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Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates.The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients' data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical-radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes.The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological-anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup 'a' was correlated with higher resection rates (GTR and NTR), whereas the subgroup 'b' was correlated with STR.Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.

Secondary leptomeningeal gliomatosis is a condition known as a result of invasion of the subarachnoid space or the ventricular system of primary intraparenchymal glioma. In this article, we present a 7-year-old boy presented with neck and back deformity and deterioration of gait. Cranial and spinal magnetic resonance imaging revealed lesions in the supratentorial and infratentorial areas, in the brainstem downward the spinal cord. Disseminated oligodendrogliomatosis is extremely rare and our case we present is the 24th in the literature.

Intravascular papillary endothelial hyperplasia (IPEH) also known as Masson's tumor, is a benign, slow growing, vascular lesion which is seen very rarely and only a few cases have been reported intracranially in the literature. It has been reported at many sites, but the posterior fossa involvement is very rare. The preoperative diagnosis is very difficult, as there is no enough cases to achieve a clear understanding about the details of its radiological findings. Differential diagnosis have to be made especially from angiosarcoma and meningioma. It is curable by total surgical removal. In this article we presented the characteristic clinical, radiological, perioperative and pathological findings in a case of IPEH in an unusual location, origin and behavior. To best of our knowledge, we presented the first case of IPEH originating from tentorium.

Background: Langerhans cell histiocytosis (LCH) is a rare nonmalignant disease characterized by a clonal proliferation of mononuclear cells called Langerhans histiocytes and infiltrates surrounding tissues, mostly self-limiting and usually occurring in the first two decades of life. Vertebral involvement is rare, mostly seen in the thoracic region, and involves the anterior elements of the corpus. In the literature, several treatment options and surgical approaches have been reported concerning the treatment of this disease and surgery. Case Presentation: We report an 18-month-old male with thoracic LCH who underwent surgery due to progressive neurological deficit. Gross total removal of the tumor with one level corpectomy in this patient was achieved via a posterolateral approach with postoperative functional improvement. The surgical cavity was supported by corpectomy cage and unilateral screw-rod fixation system at the same stage. Conclusion: Gross total tumor removal, corpectomy, and 360° stabilization via posterolateral approach at a single stage are safe, effective, and definite neurosurgical methods in terms of providing neurological recovery, long-term tumor-free survival, and spinal stability.

Sleep disorders in intensive care units after a craniotomy can decrease melatonin secretion and increase the inflammatory stress response. The aim of this study was to investigate the influence of improving sleep quality via eye patches and earplugs on melatonin secretion and inflammatory mediator release.The study enrolled 41 patients who underwent craniotomy. Patients were randomized into 2 groups. "Group Intervention" received a sleep-promoting intervention with eye patches and earplugs to provide light and noise isolation, while "Group Control" received standard care. Blood levels of C-reactive protein and interleukin 1 and interleukin 6 along with urine levels of 6-sulphatoxymelatonin (aMT6) were measured preoperatively (baseline) and on postoperative days 1 and 3. Sleep quality was assessed with the Richards-Campbell Sleep Questionnaire.Sleep quality was higher in the intervention group (Richards-Campbell score:80.61 ± 11.96 vs. 33.50 ± 16.32; P0.001). Urine aMT6 levels increased significantly in the intervention group in spot urine samples from 10.15 (5.38-14.40) ng/mL at baseline to 14.52 (6.24-29.11) and 11.51 (7.88-29.05) ng/mL on postoperative days 1 and 3. They also increased in 24-hour urine samples from 25.73 (8.24-52.73) ng/mL at baseline to 35.38 (11.48-95.65) and 39.18 (2.36-125.23) ng/mL on postoperative days 1 and 3 (P = 0.001 and P = 0.005, respectively). The aMT6 concentration did not change significantly in the control group. The C-reactive protein concentrations increased postoperatively compared with baseline concentrations in both groups (P = 0.001 and P0.001).Melatonin secretion significantly increased as a result of improving postoperative sleep quality by noise and light isolation in neurosurgical intensive care unit patients after craniotomy.

Intradural epidermoid tumors of the spinal cord are commonly associated with spinal cord dysraphism or invasive procedures. The spinal epidermoid tumor, frequently located intradural extramedullary region, is typically found in the lumbar region, and its placement in the thoracic region is rare. Furthermore, it is rarely observed without underlying spinal dysraphism or invasive intervention. The first case, a 52-year-old female patient was evaluated for back pain. On the thoracic magnetic resonance imaging (MRI) conducted, a 7-mm diameter intradural extramedullary non-enhancing nodular formation posterior to the T3 vertebra was detected. This lesion was completely excised via surgical intervention because of the increased size and the resultant hypoesthesia below T4 dermatome noted at follow-up. The second case, a 31-year-old woman presented with new-onset weakness in both legs. Notably, she has a history of a spinal mass lesion in the thoracic region 5 years ago. Thoracic MRI was performed to examine the recurrence, and it revealed a hypointense mass lesion axial plane with intradural extramedullary circumferential enhancement in the left posterior T6 level. This lesion was completely removed. No recurrence was noted at follow-up, and the histopathological diagnosis confirmed an epidermoid tumor. An isolated epidermoid tumor should be considered in the differential diagnosis of intradural -extramedullary mass lesions of the thoracic region. The tumor was successfully resected in its entirety via surgical intervention without any neurological deficit. Our cases support the fact that surgical resection is a crucial factor in recurrence.

