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Purpose: To investigate the effect of the clival bone pattern on the abducens nerve (AN) localization in the petroclival region between the Pediatric and Adult Groups., Methods: This study used 12 pediatric and 17 adult heads obtained from the autopsy. The length and width of the clivus and the length of the petrosphenoidal ligaments (PSLs) were measured. The ratio of the length and width of the clivus was accepted as the clival index (CI). The localization of the AN at the petroclival region below the PSL, classified as lateral and medial, were recorded., Results: The average length of the clivus was 26.92 ± 2.88 mm in the Pediatric Group, and 40.66 ± 4.17 mm in the Adult Group (p < 0.001). The average width of the clivus was 22.35 ± 2.88 mm in the Pediatric Group, and 29.96 ± 3.86 mm in the Adult Group (p < 0.001). The average value of the CI was 1.20 in the Pediatric Group and 1.36 in the Adult Group (p = 0.003). The length of the PSL was 7.0 ± 1.47 mm in the Pediatric Group and 11.05 ± 2.95 mm in the Adult Group (p < 0.001). The nerve was located below the medial side of the PSL in the Pediatric Group and below the lateral side in the Adult Group (p = 0.002)., Conclusions: The petrous apex localization of the AN in adults compared with pediatric subjects could be related to the increased growth in the length of the clivus than its width.

Purpose: Despite advances in spinal biomechanic research, surgical techniques, and rehabilitation processes, no significant improvement has been identified in the treatment of spinal cord injury (SCI) and neurological recovery. Aim of the Study: This study was designed to investigate the potential therapeutic effects of methylprednisolone and levetiracetam on SCI. Materials and Methods: In this study, 42 male Wistar Albino rats, each weighing 300-350 g, were separated into three main groups: control group, acute and subacute stage groups. With the exception of the control group, a T7-8 dorsal laminectomy was performed on the spinal column of the rats. A temporary vascular aneurysm clip was then applied to the spinal cord for 1 min to create SCI and methylprednisolone or levetiracetam was administered intraperitoneally to all except the control and SHAM control groups. The damaged spinal cord was removed for histopathological and biochemical examinations. Results: Both pharmacological agents were determined to have improved the histopathological architecture in damaged neural tissues during the acute period of SCI, but could not sustain this activity in the subacute period. Neither pharmacological agent affected the biochemical data in the acute nor subacute stages. Conclusions: Both pharmacological agents showed histopathological healing effects in injured tissues during the acute phase of SCI in this rat model but these effects could not be sustained in the subacute period. No effect on biochemical data was seen in either the acute or subacute period. There is a need for further advanced studies to determine the effects of levetiracetam on the healing processes in SCI.

Aim: To measure and to compare the volume of thalamus using magnetic resonance imaging (MRI) and the anatomical sections., Material and Methods: In this study, 13 brain specimens were used. First, the images were taken in 3 mm sections on MRI, the thickness of the thalamus was measured. Subsequently, 4 mm coronal sections were prepared using a microtome. The thalamic volumes calculated from cadaveric specimens were compared with the measurements obtained using MRI., Results: On MRI, the mean thalamic volumes on the right and left hemispheres were found to be 5843.4 ± 361.6 mm3 and 5377.0 ± 666.2 mm3 respectively. The mean volumes of the cadaveric sections were 5610.8 ± 401.3 mm3 on the right side and 5618.5 ± 604.1 mm3 on the left hemisphere. No statistically significant difference was found between the volume calculated from MRI and that obtained from the cadaveric section (p < 0.05)., Conclusion: This study shows a correlation between measurement of thalamus volume based on MRI and those calculated from anatomical sections. Our findings support the reliability of DBS procedures using MRI and stereotactic method.

Objectives: The aim of this study was to establish prognostic and predictive markers in patients with subarachnoid hemorrhage (SAH) using simple laboratory methods., Methods: A retrospective examination was made of patients with SAH diagnosed secondary to isolated head trauma, isolated anterior communicating artery aneurysm rupture, and angiography-negative SAH. Age, gender, Glasgow Coma Scale (GCS) scores, and Fisher's grade scores, Glasgow Outcome Scale (GOS) scores, leukocyte count, neutrophil count, lymphocyte count, platelet count, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio results (PLR) were evaluated., Results: NLR and PLR values, which were similar in patients with spontaneous SAH, were significantly high in patients with traumatic SAH. NLR and PLR values could be 80% sensitive and 75% specific for distinguishing traumatic SAH from spontaneous SAH. Eosinophil count was lower in patients with angiography-negative SAH and patients with aneurysmal SAH than in patients with traumatic SAH. Initially measured GCS score, Fisher's grade score, eosinophil, neutrophil and lymphocyte counts could be prognostic in all patients with SAH. Moreover, it was concluded that the initially measured number of eosinophils might be directly related to patient prognosis. The eosinophil count was generally found to be high in traumatic SAH patients and it was observed that this parameter could be predictive for these patients. Lymphocyte count and NLR values could be prognostic markers in patients with angiography-negative SAH., Conclusion: NLR, PLR and eosinophil count values could be predictive for etiological factors (traumatic SAH or spontaneous SAH) of patients who were admitted unconscious to the emergency room with SAH detected on radiological imaging.

