M. Faik Ozveren

Irrigation vs. closed drainage in the treatment of chronic subdural hematoma.

A number of different techniques are used to treat chronic subdural hematomas surgically. In this study, 70 chronic subdural hematomas were surgically treated and analyzed prospectively. Patients were classified according to clinical features and computed tomography images. Results of the cases that underwent burr-hole craniostomy-irrigation (group A; n=35) were compared with those undergoing burr-hole craniostomy-closed system drainage (group B; n=35). The most common etiological factor was trauma in both groups. Complete resolution in the early period was higher in group B compared to group A (60% vs. 40%). However, no difference was noted at the first month-follow-up. Recurrence rates were 17% in group A and 14% in group B. No significant difference was noted in terms of hospitalization duration or postoperative complications. In conclusion, we believe that the burr-hole craniostomy-irrigation technique is a reliable and effective method compared to burr-hole craniostomy-closed system drainage in the treatment of chronic subdural hematoma.

Anatomic Landmarks of the Glossopharyngeal Nerve: A Microsurgical Anatomic Study

OBJECTIVECompared with other lower cranial nerves, the glossopharyngeal nerve (GPhN) is well hidden within the jugular foramen, at the infratemporal fossa, and in the deep layers of the neck. This study aims to disclose the course of the GPhN and point out landmarks to aid in its exposure. METHODSThe GPhN was studied in 10 cadaveric heads (20 sides) injected with colored latex for microsurgical dissection. The specimens were dissected under the surgical microscope. RESULTSThe GPhN can be divided into three portions: cisternal, jugular foramen, and extracranial. The rootlets of the GPhN emerge from the postolivary sulcus and course ventral to the flocculus and choroid plexus of the lateral recess of the fourth ventricle. The nerve then enters the jugular foramen through the uppermost porus (pars nervosa) and is separated from the vagus and accessory nerves by a fibrous crest. The cochlear aqueduct opens to the roof of this porus. On four sides in the cadaver specimens (20%), the GPhN traversed a separate bony canal within the jugular foramen; no separate canal was found in the other cadavers. In all specimens, the Jacobson’s (tympanic) nerve emerged from the inferior ganglion of the GPhN, and the Arnold’s (auricular branch of the vagus) nerve also consisted of branches from the GPhN. The GPhN exits from the jugular foramen posteromedial to the styloid process and the styloid muscles. The last four cranial nerves and the internal jugular vein pass through a narrow space between the transverse process of the atlas (C1) and the styloid process. The styloid muscles are a pyramid shape, the tip of which is formed by the attachment of the styloid muscles to the styloid process. The GPhN crosses to the anterior side of the stylopharyngeus muscle at the junction of the stylopharyngeus, middle constrictor, and hyoglossal muscles, which are at the base of the pyramid. The middle constrictor muscle forms a wall between the GPhN and the hypoglossal nerve in this region. Then, the GPhN gives off a lingual branch and deepens to innervate the pharyngeal mucosa. CONCLUSIONTwo landmarks help to identify the GPhN in the subarachnoid space: the choroid plexus of the lateral recess of the fourth ventricle and the dural entrance porus of the jugular foramen. The opening of the cochlear aqueduct, the mastoid canaliculus, and the inferior tympanic canaliculus are three landmarks of the GPhN within the jugular foramen. Finally, the base of the styloid process, the base of the styloid pyramid, and the transverse process of the atlas serve as three landmarks of the GPhN at the extracranial region in the infratemporal fossa.