Basilar invagination (BI) is a common malformation of the craniocervical region where the odontoid process protrudes into the foramen magnum. Surgery in this region is difficult because of the complex anatomy of the craniocervical junction. Serious life-threatening complications have been observed with previously described approaches. Therefore, we conceived a novel surgical approach that can be implemented by neurosurgeons with different skill levels to facilitate better outcomes.We describe a new surgical technique for the treatment of BI that we used in two patients in whom cervical myelopathy and direct ventral compression of the cervicomedullary junction were confirmed through clinical and radiological findings. We present the technique of posterior odontoidectomy in a step-by-step, didactic, and practical manner with surgical tips and tricks.The resection was completed without intraoperative or postoperative complications in both cases. The patients experienced substantial neurological improvements, and full recovery was observed during the 9-month and 12-month follow-up visits after discharge. Compared with the transoral approach, our technique provides a larger decompression area.We describe a novel method for the treatment of BI that was applied in two patients and suggest that the posterior approach might be a safe and effective method for ventral decompression of the craniocervical junction. Posterior odontoidectomy followed by craniocervical fixation helped achieve complete cervicomedullary decompression.

Background Retropharyngeal abscess (RPA) is a life-threatening, dangerous condition and uncommon in adults. The coexistence of RPA, cervical spinal epidural abscess (CSEA), and spondylodiscitis is extremely rare. Case presentation We present a case with a retropharyngeal and epidural abscess caused by spondylodiscitis. A 61-year-old man was referred to our clinic with the complaints of sore throat, limitation in neck range of motion, numbness, and weakness in the left arm and the left ear for one month. The airway was not obstructed. Neurological deficits were detected in his left arm. Cervical computed tomography revealed a 50 × 30 × 15 mm retropharyngeal abscess. Cervical magnetic resonance imaging showed abscess, C5–6 spondylodiscitis and epidural abscess, and myelopathic signal changes in the C3–7 spinal cord. The abscess was drained, and C5–6 discectomy was performed. The patient was discharged with cervical collar and antibiotics. Conclusions Multidisciplinary approach that consists of otolaryngologist, neurosurgeon, and infectious disease specialist is needed to avoid complications and any delay.

Objectives:Lamina terminalis fenestration is a method used to reduce hydrocephalus risk secondary to subarachnoid haemorrhage in cerebral aneurysm surgery. The aim of our article is to report our clinical experience in these patients and examine the short-term results of this procedure.Materials and Methods:We evaluated 10 patients with high-grade subarachnoid hemorrhage who underwent surgical clipping for cerebral aneurysm between 2014 and 2015 in our clinic.Results:Hydrocephalus developed in three of the 10 patients. One of these three patients had hydrocephalus in the preoperative period. In addition, hydrocephalus regressed in he postoperative period in three patients with hydrocephalus preoperatively.Conclusion:Lamina terminalis fenestration is an easy and effective procedure that can be applied to provide cerebral relaxation before surgical clipping and reduce the risk of developing hydrocephalus after clipping.

Objective The supraorbital keyhole approach through an eyebrow incision has been a potentially less invasive approach as an alternative to the standard pterional craniotomy. We aimed to review procedures for anterior and middle cranial fossa lesions and identify lessons learned from addressing various pathologies through this approach. Methods We retrospectively reviewed 106 consecutive patients who underwent this approach. We documented patients' age, sex, pathology, clinical results, extent of tumor resection, complications, use of endoscope, and cosmetic results. Results Our series addressed a variety of pathologies. Male patients accounted for 55% of the cohort and mean age was 51.7 (2–79) years. Notably, 52% of patients underwent resection of extra-axial masses. Gross total resection was achieved in 74.4% of intra-axial lesions according to postoperative imaging. Two (1.9%) patients developed transient ptosis. One (0.9%) patient developed an allergic reaction to titanium. No cerebrospinal fluid fistula or rhinorrhea occurred. Three patients developed temporary diabetes insipidus after resection of parasellar lesions (2 craniopharyngiomas and 1 pituitary adenoma). In 14 patients with olfactory groove meningiomas, 6 (42.8%) suffered from absence or diminished olfaction postoperatively, and 2 (14.2%) developed postoperative anosmia. Five (38.5%) patients underwent a subsequent resection of recurrent glial tumors. Four weeks postoperatively, 95% of patients demonstrated acceptable cosmetic results. Cosmetic results for 6 (5%) patients were unavailable. Conclusions The supraorbital keyhole approach may be safely used for various lesions within the anterior and middle cranial fossa. The effectiveness and limitations of this approach and possible complications are discussed. This is a valuable approach for selected patients.

Lower back pain (LBP) is a prevalent spinal symptom at the lumbar region of the spine, which severely effects quality of life and constitutes the number one cause of occupational disability. Degeneration of the intervertebral disc (IVD) is one of the well-known causes contributing to the LBP. Therapeutic biomaterials inducing IVD regeneration are promising candidates for IVD degeneration treatments. Here, we demonstrate a collagen peptide presenting nanofiber scaffold to mimic the structure and function of the natural extracellular matrix of the tissue for IVD regeneration. The collagen peptide presenting nanofiber was designed by using a Pro-Hyp-Gly (POG) peptide sequence on a self-assembling peptide amphiphile molecule, which assembled into nanofibers forming scaffolds. Injection of collagen peptide presenting peptide nanofiber scaffold into the degenerated rabbit IVDs induced more glycosaminoglycan and collagen deposition compared to controls. Functional recovery of the tissue was evaluated by degeneration index score, where the bioactive scaffold was shown to provide functional recovery of the IVD degeneration. These results showed that the collagen peptide presenting nanofiber scaffold can prevent the progression of IVD degeneration and provide further functional recovery of the tissue.