In the present study, we investigated the types and ratio of posterior clinoid process (PCP) pneumatization in paranasal sinus multidetector computed tomography (MDCT). Paranasal MDCT images of 541 subjects (227 males, 314 females), between 15 and 65 years old, were included into the study. Pneumatization of anterior clinoid process and pneumatization types (I, II, or III) were evaluated in the males and females. PCP pneumatization was detected in 20.7 % of the males and 11.5 % of the females. Right, left, and bilateral PCP pneumatizations were detected in 7.9, 5.7, and 7.0 % of the males and 2.9, 3.2, and 4.5 % of the females, respectively. PCP pneumatization of the males is significantly higher than the females. The most detected type of pneumatization was type I (61.2 %) for all groups. In right, left, and bilateral pneumatizations separately, type I pneumatization was the most detected pneumatization type with the ratio of the 70.4, 65.2, and 50.0 %, respectively. In males, type I (61.7 %), and similarly in females, type I (60.6 %) pneumatization were detected more. Type II and type III pneumatizations were detected in decreasing order in both groups. In younger subjects, pneumatization of posterior clinoid process was found as higher, and in older subjects, PCP pneumatization was found as lower. Sclerosis process related to the aging may be responsible for the lower pneumatization ratios in older subjects. Structure of the surrounding regions of PCP is important for surgical procedures related to cavernous sinus, basilar apex aneurysms, and mass lesions. Preoperative radiological examinations are useful for operative planning. Any anomalies to PCP can cause unnecessary injury to the neurovascular complex structure around the cavernous sinus or postclinoidectomy CSF fistulas. Posterior clinoidectomies should be avoided in patients with type III PCP pneumatization to prevent CSF fistulas.

Objectives: The aim of this paper was a retrospective investigation of calcification at the petroclival region using Multi-slice Computed Tomography (MSCT)., Methods: One hundred thirty skull bases were reviewed. The images were acquired with a 64 slice CT (MSCT). At first images were taken at the axial plane; and then coronal and sagittal reconstructions of raw data were performed. Later investigations were carried out on these 3-dimensional images (3-D imaging). Petrosphenoidal ligament (PSL) (Gruber's ligament) and posterior petroclinoid ligament (PPCL) calcifications were evaluated as "none, partial or complete calcification" for the right and left sides., Results: In the right PSL, there were partial calcifications in 9.8% and complete calcifications in 2.3%. Calcification ratio was 9.8% partial and 2.9% complete in the left PSL. In the right side, there were 26.6% partial and 5.2% complete calcifications of PPCL. In the left side, there were 29.5% partial and 4.6% complete PPCL calcifications. PPCL calcification was detected more in males compared to females in the right and left sides. In older patients, left PSL; right and left PPCL calcification were detected more., Conclusion: PPCL calcifications cannot be differentiated from PSL calcifications in MSCT slices. The distinction can be easily done in 3-D views. The presence of ossified ligaments may make surgeries in this region difficult, and special care has to be taken to avoid injuries to structures which pass under these ossified ligaments. Particularly in elderly patients, the appropriate surgical instrument for the PSL calcifications should be prepared preoperatively. If PSL is calcified, 6th cranial nerve palsy may not occur even though increased intracranial pressure syndrome is present. Whereas, in lateral trans-tentorial herniations, 3rd cranial nerve palsy occurs in earlier periods when PSL is calcified. Moreover, in subtemporal and transtentorial petrosal approaches, knowing the PSL calcification preoperatively is important to avoid damaging the 6th cranial nerve during surgery., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Technological advancements in the diagnostic radiology recently permitted reviewing the normal anatomy through multidetector computed tomography (MDCT) imagination. The aim of this paper is retrospectively investigation of the clival foramen and canal through MDCT., Materials and Methods: One hundred eighty-six MDCT scans were reviewed. First, images were taken at axial plane, and then coronal and sagittal reconstructions of raw data were performed. Later investigations were carried out on these three-dimensional images (3-D imaging). The images were evaluated as clival foramen "present" or "absent.", Results: In our 186 patients, evaluation of MDCT showed that clival foramen was absent in 66.7% (n = 124) of patients. Only 33.3% (n = 62) of patients had a clival foramen. In 3-D images, clival canal and clival foramen were shown more clearly compared with the MDCT., Conclusions: Knowledge of the clival canal might be useful in patients of questionable clival fracture or during neurosurgical operations in this region. During life the canal contained a vein connecting the basilar plexus with the venous plexus of the vertebral canal, and inferior petrosal sinuses. Before the surgical interventions in the clival region, the presence of the clival canal and foramen should also be known due to its vascular contents. By multidetector computed tomography and 3-D images, clival canal and foramen may be viewed preoperatively.

Under pathological conditions such as brain trauma, subarachnoid hemorrhage and stroke, cortical spreading depression (CSD) or peri-infarct depolarizations contribute to brain damage in animal models of neurological disorders as well as in human neurological diseases. CSD causes transient megachannel opening on the neuronal membrane, which may compromise neuronal survival under pathological conditions. Poloxamer-188 (P-188) and citicoline are neuroprotectants with membrane sealing properties. The aim of this study is to investigate the effect of P-188 and citicoline on the neuronal megachannel opening induced by CSD in the mouse brain. We have monitored megachannel opening with propidium iodide, a membrane impermeable fluorescent dye and, demonstrate that P-188 and citicoline strikingly decreased CSD-induced neuronal PI influx in cortex and hippocampal dentate gyrus. Therefore, these agents may be providing neuroprotection by blocking megachannel opening, which may be related to their membrane sealing action and warrant further investigation for treatment of traumatic brain injury and ischemic stroke.

