Nurperi Gazioglu

Endoscopic endonasal approach to the orbital apex and medial orbital wall: anatomic study and clinical applications.

Objective: The objective of this study was to recognize the endoscopic anatomy of the orbital apex and medial orbital wall to understand the pure endoscopic endonasal approaches to this region and their clinical applications. These basic information will facilitate our surgical procedures and decrease the rate of surgical complications. Material and Methods: Five fresh adult cadavers were studied bilaterally (N = 10). We used Karl Storz 0- and 30-degree 4-mm, 18-cm, and 30-cm rod-lens rigid endoscopes in our dissections. After cadaver specimen preparation, we approached each orbital apex and medial orbital wall through each nostril. After resection of medial orbital wall, an endoscopic intraorbital approach was performed. Results: The orbita could be exposed by using 0- and 30-degree endoscopes. We preferred to start the approach from the sphenoid sinus instead of transethmoidal approaches that are less familiar to the neurosurgeons. The posterior and anterior ethmoidal arteries are in close relation to the supralateral wall of ethmoid sinus, thus care must be taken not to injure these arteries during dissection. In this way, we can safely expose the whole medial wall of the orbita. Optic canal decompression can be safely done by bone resection starting from the optic nerve toward the optic canal. We continued bone resection from the posterior to the anterior of the medial orbital wall, thus we can perform medial orbitotomy. The intraorbital approach can be done medially by introducing the endoscope between the medial and inferior rectus muscles. Conclusions: Our anatomic study offered the facility to learn the endoscopic anatomy of the orbital apex and the medial wall of the orbita and understand the appropriate approaches (such as medial orbitotomy and optic canal decompression) to some pathologic lesions of this region. With skilled and experienced hands, it can superimpose many traditional orbital approaches with minimal invasiveness and less postoperative complications.

Meckel-Gruber syndrome

Abstract Meckel-Gruber syndrome is a congenital disorder characterized by occipital encephalocele, polydactyly and polycystic kidneys. This rare syndrome has been reported in the literature as incompatible with life. We present the case of a newborn afflicted with the clinical triad of Meckel-Gruber syndrome. Appropriate treatment instituted in our case led to a good early outcome.

Intracranial migration of bone dust after intraventricular neuroendoscopy complicating acute hydrocephalus and removal of bone dust: case report.

OBJECTIVETo present the first case of neuroendoscopic removal of migrated intraventricular bone dust and gel foam after intraventricular endoscopic surgery. CLINICAL PRESENTATIONA 37-year-old man was admitted with a 2-year history of headache. Brain computed tomography (CT) scan and magnetic resonance imaging revealed a cavum vergae cyst. The patient was operated on by stereotactically guided endoscopic cyst fenestration with no intraoperative complications. Postoperative CT scan demonstrated regression of the cyst with no other pathological findings. Because of a postoperative fever, a lumbar puncture was performed after the brain CT scan to eliminate meningitis as a differential diagnosis. After the lumbar puncture, the patient complained of severe headache and vomiting followed by depression of consciousness. The follow-up CT scan showed the migration of bone dust from the burr hole site to the ventricular system and acute hydrocephalus. It is thought that the negative pressure gradient generated after the lumbar puncture might have been transmitted through the cerebrospinal fluid pathway, resulting in a suction effect and migration of the bone dust from the burr hole to the ventricle. INTERVENTIONAn urgent reexplorative endoscopic procedure was performed, and most of the bone dust and gel foam were removed. The patient recovered with complete resolution of the previous symptoms. CONCLUSIONWe propose not using autologous bone dust for closure of the burr holes after endoscopic intraventricular procedures; instead, alloplastic materials designed especially for burr hole closure may be used. However, our main recommendation is to use an external ventricular drainage, which is maintained closed but can be opened if necessary. In addition, lumbar puncture should be avoided in cases in which bone dust is used for the burr hole reconstruction without dural closure.

Extended endoscopic endonasal approach to the clival region.

