Serhat Baydin

Can Recurrence of Chronic Subdural Hematoma Be Predicted? A Retrospective Analysis of 292 Cases

BACKGROUND Chronic subdural hematomas are the most common type of intracranial hemorrhage among the elderly. There is a substantial recurrence rate after evacuation by burr-hole surgery. In this study, we aimed to determine the predictors of recurrence after single burr-hole evacuation of chronic subdural hematomas. METHODS We retrospectively analyzed 292 consecutive patients with chronic subdural hematoma. Clinical parameters, anamnesis, and previous anticoagulant drug use have been evaluated with univariate and multivariate analyses to determine predictors associated with recurrence. RESULTS At least a second surgery was needed in 43 of 292 (14.7%) patients. We showed that recurrence rate was significantly higher in patients with bilateral subdural hematoma, after univariate and multivariate analyses (23.1% versus 11.4%). We did not find any significant relationship between recurrence rate and age, gender, hypertension, and/or diabetes mellitus in anamnesis, preceding head trauma, and time interval between trauma and the operation, previous anticoagulant, and/or antiaggregant therapy. CONCLUSION After analysis of all evaluated factors, only bilateral hematoma was found correlated with high recurrence rate (p = 0.01), probably due to previous brain atrophy or existing coagulopathy.

Midline and off-midline infratentorial supracerebellar approaches to the pineal gland

OBJECTIVE A common approach to lesions of the pineal region is along the midline below the torcula. However, reports of how shifting the approach off midline affects the surgical exposure and relationships between the tributaries of the vein of Galen are limited. The purpose of this study is to examine the microsurgical and endoscopic anatomy of the pineal region as seen through the supracerebellar infratentorial approaches, including midline, paramedian, lateral, and far-lateral routes. METHODS The quadrigeminal cisterns of 8 formalin-fixed adult cadaveric heads were dissected and examined with the aid of a surgical microscope and straight endoscope. Twenty CT angiograms were examined to measure the depth of the pineal gland, slope of the tentorial surface of the cerebellum, and angle of approach to the pineal gland in each approach. RESULTS The midline supracerebellar route is the shortest and provides direct exposure of the pineal gland, although the culmen and inferior and superior vermian tributaries of the vein of Galen frequently block this exposure. The off-midline routes provide a surgical exposure that, although slightly deeper, may reduce the need for venous sacrifice at both the level of the veins from the superior cerebellar surface entering the tentorial sinuses and at the level of the tributaries of the vein of Galen in the quadrigeminal cistern, and require less cerebellar retraction. Shifting from midline to off-midline exposure also provides a better view of the cerebellomesencephalic fissure, collicular plate, and trochlear nerve than the midline approaches. Endoscopic assistance may aid exposure of the pineal gland while preserving the bridging veins. CONCLUSIONS Understanding the characteristics of different infratentorial routes to the pineal gland will aid in gaining a better view of the pineal gland and cerebellomesencephalic fissure and may reduce the need for venous sacrifice at the level of the tentorial sinuses draining the upper cerebellar surface and the tributaries of the vein of Galen.

Microsurgical and Fiber Tract Anatomy of the Nucleus Accumbens

BACKGROUND: The nucleus accumbens (NAc) has been a target for deep brain stimulation (DBS) in the treatment of depression and obsessive-compulsive disorder (OCD). OBJECTIVE: To examine the anatomy and connections of the NAc using a fiber dissection technique. METHODS: Ten human brains and 2 whole cadaveric heads were examined by fiber dissection technique and ×6 to ×40 surgical magnification. The NAc was examined from the lateral, medial, superior, and inferior sides to define its fiber connections and relationships with adjacent cortical and subcortical structures. Magnetic resonance imaging (MRI) with 1-mm slices was used to define its neuronavigation coordinates. RESULTS: Eight tracts, the uncinate fasciculus, cingulum, stria medullaris thalami, fornix, diagonal band of Broca, stria terminalis, medial olfactory stria, and forceps minor, form a capsule around the anterior, inferior, and medial sides of the NAc. The uncinate fasciculus connects along the inferior and adjacent part of the medial side of the NAc, the cingulum and diagonal band along the medial surface, the medial olfactory stria along the posteromedial and adjacent part of the inferior surface, the forceps minor along the anteromedial surface, and the stria terminalis, fornix, and stria medullaris along the posterosuperior surface. The subcortical gray matter related to the NAc includes the septal nuclei, indusium griseum, substantia innominata, caudate nucleus, and hypothalamus. The cortical areas communicating with and overlying the NAc are reviewed. CONCLUSION: An increased understanding of the fiber connections and neural relationships of the NAc should allow more accurate DBS targeting for the treatment of psychiatric disorders. ABBREVIATIONS: BA, Brodmann area DBS, deep brain stimulation NAc, nucleus accumbens OCD, obsessive-compulsive disorder SLF, superior longitudinal fasciculus