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., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objective: To report a case of pituitary adenoma apoplexy presenting with bilateral proptosis and bilateral third nerve palsy that developed after cardiovascular surgery., Clinical Presentation and Intervention: A 45-year-old man developed bilateral proptosis and bilateral third nerve palsy after a coronary artery bypass grafting operation. A pituitary macroadenoma with extension into the sphenoid sinus and cavernous sinus with bilateral involvement was resected on computed tomography scan by microscopic transsphenoidal procedure. Third nerve palsy improved partially on the first postoperative day and completely improved in the fourth month after the operation., Conclusion: This is a rare case of pituitary adenoma apoplexy that presented with bilateral third cranial nerve palsy., (Copyright © 2011 S. Karger AG, Basel.)

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.

Isolated abducens nerve palsy following lumbar puncture is a very rare condition. In this case we discussed the probable causes of abducens nerve palsy and review the mechanism of action in anatomical relevant literature. A 53-year old hypertensive female patient with a saccular aneursym on the left middle cerebral artery (MCA) bifurcation underwent emergency operation. Before the operation lumbar puncture (LP) was performed to the patient lying on the right lateral position to facilitate cerebral relaxation intraoperatively. The left MCA bifurcation aneurysm was clipped successfully with a left pterional-transsylvian approach. Postoperatively, she complained of visual diplopia and postural headache. In her neurological examination, isolated abducens nerve palsy was found on the left eye. The patient was treated with intravenous hydration, bed rest and non - steroid anti-inflamatuary drugs (NSAID) for postural headache. Her postural headache was resolved in the postoperative fifth day, but her abducens nerve palsy was present in the postoperative sixth month follow-up. Many classic textbooks have attributed the vulnerability of the abducens nerve to its long intracranial course, but it is now known that abducens nerves angulation points are the vulnerable parts of the nerve. We hypothesize that the petroclival dural entrance point is the entrapment point and lateral type abducens nerve, if present may be a factor that facilitates the injury of the nerve by lumbar puncture (LP).

Symptomatic spontaneous pneumocephalus after a spinal fusion for spondylolisthesis without injury to the dura mater is rare. There are only a few reports of tension pneumocephalus after spinal operations published in English. We present a patient who developed tension pneumocephalus without recognised dural injury during surgery. CT cisternography and MRI showed no anatomical defects that could have caused the pneumocephalus. We suggest that spontaneous pneumocephalus without dural injury may occur after a spondylolisthesis operation because of increased intra-abdominal pressure, and thus may be avoided by the careful management of abdominal pressure.

Middle turbinate osteoma is very rare and only two times have been reported before. We reported a 31-year old male presenting middle turbinate osteoma that extending into the anterior cranial fossa, causing pneumocephalus. The osteoma was resected by combining endoscopic sinus surgery with bifrontal craniotomy and the patient was relieved of headaches.

A 36-year-old male patient with Behcet's disease consulted our hospital for treatment of an unruptured intracranial aneurysm. He was neurologically intact. He had undergone surgery for an aneurysm of the superior mesenteric artery 2 years ago and had been followed up because of the aneurysm of the left radial artery for 1 year. He had been receiving steroid treatment for 4 years. Three-dimensional computed tomography angiography identified an aneurysm of the left intracranial internal carotid artery. The lesion was treated by coil embolization. He was discharged without complications. Intracranial aneurysm formation is extremely rare in patients with Behcet's disease. The presence of extracranial aneurysms indicates screening for intracranial aneurysms. The present case shows that coil embolization can be used to treat unruptured intracranial aneurysm in patients with Behcet's disease.

Purpose: To investigate the features of orbital injuries by pellets fired from the front., Design: Retrospective, 4 cases of pellet injuries., Methods: Five orbits of 4 patients who sustained pellet injuries received from the front were reviewed retrospectively. The course of injury and results were assessed. Radiological examinations were reviewed. The patients were evaluated between December 1996 and June 2004., Results: Five orbits of 4 patients sustained injuries caused by pellets fired from an anterior direction. The globe in the injured orbit was intact in 2 cases. Severe loss of vision was also present in these 2 globes due to optic nerve involvement. Final visual acuity was down to no light perception in 4 eyes and limited to light perception in 1 eye., Conclusions: The prognosis of orbital pellet injuries is, unfortunately, poor. A pellet passing through the floor of the orbit often causes double perforation of the globe and, once in the orbital aperture, it travels towards the apex as a result of the conical shape of the orbit and lodges in the optic canal or its entrance, severely damaging the optic nerve. Surgery or other treatments are usually unsuccessful. Even if the globe is intact, vision is usually severely impaired., (Copyright 2009 S. Karger AG, Basel.)

Objective: Cellular schwannomas (CS) are rare in the cranial space. This report is the first of a patient with a greater superficial petrosal nerve CS presenting with abducens nerve palsy and xerophthalmia., Clinical Presentation: A 16-year-old female patient presented with a 1-month history of diplopia. Neurological examination was normal except for the presence of right abducens nerve palsy. Schirmer's test revealed decreased tear secretion in the right eye. Computed tomography and magnetic resonance imaging showed a mass in the right petrous apex. It was thought that the schwannoma in our patient originated from the greater superficial petrosal nerve, based on the location of the tumor in addition to the absence of partial Horner's syndrome and a persistent decrease in tear secretion., Intervention: The tumor was exposed with the use of a right subtemporal extradural approach and removed entirely. Pathological evaluation of the tumor revealed a CS., Conclusion: The abducens nerve palsy improved completely in the follow-up period, but the decreased tear secretion did not resolve. CS is one of the subtypes of ordinary schwannomas and exhibits malignant features on microscopic examination, although it has a good clinical prognosis. No adjuvant treatment was applied because of the tumor's benign character. The greater superficial petrosal nerve schwannoma should be considered in the differential diagnosis of the abducens nerve palsy and petrous apex mass.

