Pulat Akin Sabanci

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.

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.

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.

Traumatic epidural hematomas of the posterior cranial fossa

BACKGROUND Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF. METHODS Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively. RESULTS Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery. CONCLUSION When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans.

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.

The effects of tibolone on the human primary glioblastoma multiforme cell culture and the rat C6 glioma model

Abstract Objectives: In the light of recent advances in tumor biology and genetics, we hypothesized that tibolone, an estrogen receptor agonist, may have antiproliferative effects on primary human glioblastoma cells and rat C6 malignant glioma cell lines. We thought that tibolone should exert its antiproliferative effects by augmenting glial cell differentiation through the naive, nonhypermethylated estrogen receptors in the glioma cells. Methods: Human primary glioblastoma multiforme (GBM) cells were acquired perioperatively from ten patients aged between 45 and 69 years, diagnosed clinically and radiologically with GBM. The diagnosis was confirmed using immunohistochemical assays. Human GBM and rat C6 malignant glioma cells were cultivated in vitro to obtain monolayer cell cultures. Tibolone was then applied to these cultures in wells, each containing 500,000 tumor cells. Results: Tibolone significantly decreased the number of human GBM cells at the concentrations of 10 and 100 mg/ml. For tibolone, a strong dose-dependent correlation in tumor inhibition was found (p=0.001). This antiproliferative effect of tibolone in human GBM cells was not observed in rat C6 malignant glioma cells. Tibolone demonstrated differential effects on human GBM and rat C6 glioma cells. Discussion: In vitro antiproliferative effects of tibolone on human GBM need to be investigated further in in vivo works.

A thrombosing, giant, distal posterior cerebral artery aneurysm in a newborn infant

Intracranial aneurysms are extremely rare in infancy. No consensus has yet been developed about the exact treatment of this rare situation. The authors report the case of a 47-day-old male infant who had multiple seizures on the same day, leading to the diagnosis of an intracranial aneurysm. The case was managed conservatively with close imaging follow-up, and the patient had a good recovery. The results of neurological examination were completely normal at the 5-year follow-up visit. These rare lesions may be suspected on the basis of clinical findings and correctly diagnosed with current neuroradiological imaging modalities. The authors believe this report contributes valuable imaging data on rare childhood aneurysms to the literature, as well as emphasizing the importance of clinical and imaging information in therapeutic decision making in children with intracranial vascular problems.

Comparison of 3% Hypertonic Saline and 20% Mannitol for Reducing Intracranial Pressure in Patients Undergoing Supratentorial Brain Tumor Surgery: A Randomized, Double-blind Clinical Trial

Background: In the present study, we hypothesized that 3% hypertonic saline (HS) is more effective than 20% mannitol to reduce intracranial pressure (ICP) and to modify brain bulk in patients undergoing an elective supratentorial craniotomy. Materials and Methods: After institutional review board approval, patients scheduled to undergo supratentorial craniotomy were enrolled into this prospective, randomized, double-blind study. The patients were monitored for routine hemodynamic parameters, depth of anesthesia, and ICP. They received 5 mL/kg 20% mannitol (n=20) or 3% HS (n=19) as infusion for 15 minutes. The patients’ ICP values were monitored during hypertonic fluid infusion and throughout 30 minutes after infusion as a primary outcome. Secondary outcomes were hemodynamic variables, serum sodium value, blood gases, and surgeon brain relaxation assessment score (1=relaxed, 2=satisfactory, 3=firm, 4=bulging). In addition, the length of intensive care unit and hospital stay were recorded. Results: Demographic and tumor characteristics were similar between groups. The basal (before hypertonic infusion, ICPT0) and last (30 min after hypertonic infusion finished, ICPT45) ICP values were 13.7±3.0 and 9.5±1.9 mm Hg, respectively, for the M group, which were comparable with the corresponding levels of 14.2±2.8 and 8.7±1.1 mm Hg in the HS group (P>0.05). The median amount of ICP reduction between T0 and T45 timepoints were 4 (1 to 7) and 5 (1 to 9) mm Hg for group M and group HS, respectively (P=0.035). Baseline central venous pressure, pulse pressure variation, and serum sodium and lactate values were similar between groups, but the last measured pulse pressure variation and lactate value were lower, and sodium value was higher in group HS than in group M (P<0.05). Duration of hospital and intensive care unit stay were similar between groups. Conclusions: Our results suggest that 3% HS provided more effective ICP reduction than 20% mannitol during supratentorial brain tumor surgery.

