Kemal Hepgul

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.

Fully Endoscopic Interlaminar and Transforaminal Lumbar Discectomy: Short-Term Clinical Results of 163 Surgically Treated Patients

OBJECTIVE To evaluate the clinical outcomes of patients with lumbar disc disease undergoing fully endoscopic surgery at a single clinic. METHODS Between August 2009 and January 2012, 163 patients (74 men and 89 women) underwent fully endoscopic lumbar discectomy. All patients were followed for 1 year after surgery. The Oswestry Disability Index and a visual analog scale were used to analyze outcomes. RESULTS During the follow-up period, 114 (70%) patients had no complaints, 30 (18%) patients had occasional pain, and 19 (12%) patients had no improvement. During postoperative follow-up, 8 patients required repeat surgery for recurrence or residual fragments. Postoperatively, 4 patients experienced dysesthesia, which completely resolved in time. Neurologic deterioration occurred in 5 patients, 4 of whom recovered completely without any intervention. Dural tears occurred in 6 patients. CONCLUSIONS Fully endoscopic interlaminar or transforaminal surgeries are safe and effective treatment modalities for lumbar disc herniations. Despite the difficulties of acquiring this new technique, good results can be achieved with sufficient experience.

Anterolateral approach to the cervical spine: major anatomical structures and landmarks. Technical note.

OBJECT The authors undertook a study to explore the topographic anatomical features seen during the anterolateral approach to cervical spine, anatomical variations, and certain landmarks related to the surgical procedure. METHODS The study was conducted in 30 fresh cadavers. RESULTS The common carotid artery bifurcation was mostly found at the level of C-4 (78%). The inferior belly of the omohyoid muscle was seen to cross the sternocleidomastoid muscle at the C5-6 disc level along the entire C-6 vertebral body. To reach the lower cervical region, the sacrifice of this muscle makes the procedure easier. The facial vein drained into the internal jugular vein mostly at the level of C3-4 (54%). The superior ganglion of the cervical sympathetic chain was located at the C-4 vertebra, but the location of the intermediate ganglion exhibited some variation. The vertebral artery entered the transverse foramen of C-6 in 27 cadavers (90%), the transverse foramen of C-7 in two cadavers (7%), and the transverse foramen of C-4 in one cadaver (3%). Because the inferior thyroid artery crossed the C6-7 interspace obliquely, the course of the inferior thyroid artery may complicate the procedure. The C-5 uncinate process was shortest and narrowest and had the greatest distance from the medial edge of the process to the anterior tubercle (p < 0.001). CONCLUSIONS Understanding the qualitative anatomy of this region not only improves the safety of anterior and anterolateral cervical spine surgery but also allows adequate decompression of neural elements and resolution of the other pathological processes of this region. In this fresh cadaveric study, our goal was to improve the approach and decrease the incidence of complications.

Bromocriptine-induced cerebrospinal fluid fistula in patients with macroprolactinomas : report of three cases and a review of the literature

Bromocriptine therapy for macroprolactinoma induced cerebrospinal fluid (CSF) rhinorrhea in three patients. The tumor had extended well beyond the sella turcica and caused bony erosion in all the cases. All three patients responded to bromocriptine therapy rapidly. CSF fistula occurred concomitantly with the reduction of tumor size and caused meningitis in two of the patients. Withdrawal of bromocriptine resulted in cessation of the leakage. One of the patients underwent transsphenoidal repair. Two patients refused surgery. This potentially lethal complication encountered in these three cases demonstrates the need for close supervision of macroprolactinoma patients with skull base erosion placed under bromocriptine therapy.

Effect of magnesium, MK-801 and combination of magnesium and MK-801 on blood–brain barrier permeability and brain edema after experimental traumatic diffuse brain injury

Abstract Objective: Glutamate antagonists are very attractive drugs in laboratory works to protect neural tissue against ischemia. In this work, the effects of magnesium, MK-801 and combination of magnesium and MK-801 on blood–brain barrier (BBB) and brain edema after experimentally induced traumatic brain injury are evaluated. Methods: A standard closed head injury was induced on the rats by a controlled impact device using a 450-g free falling mass from a height of 2 m onto a metallic disc fixed to the intact skull. One of the following was injected to animals intraperitoneally 30 minutes after injury: saline, magnesium, MK-801 and magnesium plus MK-801. To quantify the brain edema, the specific gravity of the brain tissue was determined. To demonstrate the alteration of the BBB permeability, Evans blue dye was used as a tracer. Results: In all treatment groups, the specific gravity of brain tissue values was significantly higher compared with the control group. Evans blue dye content in the brain tissue was significantly reduced in all three treatment groups with respect to the control group. There was no significant difference of effect between the groups of magnesium alone and MK-801 alone when compared with each other and when compared with their combination. Conclusion: The present data demonstrate that treatment with magnesium, MK-801 and combination of magnesium and MK-801 can reduce formation of brain edema and can help restore BBB permeability after experimental diffuse brain injury.