Objective: In this report, we aimed to investigate the patients that presented at our clinic complaint with diplopia due to the abducens nerve palsy and neurosurgical disease., Methods: The study design was a retrospective review of ten cases with the abducens nerve palsy. The causes of the abducens nerve paralysis of our patients were as follows: two cases with head trauma, three cases with pituitary tumors, one case with sphenoid sinus mucocele, one case with greater superficial petrosal nerve cellular schwannoma at the petrous apex, one case with hypertensive intraventricular hemmorhage, one case with hydrocephalus, and one case with parotid tumor and skull base/brain stem invasion., Results: Depending on the location of the lesion, the symptoms due to nuclear damage showed no improvement as in our case with adenocarcinoma of the parotid gland. The lesions sited at the subarachnoid portion of the abducens nerve or in the cavernous sinus, the abducens nerve palsy improved or botilinum injection was performed during recovery period., Conclusion: We presented abducens nerve palsy cases due to neruosurgical disorders. A botilinum injection was performed in three patients with the abducens palsy. Botilinum injection can help patients with sixth nerve palsy during the recovery period.

The combination of anterior and posterior instrumentation provides the most stable repair for burst fractures of the thoracolumbar spine. However, the use of both approaches on a trauma patient may increase morbidity. Stabilization of three columns through only one approach can provide an effective outcome. We treated eight patients with burst fracture involving the thoracic or lumbar vertebrae by the application of anterior and posterior stabilization instruments through only the posterior approach. The desired stabilization was obtained in all patients. The advantages are the absence of the risks of the anterior approach, facilitation of the placement of anterior and posterior stabilization devices through only one approach, preserving the unity of the anterior longitudinal ligament, the effect of the anterior corpus in preventing displacement of the cage, application of compression on the pedicle screw system to both decrease the kyphosis angulation due to collapse of vertebra and to help the stabilization of the cage, repair of the dural tears at the posterior side, prevention of cage displacement by distraction and thus leaning on the endplates, and ease of performance by a neurosurgeon alone.

Vascular involvement is common in Behçet's Disease (BD). The venous system is often affected, while arterial system involvement is a rare occurrence. Intracranial aneurysm formation associated with BD is extremely rare. A 38- year-old male patient with BD under the follow-up of the Dermatology department presented with acute headache. The cranial computed tomography revealed subarachnoid bleeding. A basilar artery aneurysm, which was ruptured during the procedure, was found on the cerebral angiography and the patient died the next day. This report adds our case to the literature of posterior cerebral circulation aneurysms associated with BD among the limited number of articles on this topic.

Objective: To describe a way to increase the exposure for L5-S1 neurofibroma extending to presacral area., Summary of Background Data: Since the neurofibromas of L5-S1 level generally extend to the extraforaminal and presacral area, their resection is difficult compared to other lumbar levels., Methods: A 46-year-old female presented with severe pain in her left leg. There was a mild motor power loss in her left ankle and toe at plantar and dorsiflexion, and a mild hypoesthesia in the posterior of the left foot and its base. Lumbar computed tomography and magnetic resonance imaging showed a mass in the left intervertebral foramen extending to the extraforaminal presacral area at the level of L5-S1. The tumor was removed through a surgical bone window in the base of the sacrum and resection of L5 transverse process on the left side., Result: The tumor was removed totally. Following surgery, the patient's pain had totally disappeared and there was no alteration in her neurological status., Conclusion: L5-S1 neurofibroma was totally resected through a surgical window in the base of the sacrum.

We aim to evaluate the mechanisms responsible for complications during trigeminal rhizotomy via foramen ovale puncture. Ten dry skulls and 10 skull-base specimens were investigated in the present study. In cadaveric skull-base specimens, the anatomical relationships between the foramen ovale, mandibular nerve and Gasserian ganglion and the surrounding neurovascular structures were investigated intradurally. The distance between the foramen ovale and Gasserian ganglion was measured as 6 mm. The abducent nerve, adjacent to the anterior tail of the petrolingual ligament, was observed passing along the lateral wall of the cavernous sinus. Advancement of the catheter more than 10 mm from the foramen ovale is likely to damage the internal carotid artery and the abducent nerve at the medial side of the petrolingual ligament. Thermocoagulation of the lateral wall of the cavernous sinus may damage the cranial nerves by heat, giving rise to pareses.

A 31-year-old male was presented with a very rare case of ipsilateral palsies of the nerves IX through XII (Collet-Sicard syndrome) after a closed head injury. An occipital condyle fracture that was associated with epidural hematoma was diagnosed by computed tomography. The patient was conservatively managed, and following the treatment, partial neurological recovery ensued. The phenomenon of occipital condyle fracture involving the last four cranial nerve palsies is relatively rare. Although 3 cases of Collet-Sicard syndrome that were caused by an occipital condyle fracture has been reported, the association between condyle fracture and epidural hematoma has never been described before.