Duplication of the abducens nerve at the petroclival region. An anatomic study

OBJECTIVEDuring its course between the brainstem and the lateral rectus muscle, the abducens nerve usually travels forward as a single trunk, but it is not uncommon for the nerve to split into two branches. The objective of this study was to establish the incidence and the clinical importance of the duplication of the nerve. METHODSThe study was performed on 100 sides of 50 autopsy materials. In 10 of 11 cases of duplicated abducens nerve, colored latex was injected into the common carotid arteries and the internal jugular veins. The remaining case was used for histological examination. RESULTSFour of 50 cases had duplicated abducens nerve bilaterally. In seven cases, the duplicated abducens nerve was unilateral. In 9 of these 15 specimens, the abducens nerve emerged from the brainstem as a single trunk, entered the subarachnoid space, split into two branches, merged again in the cavernous sinus, and innervated the lateral rectus muscle as a single trunk. In six specimens, conversely, the abducens nerve exited the pontomedullary sulcus as two separate radices but joined in the cavernous sinus to innervate the lateral rectus muscle. In 13 specimens, both branches of the nerve passed beneath the petrosphenoidal ligament. In two specimens, one of the branches passed under the ligament and the other passed over it. In one of these last two specimens, one branch passed over the petrosphenoidal ligament and the other through a bony canal formed by the petrous apex and the superolateral border of the clivus. In all of the specimens, both branches were wrapped by two layers: an inner layer made up of the arachnoid membrane and an outer layer composed of the dura during its course between their dural openings and the lateral wall of the cavernous segment of the internal carotid artery. This finding was also confirmed by histological examination in one specimen. CONCLUSIONDouble abducens nerve is not a rare variation. Keeping such variations in mind could spare us from injuring the VIth cranial nerve during cranial base operations and transvenous endovascular interventions.

Giant aneurysm of the azygos pericallosal artery: case report and review of the literature.

BACKGROUND Pericallosal aneurysms are encountered less than 6.7%, and giant aneurysms among them even less. Giant azygos pericallosal artery aneurysm at the callosomarginal bifurcation is extremely rare, and our case presented herein is the second one. The case is discussed with thorough review of the literature. METHODS A 65-year-old woman presented with an extremely rare giant aneurysm on the azygos pericallosal artery manifesting as subarachnoid hemorrhage in World Federation of Neurosurgical Societies Grade 3. Computed tomography (CT), magnetic resonance angiography (MRA), and four vessel angiography revealed a giant azygos pericallosal artery aneurysm associated with a second aneurysm at the left M1. RESULTS After recovery to Grade 2, she underwent surgery via the right frontal interhemispheric approach for the azygos artery aneurysm on the 17th day after bleeding. The true dimensions of the aneurysm were greater than indicated by angiography because of partial thrombosis. Trilobulate aneurysm was carefully dissected from the surrounding structures. Postoperative cerebral angiography showed no filling of the clipped aneurysm and preservation of circulation. CONCLUSIONS The treatment of distal anterior cerebral artery aneurysms is often difficult, because of their broad-based irregular configurations and adherence to surrounding tissue, tendency to bleed irrespective of size and the coexistence of other cerebral aneurysms. However, excellent outcomes can be obtained based on thorough preoperative radiologic evaluation, including magnetic resonance imaging (MRI), and correct selection of surgical approach.

Coexistence of Rapidly Resolving Acute Subdural Hematoma and Delayed Traumatic Intracerebral Hemorrhage

Rapid resolution of acute subdural hematoma is rare. Delayed traumatic intracerebral hematomas following medical or surgical treatment of increased intracranial pressure have also been reported. Coexistence of a quickly resolving acute subdural hematoma and a delayed traumatic intracerebral hemorrhage has not been reported before. A 13-month-old boy was admitted to our emergency department after a car accident. On CT, a thin acute subdural hematoma on the right frontotemporal region and a small epidural hematoma on the left frontal region could be seen. On 24-hour follow-up CT, the right subdural hematoma was found to be less dense but larger than it had been before. At 36 h after hospitalization, CT showed that the right acute subdural hematoma had completely disappeared; however, a delayed traumatic intracerebral hematoma on the left occipital region was identified. We think that the mechanism involved in the development of a delayed intracerebral hematoma in our case was similar to the one causing delayed traumatic intracerebral hematoma after treatment for increased intracranial pressure.

Asymptomatic interval in delayed traumatic intracerebral hemorrhage: report of two cases

Delayed traumatic intracranial hemorrhage (DTICH) is seen mostly in trauma to the occipitoparietal region by countercoup mechanism. It is most encountered within the first posttraumatic 10 days, particularly in the first 3. Herein, two cases of delayed traumatic intracerebral hemorrhage were discussed, first one presented with headache and vomiting who had been asymptomatic for 168 days after head trauma and the other presented with dysarthria and hyperkynesias after 92 days of asymptomatic interval, either being longer than that of the previous cases reported in the literature. Despite a long time elapse, DTICH should be considered in the differential diagnosis in the patients with history of head trauma that manifests at later stages with intracranial pressure elevation symptoms such as headache, vomiting.

