Selim Kayaci

Subarachnoid, subdural and interdural spaces at the clival region: an anatomical study.

AIM We aimed to show the significance of the anterior pontine membrane as a determining structure between the subdural and subarachnoid space in the clival region. MATERIAL AND METHODS Five adult cadaver heads and five cerebral hemispheres were used. The skull vault and hemipheres were removed by sectioning through the pontomesencephalic junction. Five other heads hemispheres were removed but the arachnoid membrane was protected and the cerebral side of the clival dura mater was dissected. In another specimen, the dural porus of the abducens nerve was sectioned for histological evaluation. Three cases of hematoma at the clivus were presented to support our findings. RESULTS The anterior pontine membrane is the arachnoid membrane forming the anterior wall of the prepontine cistern with its lateral extension at the skull base. This membrane forms the subdural and subarachnoid spaces by forming a barrier between the clival dura mater and neurovascular structures of the brainstem. There were rigid fibrous trabeculations between both cerebral and periosteal dural layers forming the basilar plexus as the interdural space in the clivus. CONCLUSION The anterior pontine membrane separates the subdural and subarachnoid spaces at the clival region. The hematomas of the clival region require to be evaluated with consideration given to the existance of the subdural space.

Role of neuron density of the stellate ganglion on regulation of the basilar artery volume in subarachnoid hemorrhage: An experimental study

BACKGROUND The role of neuron density (of the stellate ganglion) in basilar artery vasospasm after subarachnoid hemorrhage (SAH) has not previously been investigated. This subject was studied. METHODS This study was conducted on 24 rabbits. Four of them were used as the baseline control group. Experimental SAH was applied to the 15 animals; the remaining five of them were used as a sham group injecting by the serum physiologic saline (PS) and followed up twenty days later. Stellate ganglion neuron densities were estimated stereologically. Vasospasm index (VSI) was used to assess the severity of vasospasm. The value of VSI between 1 and 1.5 was accepted as no vasospasm, 1.5-2 was accepted as light vasospasm and 2 or greater than 2 was accepted as severe vasospasm. Results were compared statistically. RESULTS The mean basilar artery VSI in the control group (n: 4) was calculated as 1.24±0.39 and the neuron density of stellate ganglion was calculated as 8320±675/mm(3). These values in the PS group (n: 5) were calculated as 1.26±0.37 and 8380±680/mm(3). In animals with light basilar artery vasospasm (n: 6), the basilar artery VSI and neuron density of stellate ganglion were 1.65±0.37, 9210±460/mm(3) consecutively, but the basilar artery VSI was 2.07±0.40 and neuron density was 12,075±950/mm(3) in animals with severe vasospasm (n: 9). CONCLUSION The neuron density of stellate ganglion may play an important role in the development of basilar artery vasospasm. The beneficial effect of sympathectomy for the prevention of cerebral vasospasm may be explained through this mechanism.

Effect of Inner Membrane Tearing in the Treatment of Adult Chronic Subdural Hematoma: A Comparative Study

The postoperative results of chronic subdural hematoma (CSDH) procedures using catheterization and tearing of inner membrane (CTIM) technique have not previously been discussed in the literature. This article compares the effects of CTIM technique on brain re-expansion and re-accumulation with cases operated on with a burr-hole craniotomy and outer membrane incision (BCOMI) technique. The study involved operations on 144 patients (Group 1) using the CTIM technique and 108 patients (Group 2) using the BCOMI technique. In the operations using the CTIM technique in Group 1, the mean effusion measured in the subdural space (SDS) was 10.0 ± 0.2 mm, and for Group 2, 14.3 ± 0.6 mm in the postoperative period on the first and third days and this difference was found to be significant (p < 0.05). The means were 6.6 ± 0.2 mm for Group 1 and 10.3 ± 0.5 mm for Group 2 on the seventh day (p < 0.05). Recurrence rate was 8.3% in Group 2 and 0 in Group 1. This difference was statistically significant (p = 0001). The length of hospital stay was 7.0 ± 0.1 days for the Group 1 and 8.8 ± 0.2 days for Group 2 and this difference was significant (p < 0.05). These results indicate that the CTIM technique is preferable because it results in earlier re-expansion, lower recurrence, less subdural effusion and pneumocephalus, and shorter hospital stays.