Objective: We investigated the membranous architecture of the abducens nerve at the petroclival region and describe the characteristics of this area in cadaveric specimen and two children with hydrocephalus and sixth nerve palsy using magnetic resonance imaging (MRI)., Materials and Methods: Five adult cadaver heads were used to investigate the petroclival part of the abducens nerve. The heads were injected with colored latex for microsurgical dissection, and the length of the dural sleeve of the abducens nerve and its width at the apex were measured. In one cadaver head, the area between the petroclival entrance porus of the abducens nerve and the cavernous sinus was histologically studied under light microscopy. In two patients with hydrocephalus and abducens nerve palsy, the petroclival area was screened by using the MRI fat suppression technique., Results: In the cadavers, the arachnoid membrane on the clivus extended within the dural sleeve as far as the petrous apex, as an extension of the subarachnoid space. The average length of the dural sleeve was 9.5 mm and the average width was 1.5 mm at the apex, where the nerve entered the cavernous sinus. MRI scans showed that the cerebrospinal fluid distance of the petroclival region was 5 mm in the first patient and 7 mm in the second., Conclusion: The subarachnoid space inside the dural sleeve of the abducens nerve can be defined by using thin-slice MRI scans. Enlargement of the dural sleeve at the petroclival region may coexist with the abducens nerve palsy. It has been documented in this study that the arachnoid membrane forms a membraneous barrier between the subarachnoid and subdural spaces within Dorello's canal.

Unilateral paresis of 9th-11th cranial nerves together is defined as jugular foramen (Vernet's) syndrome. A cholesteatoma case that penetrated into intracranial area after eroding temporal bone and led to jugular foramen syndrome is presented here, since such a case has not been reported in the literature hitherto. A 46-year-old male patient was evaluated for hoarseness. It was learnt from his anamnesis that he had been operated for otitis media nearly 20 years ago. Uvula deviated towards right. Loss of gag reflex was remarkable on the left. Paresis was found on the left vocal cord. There was weakness in rotation of the head to the right. Computerized tomography (CT) scan revealed that the temporal bone lost its integrity and that there was an extra-axial hypodense mass neighboring pontocerebellum. Post-contrast magnetic resonance imaging showed that the mass, which showed thin, regular circular contrasting and which was hypointense in T1-weighted MR and hyperintense in T2-weighted MR, extended to the left jugular foramen. The mass was totally removed with left sub-occipital approach in the treatment. After the treatment, hoarseness, weakness in the rotation movement of the head and loss of gag reflex recovered totally, while deviation in the uvula was permanent. Cholesteatomas can extend to posterior fossa and cause jugular foramen syndrome. Early surgery is important to completely reverse the lost nerve functions in treatment.

Spondylodiscitis is a rare but serious complication of epidural catheter use. It is controversial as to which mechanism is responsible for development of this complication. It may develop due to direct contamination or hematogenous spreading. We report a 54-year-old woman who developed spondylodiscitis after epidural catheter was inserted and to whom analgesic and steroid treatment was given for chronic lumbar pain. In this case, each of 2 pathological mechanisms may be responsible. The diagnostic methods, mechanisms and management are discussed.

A 57-year-old male patient presented with an immobile ellipsoid mass of 6-cm diameter in the right occipitoparietal region. Cranial computed tomography showed the mass with dense contrast enhancement causing bone destruction. After embolization of the mass, total resection was performed. Histological examination showed the mass had a capsule, with no invasion of the dura mater or dermis, and the follicles of various sizes covered with mono-lined thyrocytes were full of colloid. Immunohistochemical examination showed positive staining for thyroglobulin. Postoperatively, levels of thyroid hormones were normal, and thyroid ultrasonography and technetium-99m scintigraphy showed no abnormalities. Fine needle aspiration biopsy performed at various locations of the thyroid gland revealed no atypical thyroid cells. Whole body technetium-99m scintigraphy found no abnormal bone involvement. The histological evidence was suggestive of follicular carcinoma metastasis. Surgical treatment was planned for the thyroid gland, but the patient did not consent. Two years later, the patient presented with the pain and sensitivity in the sacrum, the right iliac wing, and the right caput femoris. Computed tomography revealed lytic lesions in these areas. Bone metastases were identified. Whole body scintigraphy showed increased activity in these regions, but the cranium and all other tissues were normal. The patient underwent total thyroidectomy under a diagnosis of follicular carcinoma. The present case of a lytic skull lesion associated with normal thyroid tissue on admission but finally treated as follicular thyroid cancer emphasizes the difficulty in histological discrimination of follicular carcinoma from normal thyroid tissue.

Rapid resolution of acute subdural hematoma is rare. Delayed traumatic intracerebral hematomas following medical or surgical treatment of increased intracranial pressure have also been reported. Coexistence of a quickly resolving acute subdural hematoma and a delayed traumatic intracerebral hemorrhage has not been reported before. A 13-month-old boy was admitted to our emergency department after a car accident. On CT, a thin acute subdural hematoma on the right frontotemporal region and a small epidural hematoma on the left frontal region could be seen. On 24-hour follow-up CT, the right subdural hematoma was found to be less dense but larger than it had been before. At 36 h after hospitalization, CT showed that the right acute subdural hematoma had completely disappeared; however, a delayed traumatic intracerebral hematoma on the left occipital region was identified. We think that the mechanism involved in the development of a delayed intracerebral hematoma in our case was similar to the one causing delayed traumatic intracerebral hematoma after treatment for increased intracranial pressure.