Background Spinal arachnoid cysts (SACs) are uncommon lesions in the spinal canal. They are usually asymptomatic, but can occasionally cause mass effect leading to neurologic symptoms. They can be congenital or secondary to a variety of causes. They can produce a variety of neurologic symptoms including pain, weakness, sensory changes, incontinence, and more. Surgical intervention may be necessary when SACs cause symptomatic mass effect. Methods Thirteen consecutive patients who underwent surgical intervention for an SAC were retrospectively reviewed. The data included presenting symptoms, imaging findings, neurologic status, and follow-up. Results Of the 13 patients, the majority of cases were located in the thoracic spine (54%) and all but one case were located dorsally or dorsolaterally. Furthermore, 38% were located extradurally and 54% were located intradurally. Pain (80%) was the most common presenting symptom. Most patients had improvement or complete resolution of their symptoms after intervention. Extradural SACs and their capsules were completely resected, whereas intradural SACs underwent fenestration. No complications occurred in this series. Conclusions SACs are usually asymptomatic, but rarely cause mass effect and neurologic deficits requiring surgical intervention. Surgical intervention is tailored to the position of the cysts' dorsal or ventral locations. Pain and weakness are the most likely symptoms to improve, whereas sensory symptoms are least likely to improve.

To evaluate changes in the Evans? index (EI) and callosal angle (CA) in patients who underwent lumboperitoneal (LP) shunting for idiopathic normal pressure hydrocephalus (INPH) and whose symptoms improved post-operatively.We retrospectively analysed patients who were clinically and radiologically diagnosed with INPH and treated with an LP shunt between 2010 and 2020. In all patients, we performed radiological imaging with EI and CA measurements and completed clinical assessments, including Mini-Mental State Examination (MMSE) and cognitive, urinary continence, balance and 10-m walking tests, preoperatively and post-operatively (less than 1 year later). Results were compared by statistical analyses.We evaluated 42 patients who received an LP shunt for INPH and had cranial magnetic resonance imaging (MRI) performed within the first 2 months after surgery. When the pre-operative and post-operative MRIs of the patients were compared, a statistically significant decrease was found in EI and CA measurements (p.001, for each). A statistically significant improvement was found in clinical tests. Post-op early radiological images predicted recovery of the gait-balance function and urinary incontinence (p.001) but did not predict recovery of dementia (p=.06).Radiological and clinical improvements are expected after the placement of ventriculoperitoneal (VP) or LP shunts in patients with INPH. Radiological measurements after an LP shunt in patients with INPH have not been reported in the literature. In the current study, radiological measurements after LP shunt placement were evaluated for the first time in patients with INPH. Significant changes in EI and CA after LP shunt placement may indicate whether patients will benefit clinically from an LP shunt during follow-up. A significant decrease in CA and EI measurements in the early period may be a marker for whether patients with INPH will show signs of clinical improvement and benefit from an LP shunt.

Objective In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. Methods Results from 437 patients 18–91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. Results Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure. Conclusions Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.

The highly complex nature of spinal cord injuries (SCIs) requires design of novel biomaterials that can stimulate cellular regeneration and functional recovery. Promising SCI treatments use biomaterial scaffolds, which provide bioactive cues to the cells in order to trigger neural regeneration in the spinal cord. In this work, the use of peptide nanofibers is demonstrated, presenting protein binding and cellular adhesion epitopes in a rat model of SCI. The self-assembling peptide molecules are designed to form nanofibers, which display heparan sulfate mimetic and laminin mimetic epitopes to the cells in the spinal cord. These neuroactive nanofibers are found to support adhesion and viability of dorsal root ganglion neurons as well as neurite outgrowth in vitro and enhance tissue integrity after 6 weeks of injury in vivo. Treatment with the peptide nanofiber scaffolds also show significant behavioral improvement. These results demonstrate that it is possible to facilitate regeneration especially in the white matter of the spinal cord, which is usually damaged during the accidents using bioactive 3D nanostructures displaying high densities of laminin and heparan sulfate-mimetic epitopes on their surfaces.

Thalamic neuroepithelial cysts are rare, benign lesions. Thirteen cases have been published in eight articles. The most frequent symptoms are headache, hemiparesis, tremor and related signs of hydrocephalus such as gait disturbance, confusion, and Paranaud's syndrome. Surgical interventions include endoscopic fenestration, open surgery and stereotaxic biopsy or aspiration. We report a case of a 63-year-old woman who had headache and right hemiparesis for 1 week, but no hydrocephalus. We treated her with transcranial neuronavigation-guided endoscopic complete resection. The patient recovered completely after cyst removal.

Primitive neuroectodermal tumors (PNETs) are aggressive, poorly differentiated tumors in children and young adults. However, the embryonal tumor group did not include the central nervous system (CNS) PNET title and ependymoblastoma subtitle in the 2016 World Health Organization CNS tumor classification. Here, we report the case of a 6-year-old boy with a sellar embryonal tumor and present a review of the related literature. To the best of our knowledge, this is the first case of an endoscopically operated sellar embryonal tumor in the pediatric age group.