Jugular foramen syndrome caused by choleastatoma

Unilateral paresis of 9th-11th cranial nerves together is defined as jugular foramen (Vernets) syndrome. A cholesteatoma case that penetrated into intracranial area after eroding temporal bone and led to jugular foramen syndrome is presented here, since such a case has not been reported in the literature hitherto. A 46-year-old male patient was evaluated for hoarseness. It was learnt from his anamnesis that he had been operated for otitis media nearly 20 years ago. Uvula deviated towards right. Loss of gag reflex was remarkable on the left. Paresis was found on the left vocal cord. There was weakness in rotation of the head to the right. Computerized tomography (CT) scan revealed that the temporal bone lost its integrity and that there was an extra-axial hypodense mass neighboring pontocerebellum. Post-contrast magnetic resonance imaging showed that the mass, which showed thin, regular circular contrasting and which was hypointense in T1-weighted MR and hyperintense in T2-weighted MR, extended to the left jugular foramen. The mass was totally removed with left sub-occipital approach in the treatment. After the treatment, hoarseness, weakness in the rotation movement of the head and loss of gag reflex recovered totally, while deviation in the uvula was permanent. Cholesteatomas can extend to posterior fossa and cause jugular foramen syndrome. Early surgery is important to completely reverse the lost nerve functions in treatment.

Characteristics of Pellet Injuries to the Orbit

Purpose: To investigate the features of orbital injuries by pellets fired from the front. Design: Retrospective, 4 cases of pellet injuries. Methods: Five orbits of 4 patients who sustained pellet injuries received from the front were reviewed retrospectively. The course of injury and results were assessed. Radiological examinations were reviewed. The patients were evaluated between December 1996 and June 2004. Results: Five orbits of 4 patients sustained injuries caused by pellets fired from an anterior direction. The globe in the injured orbit was intact in 2 cases. Severe loss of vi- sion was also present in these 2 globes due to optic nerve involvement. Final visual acuity was down to no light perception in 4 eyes and limited to light perception in 1 eye. Conclusions: The prognosis of orbital pellet injuries is, unfortunately, poor. A pellet passing through the floor of the orbit often causes double perforation of the globe and, once in the orbital aperture, it travels towards the apex as a result of the conical shape of the orbit and lodges in the optic canal or its entrance, severely damaging the optic nerve. Surgery or other treatments are usually unsuccessful. Even if the globe is intact, vision is usually severely impaired.

Brain Abscess Developing at the Site of Preceding Stroke: Report of Three Cases: Review of Literature

Abstract:Abscess formation after a stroke is a rare event. The 3 cases treated at our clinic are presented in combination with an evaluation of other previously reported cases so as to establish their common characteristics. One of the cases had the characteristics of nonseptic ischemic stroke, whereas the other 2 had characteristics of hemorrhagic stroke. The patients presented to our clinic in the early poststroke period with complaints of headache of increasing intensity, nausea, and vomiting. All 3 cases had other infection findings, and there were no new neurologic deficits other than those related to the stroke. The diagnoses of abscess formation at the same location as the stroke were established through cranial computed tomography or cranial magnetic resonance imaging. The diagnoses were also confirmed by microscopic evaluation. After drainage of the abscess, treatment involved 8 weeks of antibiotic treatment based on antibiogram results. Stroke facilitates the formation of an abscess at the same location. The early period of the first 3 months after a stroke is when there is the highest risk for this complication. The most prevalent source of infection is bronchopulmonary. An abscess usually presents with deterioration of neurologic condition, increased intracranial pressure, and findings of infection. Because it is located at the same location as the stroke, however, it may not create additional new neurologic deficits. The stroke experienced previously does not affect the efficiency and treatment time of the antibiotics used after drainage of the abscess.

Wooden foreign body in the orbitocranial location

Orbitocranial injuries caused by a wooden foreign body are rarely encountered.We present a 17-year-old boy who sustained an intracerebral injury from a wooden foreign body via the transorbital route. Almost all neuro-ophthalmological signs were present due to penetration of the material into the optic canal and superior orbital fissure.There was a minute laceration on the upper eyelid, whereas the eye bulb was macroscopically intact.The wooden foreign body (6.5cm in length) was removed via the upper eyelid. The diagnostic and therapeutic modalities of intracranial injuries caused by a wooden foreign body through the transorbital route are discussed in this paper.