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.

Microvascular decompression as a surgical management for trigeminal neuralgia: A critical review of the literature

Trigeminal neuralgia (TN) is a common pain syndrome and is characterized by recurrent episodes of intense lancinating pain in one or more divisions of the trigeminal nerve. Neurovascular compression (NVC) has been considered as the main cause of TN in the root entry zone (REZ) of the trigeminal nerve in the cerebellopontine angle cistern. Microvascular decompression (MVD) is the surgical procedure of choice for the treatment of medically refractory TN. MVD has also been shown to provide pain relief even in patients without visible neurovascular compression. Additionally, it has been accepted that MVD can provide the highest rate of long-term patient satisfaction with the lowest rate of pain recurrence. We did, systematic review of the subject and also our own experiences.

Neural and anatomical abnormalities of the gastrointestinal system resulting from contusion spinal cord injury.

Gastrointestinal (GI) abnormalities resulting from spinal cord injury (SCI) are challenging disorders that have not been examined experimentally using clinically relevant models. In this study, female Sprague-Dawley rats (n=5/groupx4: T10-T11 contusion, laminectomy, or naïve) were fasted for 24 h before being submitted to dye recovery assays (Phenol Red solution, 1.5 ml/rat; per oral) on GI emptying/transiting at 48 h or 4 weeks postinjury (p.i.). Compared with controls, SCI significantly increased dye recovery rate (DRR, determined by spectrophotometry) in the duodenum (+84.6%) and stomach (+32.6%), but decreased it in the jejunum (-64.1% and -49.5%) and ileum (-73.6% and -70.1%) at 48 h and 4 weeks p.i., respectively (P<or=0.005, ANOVA with post hoc t-test). Electrophysiological analysis revealed that purinergic fast inhibitory junction potential (IJP) was reduced approximately 30% in the antrum and duodenum of rats 48 h p.i. (numbers of animals/numbers of tissue samples=3/7; P<0.001), and slow IJP was essentially abolished. Immunocytochemistry consequently uncovered significant reductions in the GI vasoactive intestinal polypeptide and neuronal nitric oxide synthase (i.e. slow IJP mediators) reactivity at 48 h and 4 weeks p.i., suggesting that SCI disrupted interstitial neurotransmission. Importantly, SCI caused discernible atrophy of the GI mucosa and muscle coat (e.g. the two layers of gastric wall were correspondingly 28% and 27% thinner 4 weeks p.i.). We conclude that contusive SCI triggers GI abnormalities with unique pathophysiology and pathology in different segments. Such GI disorders evolve continuously during the entire post-SCI period examined, and may require therapeutic development to target specific underlying mechanisms.

Sporadic Multiple Cerebral Cavernomatosis Report of a Case and Review of Literature

Objective:Cerebral cavernous malformations (CCM) are vascular malformations causing seizures and cerebral hemorrhages. They occur in sporadic and familial forms. Familial cases are associated with a high frequency of multiple lesions, which are less frequently associated with sporadic cases. Case Report:We report a 46-year-old woman presenting with epilepsy with multiple cerebral cavernomatosis on MRI. Because she had had a previous liver transplantation operation, and received immunosuppressants, she was not advised to have a brain operation. However, she had to be operated as a result of a bleeding in one of her cerebral cavernomas. The histologic diagnosis was cavernoma. She has been seizure free after the operation with levetiracetam therapy for the last 17 months. She had no positive family history for both epilepsy and cavernomatosis. Conclusion:When multiple cerebral cavernomatosis are identified in a patient, a detailed neurologic family history should be sought despite the possibility of its being a sporadic case. Our main intention is to present a patient who is surgically controversial and to point out the importance of genetic heredity.

Imaging in tuberculosis of the skull and skull-base: case report

Abstract.We report a 19-year-old girl, who presented with headache and tonic/clonic seizures. Imaging revealed a lytic parietal skull lesion with an adjacent epidural mass, masses in the right parietal lobe and a posterior skull-base mass. The diagnosis of tuberculosis was made after resection of the extradural mass and later verified with culture of Mycobacterium tuberculosis. The parenchymal and skull-base lesions resolved following antituberculous treatment. We present CT, scintigraphic, angiographic and MRI findings.