Objectives:The shape and localization of the scalp incision are the factors that affect surgical outcome. With the help of developing technology, it is aimed to decrease the size of incisions and decrease the morbidity. The ideal shape and length of the incision should not disrupt the scalp feeding and provide the best possible wound healing, but also have to provide adequate control of the surgical field. In our study, we aimed to observe the effects of linear scalp incision on patients’ surgical comfort and wound healing.Materials and Methods:In our retrospective study, we evaluated linear scalp incision in 26 patients with supratentorial cortical-subcortical tumors between 2017 and 2018. Tumor location was determined by neuronavigation and linear incision lines were planned pre-operatively in all patients.Results:The size of superficially located tumors was equal or less than 5 cm. The average length of incision was 9.2 cm and was parallel to the coronal suture. No difficulties were seen in reaching the lesion in terms of incision length or location. There was no significant morbidity and mortality in the postoperative period, except of patients which were temporary paresis. No complications were seen in wound healing. Silk sutures were taken on average for 7.4 days. Thirty four of the thirty two patients were discharged on the 3rd postoperative day.Conclusion:A linear incision can be applied as an alternative to other incisions in superficially localized and to adequate size (≤5 cm) supratentorial region tumors which were determined with neuronavigation.

This study aimed to report the authors' single-center clinical experience about craniopharyngiomas and discuss surgical outcomes of these patients according to the type of surgical approach (endoscopic endonasal or open microscopic transcranial approach).Twenty-four patients diagnosed with craniopharyngiomas between May 2013 and April 2017 were considered for inclusion. The patients were divided into 2 groups according to the surgical approach (open transcranial microscopic approach [group A] and endoscopic endonasal approach [group B]). These groups were compared in terms of postoperative surgical outcome scores (extent of tumor removal, visual deficit, hydrocephalus, metabolic disorders, and Glasgow coma scale) and hospitalization interval.There was no patient of mortality in both groups. In this study, 4 of the 13 patients in group A and 9 of the 11 patients in group B underwent gross total resection. However, 1 patient in group B underwent repair because of cerebrospinal fluid leakage postoperatively. In addition, 1 patient in group A had a wound healing problem postoperatively. The postoperative outcome scores were 9.5 in group A and 11.5 in group B. The hospitalization interval in group A (range, 7-9 days) was longer than that in group B (range, 5-7 days).The endoscopic endonasal approach should be considered the first-line surgical treatment modality in patients with a preliminary diagnosis of craniopharyngioma in terms of low complication risk, minimal invasiveness, and better outcome scores. Open microscopic transcranial procedures may be combined with this approach in a single session for challenging cases.

Intracranial dermoid tumors are extracerebral congenital cysts. Dermoid cysts have two types as intradural and extradural. Intradural dermoid cysts are originated from the intracranial cerebrospinal fluid space. However, calvarium-originated extradural lesions increase in size with a slow growth in cyst volume, but the cause of active growth is unknown. Dermoid cysts act like slow-growing cerebral tumors. Differential diagnosis includes other cysts and cystic tumors. Their radiologic appearance looks like polycystic lesions which is associated with a wide expansion in the cerebrospinal fluid areas and cause brain translocation. In the cranial tomography and magnetic resonance imaging assessment, high-cholesterol-containing dermoids demonstrate cerebrospinal fluid characteristics. The present study based on the review of central nervous system patients with highly rare dermoid localizations such as calvarial bone, temporal lobe and lateral ventricle.

Objective Intracerebral hemorrhage continues to be a major global problem. No standard treatment or surgical procedure has been identified for intracerebral hemorrhages. High morbidity and mortality rates caused by conventional approaches and the disease itself have necessitated more-invasive treatment methods. The endoscopic approach is a more minimally invasive method than craniotomy, which is another alternative surgical treatment. Methods We compared intracerebral hematoma drainage in 2 groups of 17 patients each, treated with minimally invasive endoscopic method versus craniotomy. All the patients were treated for supratentorial spontaneous hemorrhage between December 2013 and February 2017 at the Neurosurgery Clinic of Ankara University Faculty of Medicine. Results We retrospectively evaluated 34 patients surgically treated between December 2013 and February 2017. All patients underwent surgery within the first 24 hours. Patients in the early surgery group had better surgical outcomes. In the neuroendoscopic group, Glasgow Coma Scale increased from 6 to 11 at 1 week postoperatively compared with 5 to 9 in the craniotomy group. Conclusions Minimally invasive endoscopic hematoma evacuation may be a good alternative surgical method for treating supratentorial spontaneous cerebral hematomas.

The location of burr holes in posterolateral cranial base approaches should be appropriate to provide an adequate operative field, and surgical freedom is crucial for bone window opening. The aim of this study was to search for more convenient and easily detectable landmarks in comparison with current landmarks in posterolateral cranial base surgery. Twenty 3-dimensional reconstructed head and neck computed tomography angiography images (group 1) and 20 cadaver heads (group 2) were evaluated. An imaginary line connecting the angle of the mandible and the mastoid tip was extended upward. A second line passing through the lateral edge of the zygomatic arch was also extended posteriorly. The authors examined if the first line met with the sigmoid sinus throughout its course and determined the location of the intersection point of these 2 lines relative to the sigmoid-transverse sinus junction. The intersection point did not correspond to the sinus region in 3 images from group 1 and 4 specimens from group 2. The matching of the mandibula-mastoid line trajectory with the sigmoid sinus course was unacceptable in 4 images and 5 cadavers. For venous anatomy preservation and anatomic skull base fossa orientation during posterolateral cranial base approaches, upward extension of the mandibula-mastoid line can be a proper landmark for surgical planning in this region. The authors' proposed superficial anatomical line and intersection point over the skull could be used as a reliable indicator for the external projection of the sigmoid sinus and an appropriate initial burr-hole location.

