Suat Boyaci

Complications of brain tissue pressure monitoring with a fiberoptic device.

Seventy-five patients with intracranial hypertension whose Glasgow Coma Score (GCS) was 8 or below and in whom intracranial pressure (ICP) was monitored were examined for complications of this procedure. In 20 of the 75 patients we used only an intraparenchymal fiberoptic ICP monitoring transducer, while, in the remaining 55 patients, who required CSF drainage, a ventricular drainage set (VDS) was used in addition to ICP monitoring. The duration of monitoring with the ICP transducer alone was approximately 5.1 ± 2.6 das (min. 1, max. 13) and that of ICP monitoring with VDS was 6.2 ± 3.1 days (min. 1, max. 13). In 8 cases a total of 9 complications were experienced (12 %). These complications were infection in 3 cases (4 %), epidural hematoma in 2 cases (2.7 %), disconnection in 2 cases (2.7 %) and contusion in 2 cases (2.7 %). Although none of the 44 patients who were monitored for less than 5 days experienced infection, 3 of the 31 patients monitored for longer than 5 days did experience infection (9.7 %) (p < 0.05). None of the 20 patients who underwent ICP monitoring only experienced infection. However, 3 of the 55 patients in whom the ventricular drainage set was implanted in addition to the transducer for ICP monitoring experienced infection (p < 0.05).Owing to its minimally invasive nature, low complication rate, and accuracy in monitoring the parenchyma pressure, the Camino fiberoptic intraparenchymal monitor has become the system of choice in our clinic.

Intraocular neuromuscular choristoma: a case report and literature review.

BACKGROUND AND IMPORTANCE: Neuromuscular choristomas (NMCs) are rare benign tumors of the peripheral nerves. Although histopathological characteristics of this unusual lesion have been recognized, in this regard, neuroimaging findings have not been well described previously. We report the first intraconally located NMC affecting the oculomotor nerve, with histopathological and radiological characteristics. CLINICAL PRESENTATION: A 10-year-old girl presented with sudden-onset left temporal and retro-orbital pain. Magnetic resonance imaging scans demonstrated a small, capsulated, retro-orbital, intraconal solid lesion that was diagnosed as an atypical dermoid cyst preoperatively. The tumor was resected subtotally. Postoperatively, the patient became pain free, but ipsilateral ptosis and upward eye movement failure developed. Histologically, the lesion consisted of well-differentiated striated muscle fibers intermingled with mature nerve elements consistent with the NMC. CONCLUSION: Although intracranial NMCs need histological confirmation for diagnosis, neuroimaging might contribute to the preoperative diagnosis and management strategy of treatment. We report the first intraconal NMC, which should be considered in the differential diagnosis of intraorbital tumors.

Anatomical study of the cavernous sinus emphasizing operative approaches.

AIM The aim of this article is to describe the microsurgical anatomy of the cavernous sinus, the triangles, and the osseous relationships in the region with special attention to the relationships important in surgical approaches on the intracavernous structures. MATERIAL AND METHODS Fifty cavernous sinuses obtained from twenty-five cadaver heads were studied in detail using magnification. Stepwise dissections of the cavernous sinuses performed to demonstrate the intradural and extradural routes, anatomy of the triangles and osseous relationships in the region. RESULTS The main branches of the intracavernous portion of the carotid artery were the meningohypophyseal, the inferior cavernous sinus, and McConnell;s capsular artery . The main branches of the meningohypophyseal trunk were the tentorial, the dorsal meningeal, and the inferior hypophyseal artery. There were variations of the main branches of the meningohypophyseal trunk. The sixth cranial may splite into rootlets as it passes lateral to the carotid artery. There were size and shape variation of the triangles. CONCLUSION Aprecise understanding of the bony relationships, the anatomy of the triangels and neurovascular content of the cavernous sinus, together with the use of cranial base and microsurgical techniques are necessary for safer surgery. Asingle approach is not capable of providing exposure of all parts of the sinus.

Surgical anatomy of the cavernous sinus, superior orbital fissure, and orbital apex via a lateral orbitotomy approach: a cadaveric anatomical study

BackgroundTumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions.MethodsLateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections.ResultsChanging the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit.ConclusionsThis approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.

Long-term Clinical Outcome of the Lumbar Microdiscectomy and Fragmentectomy: A Prospective Study

Currently microdiscectomy is the standard treatment for the herniated lumbar disks. The aim of this study is to compare the long-term outcome of microdiscectomy versus sequestrectomy/free fragmentectomy for lumbar disk herniation and the effect of disk herniation type to reherniation. Disk herniations are classified into 3 categories: (a) fragment-fissure herniations, (b) fragment-defect herniations, and (c) fragment-contained herniations. Reherniation rate, annular competence, perioperative complications, operating time, the preoperative and postoperative Visual Analog Scale, Oswestry Disability Questionnaire, and the use of analgesics at the time of follow-up were compared. A total of 170 (78 sequestrectomy, 92 microdiscectomy) patients covered the inclusion criteria for study, and follow-up examinations were conducted completely. Reherniation rates did not differ significantly (2.56%, sequestrectomy; 4.34%, microdiscectomy; P>0.05). The highest recurrence rate was observed in the fragment-defect herniations group that received discectomy (10.8%). Self-rated assessment demonstrated clinical deterioration of the surgical results within the first 2 years after microdiscectomy, although they rather improved after sequestrectomy. Outcome measures at 2 years pointed in favor of sequestrectomy, with results being significant. Outcome after microdiscectomy seems to worsen over time, whereas it remains stable after sequestrectomy. The degree of annular competence seems to have effect on reoperation rate.