The double massa intermedia

Background: To describe the rare finding of a double massa intermedia (MI). Typically, the MI (interthalamic adhesion) is a single bridge of gray matter connecting the medial surfaces of the thalami. Methods: Twelve formalin- and alcohol-fixed human third ventricles were examined from superior to inferior by fiber dissection technique under ×6 to ×40 magnifications and with the endoscope. Results: In all hemispheres, the anterior and posterior commissure were defined. The MI, which bridges the medial surfaces of the thalami, was defined in all hemispheres. In one hemisphere, there was a second bridge between the thalami, located posteroinferior to the common MI. Endoscopic view confirmed that there was a second MI in this specimen. The MI usually traverses the third ventricle posterior to the foramen of Monro and connects the paired thalami. The MI is an important landmark during endoscopic and microscopic surgeries of the third ventricle. Although a double MI is very rare, surgeons should be aware of the possibility in their surgical planning. Conclusion: The surgeon should be aware of the possibility of a double MI to avoid confusion during third ventricle surgery.

Prevention of postoperative visual field defect after the occipital transtentorial approach: Anatomical study

OBJECTIVE A postoperative visual field defect resulting from damage to the occipital lobe during surgery is a unique complication of the occipital transtentorial approach. Though the association between patient position and this complication is well investigated, preventing the complication remains a challenge. To define the area of the occipital lobe in which retraction is least harmful, the surface anatomy of the brain, course of the optic radiations, and microsurgical anatomy of the occipital transtentorial approach were examined. METHODS Twelve formalin-fixed cadaveric adult heads were examined with the aid of a surgical microscope and 0° and 45° endoscopes. The optic radiations were examined by fiber dissection and MR tractography techniques. RESULTS The arterial and venous relationships of the lateral, medial, and inferior surfaces of the occipital lobe were defined anatomically. The full course of the optic radiations was displayed via both fiber dissection and MR tractography. Although the stems of the optic radiations as exposed by both techniques are similar, the terminations of the fibers are slightly different. The occipital transtentorial approach provides access for the removal of lesions involving the splenium, pineal gland, collicular plate, cerebellomesencephalic fissure, and anterosuperior part of the cerebellum. An angled endoscope can aid in exposing the superior medullary velum and superior cerebellar peduncles. CONCLUSIONS Anatomical findings suggest that retracting the inferior surface of the occipital lobe may avoid direct damage and perfusion deficiency around the calcarine cortex and optic radiations near their termination. An accurate understanding of the course of the optic radiations and vascular relationships around the occipital lobe and careful retraction of the inferior surface of the occipital lobe may reduce the incidence of postoperative visual field defect.