OBJECTIVETransorbital approaches for neurosurgery have recently attracted attention and several anatomical studies have aimed to improve these techniques, but significant deficiencies in clinical practice remain, especially for aneurysm surgery. The authors present an alternative microsurgical route and the results of an analysis of patients with intracranial aneurysms who underwent a lateral transorbital approach (LTOA) using lateral orbito-zygoma-sphenotomy (LOZYGS).METHODSThe clinical and surgical results of a series of 54 consecutive patients with 1 or more aneurysms who underwent surgery via LTOA are reported. A lateral orbitotomy was performed after making a 3-cm skin incision parallel to the lateral orbital rim. A second bone flap, which included the zygoma and sphenoid bones that form the lateral orbital wall, was removed. The lesser sphenoid wing, including the anterior clinoid process, was fully drilled, except in cases of middle cerebral artery (MCA) aneurysms. Cisternal dissection was performed using the classic microsurgical technique starting from the proximal Sylvian fissure and carotid cistern. After the aneurysm was clipped following microsurgical principles, the dura mater was closed in a watertight fashion and 2-piece bone reconstruction was achieved.RESULTSSixty aneurysms in 54 patients were clipped using the LOZYGS route. Twenty-one aneurysms were located on the MCA, 30 on the anterior communicating artery, 8 on the internal carotid artery, and 1 at the apex of the basilar artery. The unruptured-to-ruptured aneurysm ratio was 17:43. The operative field was moved to the orbit using the LTOA to avoid interference by bone and muscle tissues. Early proximal control was achieved using a short working distance and direct exposure of the base of the cerebrum, without any requirement for retraction. Because different view angles and surgical corridors were used, no segment of the aneurysm or the parent artery remained unexposed. Therefore, the introduction of additional tools was not required.CONCLUSIONSThe LTOA allowed enhanced broad-perspective exposure of the operative field, early proximal control, and satisfactory surgical freedom. This alternative surgical approach safely exposed the target area and the operative field. The LOZYGS route is safe and effective for the LTOA and microsurgical clipping of anterior circulation aneurysms. According to the authors’ surgical experience and clinical experience, the LTOA can be considered an alternative surgical route to supratentorial aneurysm surgery.

PubMed: 31192442, 2-s2.0-85075805534, AIM: To investigate the effects of Phenyramidol (Phe) on neural development in an early chicken embryo model. MATERIAL and METHODS: Sixty fertile non-pathogenic Super Nick eggs were incubated for 24 hours (h) and divided into four groups of 15 eggs each. Phe was administrated through the sub-blastoderm, and the eggs were incubated for another 24 h. All eggs were opened after 48 h of incubation, and the embryos were evaluated morphologically and histopathologically. RESULTS: In Group 1 (control group), none exhibited neural tube defects (NTDs) (0%), 1 (6.6%) was undeveloped; in Group 2 (low dosages), 1 did not develop (6.6%); in Group 3 (normal dosages), 2 (13.4%) had NTDs, 1 (6.6%) was undeveloped; in Group 4 (high dosages), 5 (33.3%) had NTDs, 2 (13.3%) were undeveloped. CONCLUSION: In light of the results, it was determined that the use of increasing doses of Phe led to defects in midline closure in early chicken embryos. This is the first report in the literature on Phe used in an early chicken embryo model. © 2019, Turkish Neurosurgical Society., Preparation for publication of this article is partly supported by Turkish Neurosurgical Society.

Primary spinal tumors are a group of tumors which originate from the spinal cord (intradural) or the vertebral column (extradural). In contrary, the metastatic tumors of these regions constitute the secondary tumors of the spine which metastasis or extend to these spinal compartments from a long-distance via hematogenous way or from close surrounding structures. The primary tumor group includes a wide range of neoplasms that can be encountered throughout the spine. Primary tumors of the spine commonly originate from cartilaginous, osseous, neural, and perineural structures. Although, these tumors differ significantly from each other in terms of origin and location, improper use of the correct terminology related to the spinal tumor classification and its subtypes can be found in the literature. To eliminate this confusion, and for the ease of understanding, clarification of the relevant definitions of these terms is of great importance and priority. The terminological contradiction is commonly found between the terms “spinal tumor” and “spinal cord tumor”. These two terms are sometimes used interchangeably. Even when it does not originate from the spinal cord, any pathology affecting the spinal cord—whether it is a metastatic or primary vertebral column tumor—can be misnamed as spinal cord tumor without considering its origin.

