique for preserving the bone flap under the scalp until brain swelling has resolved. The bone flap is reimplanted 12-48 days later. No serious complications related to this technique have been encountered in the 37 patients in which it was used.

Impact of novel PTEN mutations in Turkish patients with glioblastoma multiforme

Glioblastoma multiforme (GBM) represents the most common and aggressive type of primary neoplasms of the central nervous system. The PTEN (phosphatase, tensin homologue, deleted on chromosome TEN; MIM # 601728) tumor suppressor gene has an essential biological role in the formation of glioblastomas. It is known that there are variations in genetic alterations in tumors that develop in patients with different ethnic backgrounds and because there is no study evaluating PTEN mutation in Turkish patients with GBM, we aimed to realize the present study. We investigated 62 GBM tumors for mutations of the PTEN gene using single strand conformational polymorphism (SSCP) method followed by DNA sequencing. As a result of our investigation, PTEN mutations were detected in 15 of 62 tumors (24.19%). Nine different sequence variants were identified: one novel promoter site mutation (5′UTR −9C→T), one novel intronic mutation (IVS2-2delA), four novel point mutations (61A→G, 105T→G, 248C→G, and 364C→G), two novel frameshift mutations (213delC) and 378delGATA) and one previously reported global exonic transition type mutation (129G→A). Since the majority of PTEN mutations identified in the present study are novel, we believe that these alterations may be specific to Turkish population. Furthermore, though no significant correlation was found between PTEN mutations and histopathological properties of GBM tumors, our findings indicate that localizations of mutations in PTEN gene may have an effect on clinical aggressiveness of GBM tumors.

Quadrigeminal cistern lipoma

Intracranial lipomas are rare benign congenital neoplasms accounting for 0.1 to 0.5% of all primary brain tumours. Approximately 50% are associated with other cerebral developmental disorders. These slow growing benign lesions are usually asymptomatic and rarely require surgery. We report the case of a 37 year old woman presented with signs of raised intracranial pressure. Computerized tomography and magnetic resonance imaging demonstrated a quadrigeminal cistern lipoma compressing the aqueduct of Sylvius. The patient underwent surgery and a distinct plane of cleavage between the lipoma and the adjacent neural structures was found, allowing total removal of the lesion. Postoperatively, the patient was relieved of her original symptoms but developed akinetic mutism which lasted for two weeks. Intracranial lipomas rarely become symptomatic and surgery is seldom required. If the lesion progresses and causes symptoms of raised intracranial pressure or compression of neural structures, surgical intervention is indicated. Total removal should not be attempted unless a plain of cleavage between the lesion and adjacent neural structures is present. Surgical manipulation should be minimised to avoid complications.

Is supratentorial pressure difference clinically relevant? Analysis of 55 consecutive cases by bilateral intracranial pressure monitoring

Abstract Objective: The purpose of this study is to explore the possibilities of an early warning system by measuring intracranial pressure differences in order to prevent secondary insults to the injured brain. Methods: Fifty-five cases with a Glasgow coma scale (GCS) score 8 or below who presented with intracranial hypertension due to various intracranial pathologies underwent bilateral intraparenchymatous intracranial pressure (ICP) monitorization in an attempt to find out the existence of interhemispheric pressure differences. ICP values were recorded every 30 minutes during the first 24 hour interval. Patients were stratified into two groups as diffuse and focal according to the magnitude of their pathologies. Focal cases were also grouped according to lesion size and/or midline shift. Results: ICP differences that necessitated changes in the treatment were found at different time intervals in patients with focal lesions, but these did not reach statistical significance within the whole group (p>0.05). There were significant percentage differences between focal I and II groups in correlation with lesion side and non-lesion side within the first 4.5 hours (p<0.05). There was a significant difference within the first 3 hours between diffuse and focal II groups (p<0.05). Discussion: In patients with focal lesions, although more pronounced in focal II group, apparent pressure differences between two hemispheres within the first hours of admission were found. These pressure differences were related to the volume of the intracranial pathology. ICP monitorization from the lesion side is reasonable as an early forewarning procedure and this might prevent the development of secondary insults by providing the exact ICP values of the patients.

Approach via the Floor of the Fourth Ventricle for Hydatid Cyst of the Pons

A very rare case of a pontine hydatid cyst is reported. It was diagnosed preoperatively on the basis of magnetic resonance imaging findings. The patient was operated on in the sitting position. Total excision of the cyst using the Dowling technique and gravity effect was performed through the floor of the fourth ventricle. The patient was discharged without extra neurological sequel. The significance of an accurate preoperative diagnosis, surgical approaches and technique in the management of this pathology is discussed.

Effects of Neuronotrophic Factors on Adrenal Medulla Grafts Implanted into Adult Rat Brains

The effects of neuronotrophic factors (NFs) on adult adrenal medulla grafts transplanted into the rat caudate nucleus after the destruction of the nigrostriatal dopaminergic pathways were investigated. Two months after implantation, all of the adrenal medulla grafts treated with NFs, but only 45% of the untreated grafts, had survived. The levels of tyrosine hydroxylase activity in the caudate nucleus however, were not significantly different between the sham-operated control and either NF-treated or untreated grafted groups. These results indicate that treatment with NFs significantly enhances the survival rate of the grafts.

Intraocular neuromuscular choristoma: a case report and literature review.

BACKGROUND AND IMPORTANCE: Neuromuscular choristomas (NMCs) are rare benign tumors of the peripheral nerves. Although histopathological characteristics of this unusual lesion have been recognized, in this regard, neuroimaging findings have not been well described previously. We report the first intraconally located NMC affecting the oculomotor nerve, with histopathological and radiological characteristics. CLINICAL PRESENTATION: A 10-year-old girl presented with sudden-onset left temporal and retro-orbital pain. Magnetic resonance imaging scans demonstrated a small, capsulated, retro-orbital, intraconal solid lesion that was diagnosed as an atypical dermoid cyst preoperatively. The tumor was resected subtotally. Postoperatively, the patient became pain free, but ipsilateral ptosis and upward eye movement failure developed. Histologically, the lesion consisted of well-differentiated striated muscle fibers intermingled with mature nerve elements consistent with the NMC. CONCLUSION: Although intracranial NMCs need histological confirmation for diagnosis, neuroimaging might contribute to the preoperative diagnosis and management strategy of treatment. We report the first intraconal NMC, which should be considered in the differential diagnosis of intraorbital tumors.