Evacuation of subdural collections by endoscopy.

AIM Intraoperative use of the endoscope is a hot topic in neurosurgery and it gives broader visualization of critical and hardlyreached areas. Endoscope-assisted surgical approach to chronic subdural haematoma (SDH) is a minimally invasive technique and may give an expansion to the regular method of burr-hole haematoma drainage. MATERIAL AND METHODS Endoscope-assisted haematoma drainage with mini-craniotomy was performed over a 24-month period, and prospectively collected data is reviewed. A total of 10 procedures (8 patients) were performed using the endoscopeassisted technique. Four of them were chronic SDH and six were subacute SDH. RESULTS Procedures were extended 20 minutes in average because of endoscopic intervention. There was no extra-morbidity through the study as a consequence of endoscopic assessment. CONCLUSION Endoscope-assisted techniques can make the operation safe in selected circumstances with improved intraoperative visualization. It may likewise take into consideration the identification and destruction of neo-membranes, septums and solid clots. In addition, the source of bleeding can be easily coagulated. The endoscope-assisted techniques, with all of these features, can alter the pre- and intra-operative decision-making for selected patients.

Misdiagnosed Orbital Aneurysmal Bone Cyst: A Case Report and Review

Aneurysmal bone cysts (ABCs) are benign, fibrosseous, non-neoplastic, osteolytic, and expansile lesions that develop in childhood or early adulthood. We present a review on ABC literature and a rare case of primary ABC in the orbital roof in a 17-year-old girl, with 9 years of follow-up, who had first been operated at a different department with meningioma diagnosis and subtotally excised. Then when the patient was admitted to our clinic, ABC was suspected on MRI and treated by total excision. After the second operation, a meaningful regression in proptosis diagnosis was determined as compared with her previous examination results. The vision level of both the eyes was measured as the highest level by best correction, and proptosis was not seen during her latest inspection. This case showed us the importance of MRI on ABC diagnosis and effectiveness of total excision on treatment.

Intraocular Neuromuscular ChoristomaA Case Report and Literature Review

BACKGROUND AND IMPORTANCE: Neuromuscular choristomas (NMCs) are rare benign tumors of the peripheral nerves. Although histopathological characteristics of this unusual lesion have been recognized, in this regard, neuroimaging findings have not been well described previously. We report the first intraconally located NMC affecting the oculomotor nerve, with histopathological and radiological characteristics. CLINICAL PRESENTATION: A 10-year-old girl presented with sudden-onset left temporal and retro-orbital pain. Magnetic resonance imaging scans demonstrated a small, capsulated, retro-orbital, intraconal solid lesion that was diagnosed as an atypical dermoid cyst preoperatively. The tumor was resected subtotally. Postoperatively, the patient became pain free, but ipsilateral ptosis and upward eye movement failure developed. Histologically, the lesion consisted of well-differentiated striated muscle fibers intermingled with mature nerve elements consistent with the NMC. CONCLUSION: Although intracranial NMCs need histological confirmation for diagnosis, neuroimaging might contribute to the preoperative diagnosis and management strategy of treatment. We report the first intraconal NMC, which should be considered in the differential diagnosis of intraorbital tumors.

Intraocular Neuromuscular Choristoma

BACKGROUND AND IMPORTANCE: Neuromuscular choristomas (NMCs) are rare benign tumors of the peripheral nerves. Although histopathological characteristics of this unusual lesion have been recognized, in this regard, neuroimaging findings have not been well described previously. We report the first intraconally located NMC affecting the oculomotor nerve, with histopathological and radiological characteristics. CLINICAL PRESENTATION: A 10-year-old girl presented with sudden-onset left temporal and retro-orbital pain. Magnetic resonance imaging scans demonstrated a small, capsulated, retro-orbital, intraconal solid lesion that was diagnosed as an atypical dermoid cyst preoperatively. The tumor was resected subtotally. Postoperatively, the patient became pain free, but ipsilateral ptosis and upward eye movement failure developed. Histologically, the lesion consisted of well-differentiated striated muscle fibers intermingled with mature nerve elements consistent with the NMC. CONCLUSION: Although intracranial NMCs need histological confirmation for diagnosis, neuroimaging might contribute to the preoperative diagnosis and management strategy of treatment. We report the first intraconal NMC, which should be considered in the differential diagnosis of intraorbital tumors.