The retrosigmoid approach offers hearing preservation for small and medium-sized vestibular schwannomas while providing excellent exposure of the cerebellopontine angle and lateral cerebellomedullary cisterns that contain critical neurovascular structures. A 3 × 3 cm retrosigmoid craniotomy with exposure of the TSSJ and an approximately 1/4 of the medial border of the sigmoid sinus is sufficient enough in many cases of VS surgeries. With small and medium-sized tumors, the initial exposure of the tumor includes its lateral part of the tumor, the AICA and its subarcuate branch, the lower cranial nerves and the PICA in the inferior aspect of the tumor, as well as the petrosal vein in the rostral aspect. Good postoperative FN function can be achieved by, maintaining the blood supply of the FN, minimizing bipolar coagulation around the nerve, preserving the arachnoid plane between the tumor and the FN, and keeping the tumor capsule intact during internal decompression. Surgical precautions to achieve a better postoperative hearing outcome include; gentle manipulation of the CoN, obtaining meticulous hemostasis, providing a bloodless surgical field, protecting the labyrinthine artery, avoiding excessive retraction of the cerebellum and compression of the brainstem, preservation of veins, keeping the drilling field clean to avoid aseptic meningitis, and appropriate monitoring of the CoN during the surgery. Complications of the surgery may include; cranial nerve dysfunctions such as facial, cochlear, and lower cranial nerves, CSF leak and meningitis, headache, disequilibrium, tinnitus, and also tumor recurrence.

Since the technical description by William House in 1961, the middle cranial fossa approach to the internal acoustic canal has become one of the quintessential surgical approaches for accessing the seventh and eighth cranial nerves and the upper cerebellopontine angle. In this chapter the MCF approach comprises an extradural, subtemporal exposure and removal of a portion of the superior surface of the temporal bone to expose the posterior cranial fossa. House and Doyle performed the first vestibular schwannoma removal via the MCF approach in 1961. The MCF approach and its extensions can be used to treat a wide variety of lesions including schwannomas of the 5th through 8th cranial nerves, meningiomas of the IAC, CPA, and petroclival region, and cholesterol granulomas and cholesteatomas, petrous apex infections, chondrosarcomas of foremen lacerum, vascular lesions of the ventral skull base, and nerve decompressions for inflammatory neuropathies. When considering patient’s historical and exam findings, it is important to note that patients who are considered good surgical candidates for an MCF approach will have small to medium-sized tumors, typically

AIM: To define the optimal time of shunt insertion in patients with neural tube defects and hydrocephalus. MATERIAL and METHODS: In total, 71 patients who underwent operation for neural tube defects and hydrocephalus were retrospectively evaluated between 2012 and 2018. The first group comprised 43 patients who underwent operation at different times (in 10 days after the repair of defect), and the second group comprised 28 patients who underwent operation at the same time. Ruptured and unruptured sacs were immediately considered and operated within 72 hours. RESULTS: In the first group, 43 patients underwent operation for neural tube defect after birth. Ventriculoperitoneal shunt insertion was performed 10 days after wound healing. Five (11.6%) patients were diagnosed with meningitis on follow-up. Shunt infection or meningitis was not observed on follow-up in the second group, which comprised patients who underwent operation at the same time. CONCLUSION: The lowest complication rate existed in hydrocephalus management when shunt insertion and myelomeningocele repair procedures were performed at the same time. © 2019, Turkish Neurosurgical Society.

VS account for approximately 6–8% of intracranial tumors in adults and are the most common tumor in the CPA ranging between 80% and 95%. Vestibular schwannomas constitute 6% of all intracranial neoplasms and are the most common benign lesions of the IAC and CPA cistern constituting between 60% and 90% of the entire lesions seen in this area. Growth rates in tumors that exhibit enlargement have been reported to be about 1–2 mm per year in linear growth in at least one dimension. While no formal consensus exists, most authors define normal growth rates as being between 1 and 2 mm per year and fast growth rates as 4 mm or greater per year. When considering common presenting manifestations, a helpful framework is to consider manifestations based on the size of the tumor, and its location; intracanalicular, cisternal, brainstem compressive, or hydrocephalic sizes. While any configuration is possible, hearing loss associated with vestibular schwannomas of this size is typically unilateral, progressive, and commonly affects high-frequency thresholds and speech perception. An occipital headache attributable to the tumor is a late finding with 20% of patients with tumors between 1 and 3 cm, with 40% of patients with tumors larger than 3 cm verifying this symptom. Gross total resection is the goal of surgery while maintaining good facial function, in all sizes of tumors, and hearing preservation, in small to moderate size tumors in patients with serviceable preoperative hearing status.

Aim To evaluate the efficacy of using a neuronavigation system for demonstrating the relationship between the basilar artery (BA) and ventricular floor during endoscopic third ventriculostomy (ETV). Material and methods Records of 28 patients (16 females and 12 males) diagnosed with obstructive hydrocephalus who had undergone a neuroendoscopic procedure were retrospectively examined. Patient age ranged from 1 to 76 years (median 24.46 years). The BA was marked with using the neuronavigation system in all cases to visualise its relationship to the floor of the third ventricle in real time. Results ETV was successfully performed in 28 patients with obstructive hydrocephalus. Of these, 13 (46.4%) patients had a thickened tuber cinereum (TC) membrane and 3 (10.7%) showed lateralization of the BA under the ventricular floor. No contact with the BA or related complications (e.g., major bleeding) was encountered with BA marking by using neuronavigation. Conclusion Even though thickening of the TC membrane and/or displacement of the BA might be seen otherwise, we describe a new method that combines marking the BA and using neuronavigation to provide greater safety in the area where the ventriculostomy will be performed. This permits clearer orientation for the surgeon which significantly contributes to minimizing surgical morbidity.