Objective: The objective of this study was to recognize the endoscopic anatomy of the clival region of the skull base and its neurovascular relations, which will make us able to perform safer and minimal invasive endoscopic approaches to this region with lower rate of complications. Materials and Methods: Six fresh cadavers were studied (n = 5). We approached the clivus by performing binostril extended endoscopic endonasal approach. After locating the sphenoid sinus as a key point, the vomer was totally removed to expose the clival region located inferiorly to the sphenoid sinus. Mucosal incision is done vertically from the sphenoidal portion the clivus caudally to the inferior portion of nasal cavity just medially to vidian nerve. The mucosal flap is then dissected and retracted. The clivus was resected until the foramen magnum inferiorly. The lateral limit of the resection is the paraclival portion of the internal carotid artery (ICA).The dura and the meningohypophyseal artery is exposed. A vertical dural incision was done and retracted laterally to expose the intradural structures. The prepontine cistern and basilar artery were visualized. Results: The clivus was best localized by orienting the endoscope +15 degrees rostrally. After resecting the inferior wall of the sphenoid sinus and vomer and the overlying mucosa is retracted laterally until the vidian nerve, we obtained sufficient exposure of the clivus. The safe lateral limit of the surgical corridor was the vidian nerve. The clivus is resected until the foramen magnum inferiorly. The safe lateral limit of the resection in this step was the proximal cavernous and the distal petrosal portions of the ICA. This resection provided us with a wide exposure of the clival dura. The basilar plexus, the abducens nerve (sixth cranial nerve) passing through the basilar plexus, and the paraclival portion of the ICA can be injured when careful dissection is not performed. After dural incision, the prepontine cistern and the basilar artery were able to be exposed widely. Conclusion: Binostril extended endoscopic endonasal approach is an appropriate approach to the clival region of the skull base. With good knowledge of the endoscopic anatomic features of this region and its neurovascular relations, surgical procedures can be performed safely with more minimal invasiveness.

Extradural Balloon Obliteration of the Empty Sella Report of Three Cases (Intrasellar Balloon Obliteration)

Summary Empty sella syndrome is an anatomical and clinical entity composed of intrasellar reposition of the CSF and compression of the pituitary tissue, resulting in a clinical picture of headache, visual field defect, CSF rhinorrhea and some mild endocrinological disturbances. While some cases are primary with no appreciable aetiology, secondary cases are associated with prior operation or radiotherapy of the region. In our series, 3 patients with primary empty sella syndrome were treated by the current approach of extradural filling of the sellar cavity. This technique was first described by Guiot and widely accepted thereafter. We used a detachable silicon balloon filled with HEMA or liquid silicone for obliteration of the sellar cavity and obtained clinically satisfactory results without complications. Visual symptoms regressed and headache disappeared. But at long term follow-up all the balloons were found to be deflated. Despite the facility and efficacy of the technique we do not recommend it in the treatment of the empty sella because the filling of the sella is only transient and relapses may occur.

Chiasmatic low-grade glioma presenting with sacral intradural spinal metastasis

Abstract Leptomeningeal metastasis of low-grade gliomas in children has been documented in several series, both at the time of diagnosis and at relapse. The authors report a unique case of chiasmatic low-grade astrocytoma presenting with signs and symptoms related to the metastatic site rather than the primary site. In this respect, the possibility of appearance of symptoms and signs related to leptomeningeal dissemination preceding the signs and symptoms belonging to the primary site should be considered in this type of benign tumours.

Microsurgical and endoscopic anatomy of Liliequist's membrane and the prepontine membranes: cadaveric study and clinical implications.