Purpose: The goal of this study was to identify the abducens nerve in its cisternal segment by using three-dimensional turbo spin echo T2-weighted image (3DT2-TSE). The abducens nerve may arise from the medullopontine sulcus by one singular or two separated rootlets., Material and Methods: We studied 285 patients (150 males, 135 females, age range: 9-72 years, mean age: 33.3 +/- 14.4) referred to MR imaging of the inner ear, internal auditory canal and brainstem. All 3D T2-TSE studies were performed with a 1.5 T MR system. Imaging parameters used for 3DT2-TSE sequence were TR:4000, TE:150, and 0.70 mm slice thickness. A field of view of 160 mm and 256 x 256 matrix were used. The double rootlets of the abducens nerve and contralateral abducens nerves and their relationships with anatomical structures were searched in the subarachnoid space., Results: We identified 540 of 570 abducens nerves (94.7%) in its complete cisternal course with certainty. Seventy-two cases (25.2%) in the present study had double rootlets of the abducens nerve. In 59 of these cases (34 on the right side and 25 on the left) presented with unilateral double rootlets of the abducens. Thirteen cases presented with bilateral double rootlets of the abducens (4.5%)., Conclusion: An abducens nerve arising by two separate rootlets is not a rare variation. The detection of this anatomical variation by preoperative MR imaging is important to avoid partial damage of the nerve during surgical procedures. The 3DT2-TSE as a noninvasive technique makes it possible to obtain extremely high-quality images of microstructures as cranial nerves and surrounding vessels in the cerebellopontine cistern. Therefore, preoperative MR imaging should be performed to detect anatomical variations of abducens nerve and to reduce the chance of operative injuries.

Removal of lesions involving the jugular foramen region requires detailed knowledge of the anatomy and anatomical landmarks of the related area, especially the lower cranial nerves. The glossopharyngeal nerve courses along the uppermost part of the jugular foramen and is well hidden in the deep layers of the neck, making this nerve is the most difficult one to identify during surgery. It may be involved in various pathological entities along its course. The glossopharyngeal nerve can also be compromised iatrogenically during the surgical treatment of such lesions. The authors define landmarks that can help identify this nerve during surgery and discuss the types of lesions that may involve each portion of the glossopharyngeal nerve.

Object: This is an investigation into the effects of two barrier membranes in the prevention of peridural fibrosis in an animal model., Methods: Seprafilm or Gore-Tex was applied to a laminectomy defect overlying the dura mater in rats separated into treatment groups. A third group of rats underwent laminectomy only and served as controls. Two months postoperatively a histological study was performed to compare the amount of scar tissue in each group. The gross dissection demonstrated that both membranes created a controlled dissection plane, facilitated access to the epidural space, and provided a reduction in the amount of tissue adhering to the dura mater. Statistically, Seprafilm was superior to Gore-Tex in preventing peridural fibrosis (p < 0.05)., Conclusions: Seprafilm can prevent peridural fibrosis better than Gore-Tex and can be used in humans in spinal surgery.

Objectives: A novel denervation technique of ovarian was used in rats to investigate its effects on sexual cycle, pregnancy rates and offspring numbers., Setting and Design: A total of 34 female albino rats were included. Animals were divided into 3 groups., Methods: In group 1, ovaries were bilaterally denervated. Animals in group 2 underwent sham operation and group 3 comprised of controls. Sexual cycles in animals were followed by vaginal irrigations. Gestations were determined with parturition of rats., Results: Results indicated that in denervated rats, frequency of estrus decreased and period of estrus increased resulting in a decrease in conception rates and offspring numbers when compared to control rats., Main Findings: Although the results were consistent with previous denervation techniques, the operational procedure described herein is simpler and requires no sophisticated equipment, suggesting this to be a method of choice in reproductive physiology studies., Conclusion: In this study, we denervated the ovary with a technique other than classical in which the tissues except vascular structures over ovarian suspensory ligament were excised. We found that, estrus count decreased, duration of sexual cycle increased, conception rates and the offspring numbers reduced. This is thought to be a result of blockage of ovarian neural control due to denervation.

Dermoid sinuses and meningoceles are seldom encountered in the cervical region. Besides, to the best of our knowledge, the coexistence of these types of congenital abnormalities with recurrent meningitis, as well as with mirror movement, has never been reported before. A 14-year-old female with the diagnosis of recurrent meningitis was referred to our clinic from the Department of Infectious Diseases. She had a cervical meningocele mass that was leaking cerebro-spinal fluid (CSF) and an associated mirror movement symptom. Spina bifida, dermoid sinus and meningocele lesions were demonstrated at the C2 level on computed tomography (CT) and magnetic resonance imaging (MRI). She underwent an operation to remove the sinus tract together with the sac, and at the same time the tethered cord between the sac base and the distal end of the spinal cord was detached. The diagnosis of dermoid sinus and meningocele was confirmed histopathologically. These kinds of congenital pathologies in the cervical region may also predispose the patient to other diseases or symptoms. Herein, a case of meningocele associated with cervical dermoid sinus tract which presented with recurrent meningitis and a rare manifestation of mirror movement is discussed. Neurosurgeons should consider the possible coexistence of mirror movement and recurrent meningitis in the treatment of these types of congenital abnormalities.