To assess clinical and radiographical outcomes of transspinous decompression technique for the treatment of degenerative central lumbar spinal stenosis.The single-centre, non-randomised interventional, prospective, observational study was conducted Neurosurgery Clinic of Mazhar Osman Research and Training Hospital for Psychiatry and Neurology, Istanbul, Turkey from May 2013 and May 2016 and comprised adult patients with refractory symptoms from degenerative central lumbar spinal stenosis who underwent lumbar spinous processsplitting laminectomy. Pre- and post-operative Oswestry Disability Index score, visual analogue scale for overall pain, maximum walking distance and anteroposterior diameter of the spinal canal on magnetic resonance imaging were assessed on follow up examination. SPSS 22 was used for data analysis.Of the 89 patients, 7(7.86%) were lost to follow-up, while 82(92.14%) completed the study. Of them, 42(51%) were women and 40(49%) were men. Overall mean age was 63.86±10.02 years (range: 40-85 years). A total of 95 transspinous decompressive laminectomies were performed. Mean number of decompressed spinal segments was 1.16. Median duration of surgical procedure was 45 min, while mean length of hospital stay was 1.22±0.47 days. Mean decrease in pre operative Oswestry Disability Index scoreat 1-year was 56.4% and overall visual analogue scale was 55.9%.Mean increase of 155.2% was documented over pre-operative maximum walking distance. Radiological assessment revealed a 40.7% increase in the mean and anteroposteriordiameter of the spinal canal at the level of the target lesion. The improvement in various parameters was statistically significant (p0.001)..Lumbar spinous process-splitting laminectomy led to significant improvement with respect to patient-reported perceived recovery, functional disability and radiological evidence of effective surgical decompression in patients with lumbar spinal stenosis..

Objective Stereoscopic video recordings of operative microscopy during neuroanatomic dissections are an important component of surgical training and research in well-financed medical schools and teaching hospitals. However, the high cost of the latest operative microscopes with integrated video recording equipment can be a limiting factor in their worldwide use. The aim of the present work is to provide a simple low-cost 3-dimensional (3D) stereoscopic operative microscope recording system that can be used even in economically and resource-limited locations. This is achieved by using readily available smartphones, smartphone accessories, and computer software. Methods Stereoscopic recording is accomplished by attaching and aligning matched or similar smartphones to the eyepieces of an operative microscope using readily available smartphone mounting connectors. Video recordings from the smartphones are then transferred to a personal computer and processed with a video-editing software to generate stereoscopic movies that are viewed on a smartphone using virtual-reality glasses. Results The setup time to mount and align the smartphone cameras typically requires 15–30 minutes. Video image quality and 3D depth presentation is more than sufficient for surgical training and research purposes. The implementation cost ranges from $1,315–$7,066, or much less if smartphones and a computer are already available. Conclusions The 3D video system demonstrated herein can be implemented on any type of operative microscope, including older units for which commercial stereo recording systems are not available. The system and method presented herein can be readily and affordably implemented in low-budget environments for clinical training and research.

To present our experience of 225 clipped aneurysms in 196 patients to compare indocyanine green video angiography (ICGVA), micro-Doppler ultrasonography (MDUSG), and postoperative digital subtraction angiography (DSA) in terms of determining aneurysm obliteration, neck remnants, and parent artery patency.This retrospective study included 196 patients (108 female and 88 male patients) treated between 2013 and 2016. In all cases, aneurysm neck remnants and vessel patency were assessed using ICG-VA and 16-Hz MDUSG. DSA was performed in every case postoperatively within the first 5 days.The mean patient age was 55.8 years (range, 31-80 years), and the mean follow-up duration was 25 months (range, 2-48 months). Of the 225 clipped aneurysms, 86 were located in the anterior cerebral artery and its branches, 103 in the bifurcation of the middle cerebral artery (MCA) and the branches of the MCA, 34 in the internal cerebral artery and its branches, 1 in the posterior inferior cerebellar artery, and 1 at the basilar apex. We observed 2 neck remnants (0.8%), 2 parent/perforating artery occlusions (0.8%), and 2 residual aneurysm fillings (0.8%). There were no striking differences among the assessed methods.ICG-VA, MDUSG, and dome puncturing are all useful techniques in aneurysm surgery for assessing complete obliteration of the aneurysm. In our experience, all the 3 tools are complementary to each other, and none of them is superior to the others. We recommend the use of all 3 tools to obtain a favorable outcome.

PubMed ID: 29906582, Objective: To examine the surgical results of unilateral lumbar discectomy in patients with bilateral leg pain and discuss short- and long-term outcomes within the limits of lumbar decompression. Methods: We analyzed 60 patients with unilateral disc herniation who underwent unilateral lumbar discectomy and hemipartial laminectomy between 2014 and 2017. Group 1 (30 patients) had bilateral leg pain and unilateral lumbar disc herniation. Pain lateralization was determined radiologically. Group 2 (30 patients) had unilateral leg pain and unilateral lumbar disc herniation. Pain scores were preoperatively evaluated with visual analog scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. In both groups, surgery was performed on the ipsilateral side of the herniated disc. Scores were repeated on postoperative day 1 and 1, 3, 6, 12, and 24 months later. VAS score differences for pain lateralization and disc levels were compared in group 1. ODI score differences were compared between both groups. Results were statistically analyzed. Results: VAS score differences were statistically significant at all follow-up time points in patients with ipsilateral and contralateral pain. VAS score differences between L4–L5 and L5–S1 level discopathies were statistically insignificant for all time points in both groups. All postoperative ODI score decreases for all time points were statistically significant (P < 0.001) for both groups, whereas the differences between groups 1 and 2 were statistically insignificant. Conclusions: Conventional lumbar disc surgery alone is sufficient for the ipsilateral side of radiologically demonstrated disc herniation in patients with bilateral leg pain. © 2018 Elsevier Inc., Preparation for the publication of this article was partly supported by Turkish Neurosurgical Society.