What makes Maurice Ravel’s deadly craniotomy interesting? Concerns of one of the most famous craniotomies in history

Maurice Ravel (1875–1937), the great impressionist-classicist composer of many popular compositions, such as the Boléro, suffered from a progressive disease and died following an exploratory craniotomy by Clovis Vincent. The history of his progressive dementia and the contribution of a car accident, following which he was unable to function, have received a certain amount of interest in the neurological literature previously, but his deadly craniotomy was not evaluated from a neurosurgery perspective. The car accident in 1932, with the probable consequence of a mild-to-moderate traumatic brain injury, could be the key event in his life, triggering the loss of his ability to compose. It is clear that he never recovered from his injury and within a year he became completely unable to function. His dementia progressed dramatically. This event needs to be kept in mind. In 1937, Ravel died after the craniotomy performed by Vincent, but only a speculative, retrospective diagnosis is possible since an autopsy was not undertaken.

Angiosarcoma of the liver with metastasis to the cervical spine cured with the treatment of thalidomide and radiotherapy.

Dear Editor, We would like to present a unique case of metastatic angiosarcoma of the cervical spine treated with thalidomide. A 62-year-old male patient presented at the general surgery outpatient clinic with pain in his back and epigastric area, which had lasted for several days. On examination, epigastric tenderness was noted and the liver was palpable. There were extralobular growths adjacent to the vascular structures on the abdominal magnetic resonance imaging (MRI). A biopsy was taken from the masses that largely occupied the left lobe of the liver. Histopathological examination revealed infiltration of the hepatic tissue with epitheloid-like cells that had large vesicular nuclei and eosinophilic cytoplasms, and with proliferating tumour cells with mitotic activity. Angiosarcoma was diagnosed according to above pathological findings. The patient declined a second operation, which was recommended for the removal of the remaining part of the tumour. It was decided to treat the patient with thalidomide after the consultation with the medical oncologists, as there have been several published reports concerning its anti-tumour effects, including inhibition of cytokines and angiogenesis, immunomodulation and induction of apoptosis [1]. After 3 months of treatment (600 mg of thalidomide/day), a significant regression in the tumour mass was noted. Haematological parameters were measured every 3 months, while upper abdominal MRI scans were obtained every 6 months, during the course of medical treatment. One year later the patient developed a pain in the left shoulder, which was radiating down the left arm that was numb and weak. Neurological examination revealed hypothenar atrophy and C6, 7, and T1 hypoesthesia. The cervical MRI scan showed a contrast-enhanced lesion in the seventh cervical body, left pedicle and left posterior arch, which were consistent with a metastatic lesion (Fig. 1). Radiotherapy was planned. A daily dose of 4 Gy for 13 days was administered to the cervicothoracic area with the result of significant regression of the tumour. A daily 600-mg dose of thalidomide was continued for 2 years, followed by a 2-year daily dosage of 300 mg. Hepatic angiosarcoma, also known as hemangiosarcoma, is an extremely rare malignant tumour and represents 1-3% of all primary liver cancers [4]. It develops from liver endothelial cells, and occurs in adult age groups with a peak incidence in the 6th and 7th decades. The prognosis of angiosarcoma is very poor and patients usually die within a year [2]. A haemorrhagic mass in the liver should be considered as being either a hemangioma, hepatoma, or metastatic lesion [3]. Sixty percent of patients with angiosarcomas have metastasis at the time of diagnosis. Our patient S. Kayaci (*) Department of Neurosurgery, School of Medicine, Rize University, Rize 53100, Turkey e-mail: selim_kayaci@hotmail.com

Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

Introduction The treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems of neurosurgery. We report the rupture of a giant, lobulated, and almost completely thrombosed middle cerebral artery (MCA) aneurysm that is the ninth such report in the literature. We also investigated additional solutions used in the treatment of this patient. Case Presentation A 58-year-old man had been admitted with headache 8 years previously (in 2005), and a giant MCA aneurysm was detected. Two separate endovascular interventions were performed, and both failed. The patient began to live with the giant aneurysm. As there was a large thrombosis filling the aneurysm lumen during the previous endovascular procedures, the aneurysm was not expected to rupture. However, a rupture eventually occurred, in 2013. Even if an aneurysm is very large, lobulated, old, and almost completely thrombosed, it can suddenly bleed. During surgery on this patient, we observed severe cerebral vasospasm caused by a giant thrombosed aneurysmal rupture. Despite the complications, surgery is a life-saving treatment for this emergency when other strategies are not possible. Thrombectomy and clipping are approaches that require a great deal of courage for the neurosurgeon, in terms of entering the risky area within the aneurysm. Conclusions We believe that it would be more appropriate to plan for combined treatment with surgical and endovascular approaches before the emergency condition could occur.

Importance of the perforating arteries in the proximal part of the PICA for surgical approaches to the brain stem and fourth ventricle - an anatomical study

OBJECTIVE The purpose of this study is to examine the perforating arteries (PAs) in the proximal part of the posterior inferior cerebellar artery (PICA) for surgical approaches to the brain stem and fourth ventricle, and to stress their importance in microsurgical procedures. METHODS Twenty-six adult cadaver obtained from routine autopsies were used. During the examination, the PAs and the segmental structure of the proximal part of the PICAs and their relation to the neighbouring anatomical structures were demonstrated. RESULTS We classified the PICAs into 4 types on the basis of the distance of the middle point of the width of the caudal loop to the midline, and their presence or absence as Group A (symmetrical, anterior medullary type: 26.9%), Group B (lateral medullary type: 15.4%), Group C (asymmetrical type: 38.5%), and Group D (unilateral type: 19.2%). The number of the PAs in the tonsillomedullary segment and the caudal loop was higher than those originating from the other segments. CONCLUSIONS Approaches to the medial or lateral of the PICA should be made in a way that protects the PAs (avoiding retraction of the PICA). Otherwise the PAs will be damaged and as a result brain stem ischaemia may occur, which can have serious clinical outcomes.

Split Rib Cranioplasty for Frontal Osteoma: A Case Report and Review of the Literature

Introduction Osteomas are benign bone tumors. They generally lead to a local thickness on the frontal bone in calvarium. When they occur on the forehead, they often cause a cosmetic disorder without any neurological symptoms. The significant problem is the repair method of the cranium defect. Case Presentation The rib of a 34-year-old female was split and used for a small cranium defect of 3 × 3.5 cm. The preferred method and the obtained results were presented under the guidance of the literature. Conclusions Along with the technological advancement, different materials are employed according to the size of the cranium defect and the age of the case. The application of split costa cranioplasty for the small cranium defects in the region of patient’s face is the method with the least possibility of complications, and its cosmetic and functional results are quite promising.

A Transdural Approach for Lower Lumbar Burst Fractures. A Novel(Kotil) Technical Note

The treatment of surgical procedure of lower lumbar burst fractures is challenged. The optimal method remains controversial. To assess the usefulness and safety of a novel both decompression and reconstructive procedures known as transdural approaches of lower lumbar spine burst fracture. For this reason, we presented the results of a trans-dural approach which is a new technique. We presented the reconstruction and dural repairing results of 5 cases that were operated on between the years 1995-2011 due to lower lumbar burst fractures with a trans-dural surgical technique. Cases were chosen for this technique according to the presence of lamina fractures displayed on tomography (CT) and lumbar (MRI). Intra canal fragments, lamina fractures were determined. The postoperative opening of the spinal canal, the loss of height of the middle and anterior column and the postoperative fusion results were investigated. The surgical results of the cases were classified according to the Odom’s criteria. No instances of neurological deterioration and instrument failure occurred and no complications were noted with the use of this technique. All five patients had neurological function recovery at the most recent follow-up visit. In conclusion, this reported new surgical approach is an efficient and safe method for the treatment of traumatic lower lumbar burst fractures.