Anatomic Investigation of the Trajectory for Stereotactic Laser Amygdalohippocampectomy

BACKGROUND Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) has emerged as a promising treatment for mesial temporal lobe epilepsy. Surgeons must understand the relevant anatomy that is traversed by the catheter and affected by ablation. OBJECTIVE To study the anatomic structures crossed by the LITT catheter until it reaches the amygdala. METHODS Three human cadaveric heads were implanted with catheters using a frameless stereotactic technique. The Visualase® system (Medtronic, Dublin, Ireland) was utilized to ablate along the trajectory. Coronal and oblique axial slices were created. Fiber tract dissections were performed in a lateral-medial and inferior-superior scheme. Magnetic resonance tractography was acquired to illustrate the tracts dissected. RESULTS Entry points occurred within 4 cm of the transverse and sagittal sinus, inferior to the lambdoid suture. The cortex of the inferior occipital gyrus was crossed in the region of the transverse occipital sulcus. The vertical occipital fasciculus was crossed en route to passing through the optic radiations. The catheter crossed through or inferior to the optic radiations before piercing the parahippocampal gyrus at about 4 cm from the skull. The catheter entered the hippocampus as it pierced the superior margin of the parahippocampus at 6 cm. The catheter entered the head of the hippocampus to lie inferolateral to the amygdala in the last centimeter of the trajectory. CONCLUSION Understanding the anatomic principles of LITT catheter trajectories will improve the ability to perform this procedure. The current study is the first to examine the anatomy of this trajectory and will serve as the basis for future studies.

Safe surgical approach to extrahepatic pseudocyst, a rare shunt complication: 2 case reports

BackgroundHepatic pseudocysts are not a common complication and “extrahepatic” pseudocysts are rarer complications but may occur in every ventriculo-peritoneal shunt patient.Case presentationWe present two patients with ventriculo peritoneal shunt induced extrahepatic pseudocysts, who underwent shunt surgery for different etiologies. Etiology, treatment strategies and our choice of treatment have been discussed.ConclusionsWhen a ventriculoperitoneal shunt patient is presented with non-specific abdominal symptoms, the possibility of this complication should always be considered. In the treatment of this complication, it is shown that repositioning the catheter is sufficient for cyst regression.

Bilateral Non-Traumatic Acute Subdural Hematoma in Newborn

1 Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi, Nöroşirurji Kliniği, İstanbul 2 Bakırköy Ruh ve Sinir Hastalıkları Eğitim ve Araştırma Hastanesi, Nöroşirurji Kliniği, İstanbul 3 Gevaş Devlet Hastanesi, Kadın Hastalıkları ve Doğum Bölümü, Van 4 Gaziosmanpaşa Taksim Eğitim ve Araştırma Hastanesi, Nöroşirurji Kliniği, İstanbul 5 Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi, Pediatri Kliniği, İstanbul Olgu Sunumu

Pregnancy and Lumbar Disc Herniation

Siyatalji yakinmasi olan gebelerde tetkik olarak yumusak dokuya hassasiyeti ve fetusa zararinin olmamasi nedeniyle Manyetik Rezonans Goruntuleme (MRG) tercih edilir. Şiddetli agri on planda ise ilk planda epidural steroid enjeksiyonu dusunulebilir. Ancak, motor ve/veya sfinkter kusuru tespit edildiyse cerrahi karari verilmelidir. Sol lateral dekubit pozisyonda cerrahiye alinmali ve ameliyat boyunca fetal kalp sesleri takip edilmelidir.

A Case of Neonatal Meningomyelocele Operated Under Sedoanalgesia

Norosirurji pratiginde yenidoganlarda en sik karsilasilan acil spinal girisim gerektiren patolojilerden biri, beyin-omurilik sivisi (BOS) sizintisinin eslik ettigi meningomyelosel olgularidir. Noral tup olusum ve kapanma defektlerine bagli olarak gelisen meningomyelosel olgulari, her 1000 dogumda 2-5 oraninda gorulmektedir (1,2). Bununla birlikte, prenatal goruntuleme tekniklerinin gelismesine bagli olarak olgularin erken evrede taninmasi ve gebeligin sonlandirilmasi nedeniyle meningomyelosel insidansi azalma egilimindedir (2). Meningomyelosel olgularinda cerrahi onarimla saglam noral dokuya hasar verilmeksizin acik yaranin kapatilmasi ve BOS sizintisinin onlenmesi amaclanir. Aktif BOS gelisi izlenen olgularda enfeksiyon riski nedeniyle acil cerrahi planlanmaktadir (3,4). JOPP Derg 4(2):85-88, 2012