Chordomas of the cranial base are locally destructive tumors since they are surrounded by significant complex neurovascular structures. Thus, their surgical removal is challenging, recurrence rates are high, and their therapeutic strategies remain controversial.In this video, we present a 47-year-old man with a recent onset of swallowing difficulties, hoarseness, and weight loss for several weeks. In the neurological examination, he had complete paralysis of the 9th, 10th, 11th, and 12th cranial nerves. Magnetic resonance imaging (MRI) showed a heterogeneously enhancing expansile invasive mass lesion centered within the clivus and involving the C1, the occipitocervical junction, the retropharynx, and the hypoglossal canal. The decision was made to proceed with multiple staged surgeries. In the first surgical stage, we performed a mastoidectomy with the infralabyrinthine approach to perform a test clip ligation of the sigmoid sinus and to resect the tumor component that extended into the infralabyrinthine space. In the second stage, we performed a far-lateral transcondylar approach for tumor resection and occipitocervical fusion. In the third stage, we used a transoral approach with endoscopic assistance to complete the excision of the remaining tumor in the retropharyngeal space and anterior aspect of C1 and C2 bodies that were not accessible in the first two stages.The surgeries and postoperative course were uneventful. Postoperative MRI showed a gross total resection of the tumor. Histopathology indicated a chordoma. The patient subsequently received proton radiotherapy and has continued to do well without recurrence at 14 months' follow-up.The link to the video can be found at: https://youtu.be/uP9OSlKg_rE.

Surgical treatment of the gliomas located in or adjacent to the eloquent areas poses significant challenge to neurosurgeons. The main goal of the surgery is to achieve maximal safe resection while preserving the neurological function. This might be possible with utilizing pre- and intraoperative adjuncts such as functional magnetic resonance imaging (MRI), image guidance, mapping of the function of interest, intraoperative MRI, and neurophysiological monitoring. In this video, we demonstrate the utilization of nonawake mapping and motor-evoked potential (MEP) monitoring for the resection of a right-sided posterior superior frontal gyrus grade IV astrocytoma adjacent to the primary motor cortex. The patient is a 69-yr-old woman presented with multiple episodes of simple partial seizures involving her left leg and spreading to the left arm. MRI and functional MRI examinations showed a heterogeneously enhancing mass with peritumoral edema adjacent to the primary motor cortex. Because the patient did not want to undergo an awake craniotomy, a decision was made to perform the resection of the tumor with nonawake motor mapping and continuous MEP monitoring. Nonawake motor mapping and MEP monitoring enabled us to perform gross total resection. Because it has been shown that supratotal resection may provide improved survival outcome,1,2 we extended the white matter resection beyond the contrast enhancing area in noneloquent parts of the tumor. Surgical steps in dealing with vascular anatomy as well as utilizing intraoperative adjuncts such as motor mapping and MEP monitoring to enhance the extent of resection while preserving the function are demonstrated in this 3-dimensional surgical video. The patient consented to publication of her operative video.

Pure extradural spinal arteriovenous malformations (AVMs) are formed with an epidural artery, a nidus and an arterialized intradural vein in the absence of vertebral cavernous hemangioma and uncommon lesions. The most common extradural tumors are metastasis, lymphomas, benign tumors and malignant bony tumors. Herein, we present a-29-year-old Turkish woman with pure extradural mass that histopathologically diagnosed as AVM. When an extradural spinal compressive mass is detected, neurosurgeons should consider on AVM in differential diagnosis and requirement of selective spinal angiography.

WOS: 000432959600027, PubMed: 29530700, OBJECTIVE: The pathophysiology of spinal cord injury (SCI) with the information obtained to date has not been elucidated fully. A safe drug or treatment protocol that results in cell regeneration for SCI remains unknown. Neuroprotective and neuroregenerative effects of riluzole, administered after a SCI, have been shown in experimental studies. This study aimed to investigate the effect of riluzole on neural regeneration in a rat SCI model. METHODS: Thirty-two rats were divided into 8 groups, with 4 rats in each group. Hemisection method was performed after T7-T9 laminectomy. Rats were intraperitoneally aministered with riluzole (6 mg/kg). Locomotor recovery of the rats was assessed at 1 day, and 1, 2, 3, and 4 weeks after the 21-point Basso, Beattie, and Bresnahan test. Subsequently, the spinal cords of the rats were scored according to a semiquantitative grading system using a light microscope, and the numbers of myelinated axons, neurons, and glial cells were calculated. RESULTS: Basso, Beattie, and Bresnahan test changes were statistically significant when groups 4e6 and 8 were compared with the other groups (P < 0.05, P < 0.00625). The results of the numbers of neurons, glial cells, and myelinated axons were statistically significant. Especially group 8, in which riluzole was administered 5 days before injury, more positive clinical and histopathologic results were obtained. CONCLUSIONS: Riluzole treatment is more effective when provided before injury. Riluzole may contribute to functional recovery when used in the preoperative period in patients who are at a high risk for permanent neurologic deficit.