Background: Only 2 cases of abducens nerve schwannoma solely inside the cavernous sinus have been reported. In both cases, abducens nerve palsy remained after operation. We report the first case of abducens nerve schwannoma inside the cavernous sinus proper with postoperative recovery from abducens nerve palsy., Case Description: The patient was a 47-year-old female who developed left abducens and trigeminal nerve palsies. Neuroradiological examination revealed left intra-cavernous sinus tumor. Total removal of the tumor was performed. The location of the tumor was confirmed intraoperatively inside the cavernous sinus itself, with no relation to the trigeminal nerve. Further, the relation of the tumor to one particular nerve fiber within the abducens nerve bundle was confirmed inside the cavernous sinus. After surgery, the patient had transient abducens nerve palsy. It had totally disappeared by 6 months., Conclusion: When the tumor origin is just within the spacious cavernous sinus rather than more posterior in the narrow dural tunnel of Dorello's canal, successful preservation of the nerve function is possible postoperatively through a thorough knowledge of the membranous anatomy and careful preoperative study of the radiographic findings.

This study evaluated the combination of the classical interlaminar approach and the intertransverse route through a midline approach for the treatment of 18 patients with far-lateral lumbar disc herniations, as identified by magnetic resonance imaging. The patients presented with acute severe sciatica, antalgic posture, positive Lasègue sign and femoral stretch test, motor and sensory deficits, and reflex loss findings. Discectomy of all 18 patients was performed by the combined approach. Neurological outcome of all patients was excellent in the follow-up period, ranging from 5 to 8 years. This combined midline approach permits complete evacuation of the involved disc level and treatment of additional bone resection procedures. Therefore, we advocate this approach in far-lateral lumbar disc herniation cases.

The aim of this study is to investigate the mechanism of injury of abducens nerve at petroclival region in severe head trauma. Twenty specimens provided from 10 autopsied cases due to severe head trauma were investigated macroscopically and histopathogically. The slices of the abducens nerve taken consecutively along its course at petroclival region were stained with Hematoxylline-Eosin and evaluated under light microscope. In addition, coexisting cervical injuries in these cases were assessed macroscopically. Edema and perineural hemorrhagia of abducens nerve were identified in all cases. Nerve injury was found more exaggerated at the sites of dural entry point and petrous apex than any other parts of the abducens nerve. Furthermore, microscopically, also remarkable perineural hemorrhage of the abducens nerve was observed at the site of its anastomoses with the sympathetic plexus on the lateral wall of the internal carotid artery (ICA). Abducens nerve is injured at the sites of dural entry point, petrous apex and lateral wall of the ICA, directly proportional with the severity of the trauma. This finding is also significant in verification of the severe head trauma.

Gamma radiation is known to cause serious damage in the brain, and many agents have been used for neuroprotection. In this study, lipid peroxidation levels and histopathological changes in brain tissues of whole-body irradiated rats with likely radiation injury were compared to those with melatonin and vitamin E protection. Forty rats in four equal groups were used. The control group received neither radiation nor medication. The remaining groups received doses of 720 cGy in two equal fractions 12 h apart. The second group received radiation but no medication, the third received radiation plus 100 mg/kg per day of vitamin E i.p., and the fourth received radiation plus 100 mg/kg per day of melatonin i.p. over 5 days. On the 10th postoperative day, all the rats were decapitated and specimens from parietal cortices were analyzed for tissue malondialdehyde (MDA) levels and histopathological changes. Increases in MDA were relatively well prevented by melatonin treatment but less so with vitamin E therapy. On histopathological examination, melatonin significantly reduced the rates of edema, necrosis, and neuronal degeneration, whereas vitamin E reduced only necrosis. Neither substance was capable of preventing vasodilatation. In conclusion, melatonin may be useful in preventing the pathological changes of secondary brain damage as a result of free oxygen radicals generated by irradiation.

Background: Pericallosal aneurysms are encountered less than 6.7%, and giant aneurysms among them even less. Giant azygos pericallosal artery aneurysm at the callosomarginal bifurcation is extremely rare, and our case presented herein is the second one. The case is discussed with thorough review of the literature., Methods: A 65-year-old woman presented with an extremely rare giant aneurysm on the azygos pericallosal artery manifesting as subarachnoid hemorrhage in World Federation of Neurosurgical Societies Grade 3. Computed tomography (CT), magnetic resonance angiography (MRA), and four vessel angiography revealed a giant azygos pericallosal artery aneurysm associated with a second aneurysm at the left M1., Results: After recovery to Grade 2, she underwent surgery via the right frontal interhemispheric approach for the azygos artery aneurysm on the 17th day after bleeding. The true dimensions of the aneurysm were greater than indicated by angiography because of partial thrombosis. Trilobulate aneurysm was carefully dissected from the surrounding structures. Postoperative cerebral angiography showed no filling of the clipped aneurysm and preservation of circulation., Conclusions: The treatment of distal anterior cerebral artery aneurysms is often difficult, because of their broad-based irregular configurations and adherence to surrounding tissue, tendency to bleed irrespective of size and the coexistence of other cerebral aneurysms. However, excellent outcomes can be obtained based on thorough preoperative radiologic evaluation, including magnetic resonance imaging (MRI), and correct selection of surgical approach.

Delayed traumatic intracranial hemorrhage (DTICH) is seen mostly in trauma to the occipitoparietal region by countercoup mechanism. It is most encountered within the first posttraumatic 10 days, particularly in the first 3. Herein, two cases of delayed traumatic intracerebral hemorrhage were discussed, first one presented with headache and vomiting who had been asymptomatic for 168 days after head trauma and the other presented with dysarthria and hyperkynesias after 92 days of asymptomatic interval, either being longer than that of the previous cases reported in the literature. Despite a long time elapse, DTICH should be considered in the differential diagnosis in the patients with history of head trauma that manifests at later stages with intracranial pressure elevation symptoms such as headache, vomiting.