Surgery for Pyogenic Brain Abscess over 30 Years: Evaluation of the Roles of Aspiration and Craniotomy.

AIM To evaluate the roles of craniotomy and aspiration in the treatment of pyogenic brain abscess throughout 30 years of computerized tomography. MATERIAL AND METHODS A retrospective study of 224 patients who were surgically treated at Istanbul Medical Faculty, Department of Neurosurgery between 1982 and 2012 was undertaken. The records were analyzed for demographic, clinical and radiological findings, surgical interventions (resection, free-hand aspiration and image-guided aspiration), data regarding abscesses (etiological factors, site, size, number, localization and identified microorganism), corticosteroid and antibiotic usage and complications, and the outcomes were reviewed. RESULTS The male-to-female ratio was 2.2, and the mean age was 26.2±1.25 years. The most common presenting symptom was headache (56.7%), followed by nausea and vomiting (28.5%). Otitis media and mastoiditis were the most common causes of abscess (41.9%), and 44 patients had multiple abscesses. Aerobic gram-positive microorganisms were the most frequently isolated pathogens in culture (51.5%). Primary surgical interventions were as follows: craniotomy and resection (38.8%), free-hand aspiration (49.1%) and image-guided aspiration (12.1%). The aspiration-to-resection ratio was 1.36 (64/47) in the first decade, 2.94 (50/17) in the second decade and 1 (23/23) in the last decade. Age, level of consciousness at the time of admission and potent corticosteroid usage were found to be significantly associated with mortality (p=0.001, p≤0.001 and p=0,038, respectively). The total morbidity and mortality ratios were 4.9% and 9.8%, respectively. Seizures were more common in patients of craniotomy group (p=0.023). CONCLUSION Treatment of pyogenic brain abscess remains challenging, despite advances in surgical and imaging technology, and craniotomy retains a significant role in surgical treatment.

Transcortical Removal of Third Ventricular Colloid Cysts: A comparison of Conventional, Guided Microsurgical and Endoscopic Approaches and a Review of the Literature.

AIM To compare the clinical results of different transcortical approaches for the removal of third ventricular colloid cysts (CC). MATERIAL AND METHODS Records of 41 colloid cyst patients who underwent transcortical conventional microsurgical, microsurgical with the aid of stereotactically guided cylindrical retractor (minitubular), and endoscopic removal between 1999 and 2015 were retrospectively analyzed. The clinical results of these three different transcortical surgical approaches were compared and a literature review of published series was conducted. RESULTS Ages ranged between 16 and 66 years (mean: 36.8). There were 18 female and 23 male patients. Headache was the main presenting symptom. The mean CC diameter was 15.5 mm. Intraventricular hemorrhage was encountered in 2 patients. Three patients needed postoperative ventriculoperitoneal shunt surgery. Postoperative seizures were seen in 3, postoperative neurological deficit in 3 and residual tumor in 2 patients. The conventional approach resulted in significantly higher rates of postoperative seizure compared to the minitubular and endoscopic approaches (p=0.012). The rate of residual cyst was significantly higher in endoscopic approach compared to conventional and minitubular approaches (p=0.024). Conventional approach led to significantly higher rates of neurological deficit compared to the two other approaches (p < 0.05). CONCLUSION With respect to complication rates, the stereotactic and endoscopic approaches are both safe and reliable compared to conventional microsurgical approach that has unacceptably high rates of seizures and neurological deficit. Concerning completeness of removal, both microsurgical approaches are by far superior to neuroendoscopy. The stereotactic microsurgical approach compares favorably in both respects with endoscopic and conventional microsurgical approaches.