BackgroundLiliequist’s membrane is mostly described as having a diencephalic leaf, mesencephalic leaf, and diencephalic-mesencephalic leaves in the literature. Also different descriptions of the prepontine membranes were reported. In this study, we visualized the regular structural forms of membranes without disturbing any attachments and defined infrachiasmatic and prepontine safety zones. We discussed the clinical significance of these structures.Materials and methodsThe study was carried out on 24 adult human cadavers at the Morgue Specialization Department of the Forensic Medicine Institution following the initial autopsy examination. Liliequists membrane and the prepontine membranes were explored after retraction of the frontal lobes. Dissections were performed under the operative microscope. A 0- and 30-degree, 2.7-mm angled rigid endoscope (Aesculap, Tuttlingen, Germany) was advanced through the prepontine cistern from the natural holes of membranes, or small holes were opened without damaging the surrounding structures.ResultsThe basal arachnoid membrane (BAM) continued as Liliequists membrane (LM) without any distinct separation in all specimens. The LM coursed over the posterior clinoids and split into two leaves as the diencephalic leaf (DL) and mesencephalic leaf (ML) in 18 specimens; the medial pontomesencephalic membrane (MPMM) coursed anterolaterally as a continuation of the ML and attached to the medial surfaces of the fifth and sixth nerves, joining with the lateral pontomesencephalic membrane (LPMM), which was also a posterolateral continuation of the ML in all specimens. The medial pontomedullar membrane (MPMdM) and lateral pontomedullar membrane (LPMdM) were observed in 21 specimens. The MPMdM membrane was a continuation of the MPMM, and the LPMdM was a continuation of the LPMM in all 21 specimens.ConclusionWe observed that the LM is a borderless continuation of the BAM. The MPMM and LPMM split from the ML without any interruptions. The MPMdM and LPMdM were a single membrane continuing from the MPMM and LPMM. We determined infrachiasmatic and prepontine areas that can be important for inferior surgical approaches.

Idiopathic granulomatous hypophysitis: are there reliable, constant radiological and clinical diagnostic criterias?

Abstract Idiopathic granulomatous hypophysitis is a rare inflammatory disease of unknown aetiology; few cases are reported. We review the clinical presentation and radiological characteristics of these cases and our own experience with three new surgical cases, to determine diagnostic criteria. MRI of three cases revealed sellar lesions extending into the chiasmatic cistern. Their shape varied, from dumbbell to spherical and elliptical. All were isointense with the brain on T1-weighted images and gave heterogeneously high signal on T2-weighted images. Contrast enhancement was homogeneous in one case and heterogeneous in another. The pituitary stalk could not be identified. There was no dural enhancement. The sphenoid sinus mucosa was thickened in two cases and normal in one.

Neuronavigation-guided endoscopic endonasal excision of an intraorbital intraconal cavernous hemangioma.

A 50-year-old man presented with the complaints of gradual decrease of visual acuity in his left eye since 2 years. Brain magnetic resonance imaging revealed a left intraorbital intraconal round mass lesion consistent with cavernous hemangioma. Binostril endoscopic endonasal approach was performed with the aid of neuronavigation. The lesion was well capsulated and easily dissected and resected totally without complication. Early postoperative course was uneventful. Three-month follow-up after surgery revealed that the visual acuity and visual fields of the patient were normalized, and magnetic resonance imaging demonstrated total excision of the lesion.

Microsurgical anatomy of membranous layers of the pituitary gland and the expression of extracellular matrix collagenous proteins

BackgroundThere are several reports about the microanatomical and histological features of sellar and parasellar membranous structures and clinical studies about MMP proteinase as a predictive factor. However, studies on collagen contents of sellar and parasellar membranous structures are limited. We demonstrated the membranous structures surrounding the pituitary gland and defined extracellular matrix (ECM) collagenous proteins, collagen I-IV expression patterns of sellar and parasellar connective tissues.MethodsThe study was carried out on ten fresh postmortem human bodies at the Forensic Medicine Institution. Cavernous sinuses were resected with sellar structures and were stored at −80°C liquid nitrogen tanks. Medial wall of the cavernous sinus, pituitary capsule and pituitary tissue samples were obtained for RT-PCR. Opposite side specimens were used for histological and immune staining studies. Collagens I-IV were studied by immunohistochemical and reverse transcription polymerase chain reaction (RT-PCR) methods.FindingsThe pituitary capsule and medial wall were identified as two different structures. The fibrous membrane, as the third membrane, was identified as staying whole in eight of ten specimens. Increased type IV collagen was determined in the pituitary gland, medial wall and pituitary capsule, respectively, in both RT-PCR and immunhistochemical studies. Immunhistochemical studies revealed that collagen I was strongly expressed in both the medial wall and pituitary gland.ConclusionIncreased type IV collagen was detected especially in pituitary tissue, the medial wall and the pituitary capsule by immune staining and RT-PCR. Type IV collagen was considered to be an important factor in the progression of adenoma and invasion.