Objective: Compared with other lower cranial nerves, the glossopharyngeal nerve (GPhN) is well hidden within the jugular foramen, at the infratemporal fossa, and in the deep layers of the neck. This study aims to disclose the course of the GPhN and point out landmarks to aid in its exposure., Methods: The GPhN was studied in 10 cadaveric heads (20 sides) injected with colored latex for microsurgical dissection. The specimens were dissected under the surgical microscope., Results: The GPhN can be divided into three portions: cisternal, jugular foramen, and extracranial. The rootlets of the GPhN emerge from the postolivary sulcus and course ventral to the flocculus and choroid plexus of the lateral recess of the fourth ventricle. The nerve then enters the jugular foramen through the uppermost porus (pars nervosa) and is separated from the vagus and accessory nerves by a fibrous crest. The cochlear aqueduct opens to the roof of this porus. On four sides in the cadaver specimens (20%), the GPhN traversed a separate bony canal within the jugular foramen; no separate canal was found in the other cadavers. In all specimens, the Jacobson's (tympanic) nerve emerged from the inferior ganglion of the GPhN, and the Arnold's (auricular branch of the vagus) nerve also consisted of branches from the GPhN. The GPhN exits from the jugular foramen posteromedial to the styloid process and the styloid muscles. The last four cranial nerves and the internal jugular vein pass through a narrow space between the transverse process of the atlas (C1) and the styloid process. The styloid muscles are a pyramid shape, the tip of which is formed by the attachment of the styloid muscles to the styloid process. The GPhN crosses to the anterior side of the stylopharyngeus muscle at the junction of the stylopharyngeus, middle constrictor, and hyoglossal muscles, which are at the base of the pyramid. The middle constrictor muscle forms a wall between the GPhN and the hypoglossal nerve in this region. Then, the GPhN gives off a lingual branch and deepens to innervate the pharyngeal mucosa., Conclusion: Two landmarks help to identify the GPhN in the subarachnoid space: the choroid plexus of the lateral recess of the fourth ventricle and the dural entrance porus of the jugular foramen. The opening of the cochlear aqueduct, the mastoid canaliculus, and the inferior tympanic canaliculus are three landmarks of the GPhN within the jugular foramen. Finally, the base of the styloid process, the base of the styloid pyramid, and the transverse process of the atlas serve as three landmarks of the GPhN at the extracranial region in the infratemporal fossa.

Objective: During its course between the brainstem and the lateral rectus muscle, the abducens nerve usually travels forward as a single trunk, but it is not uncommon for the nerve to split into two branches. The objective of this study was to establish the incidence and the clinical importance of the duplication of the nerve., Methods: The study was performed on 100 sides of 50 autopsy materials. In 10 of 11 cases of duplicated abducens nerve, colored latex was injected into the common carotid arteries and the internal jugular veins. The remaining case was used for histological examination., Results: Four of 50 cases had duplicated abducens nerve bilaterally. In seven cases, the duplicated abducens nerve was unilateral. In 9 of these 15 specimens, the abducens nerve emerged from the brainstem as a single trunk, entered the subarachnoid space, split into two branches, merged again in the cavernous sinus, and innervated the lateral rectus muscle as a single trunk. In six specimens, conversely, the abducens nerve exited the pontomedullary sulcus as two separate radices but joined in the cavernous sinus to innervate the lateral rectus muscle. In 13 specimens, both branches of the nerve passed beneath the petrosphenoidal ligament. In two specimens, one of the branches passed under the ligament and the other passed over it. In one of these last two specimens, one branch passed over the petrosphenoidal ligament and the other through a bony canal formed by the petrous apex and the superolateral border of the clivus. In all of the specimens, both branches were wrapped by two layers: an inner layer made up of the arachnoid membrane and an outer layer composed of the dura during its course between their dural openings and the lateral wall of the cavernous segment of the internal carotid artery. This finding was also confirmed by histological examination in one specimen., Conclusion: Double abducens nerve is not a rare variation. Keeping such variations in mind could spare us from injuring the VIth cranial nerve during cranial base operations and transvenous endovascular interventions.

The goal of this study was to determine the membranous protection of the abducens nerve in the petroclival region. The petroclival portion of the abducens nerve was studied in ten dissections from five cadaveric head specimens. One of the heads was used for histological sections. Four heads were injected with colored latex for microsurgical dissections. The histological sections were prepared from petroclival dura mater, embedded in paraffin blocks, stained, sectioned in the axial, coronal, and sagittal planes, and evaluated by light microscopy. The abducens nerve was covered by a dural sleeve and arachnoidal membrane during its course within the petroclival area. Following the petrous apex, the abducens nerve was fixed by a sympathetic plexus and connective tissue extensions to the lateral wall of the cavernous segment of the internal carotid artery and to the medial wall of Meckel's cave. Fibrous trabeculations inside the venous space were attached to the dural sleeve. The lateral clival artery accompanied the dural sleeve of the abducens nerve and supplied the petroclival dura mater. The arterioles accompanying the abducens nerve through the subarachnoid space supplied the nerve within the dural sleeve. The arachnoid membrane covered the abducens nerve within the dural sleeve to the petrous apex, and arachnoid granulations found on the dural sleeve protruded into the venous space. The extension of the arachnoid membrane to the petrous apex and the presence of arachnoid granulations on the dural sleeve suggest that the subarachnoid space continues in the dural sleeve.