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AIM: To compare the clinical and radiological results of dural splitting and duraplasty in patients with Chiari Type I Malformation. MATERIAL and METHODS: This study includes 113 adult patients with Chiari Type I malformation treated between 2009 and 2013. The patients were divided into two groups according to the surgical method (Group 1: dural splitting, Group 2: duraplasty). Neurological examinations and magnetic resonance imaging (MRI) scans were recorded periodically on 3rd, 6th,and 12th months at the postoperative period. The tonsillo-dural distance (TDD) and regression rate of the syrinx cavity were measured on T1 and T2 weighted sagittal MRI scans at the postoperative period. RESULTS: The ratio of syrinx regression was %49.6 in the Group 1 and %54.6 in the Group 2. This result was statistically significant. The TDD increased in Group 2 and this result was statistically significant (p

AIM To share the results of conventional surgery in rhinorrhea and the contribution of computerized tomography (CT) cisternography to determination of the site of cerebrospinal fluid (CSF) leak. MATERIAL AND METHODS Twelve cases treated for spontaneous rhinorrhea were included in this study. All the cases underwent cranial CT and magnetic resonance imaging (MRI). CT cisternography was performed in four patients whose bone defect or leakage site could not be detected by CT and MRI. In order to repair the defect, either the galea or galea together with collagen matrix was used and the procedure was supported with fibrin glue. RESULTS In the cases, postoperative rhinorrhea was seen in neither the early nor the late follow up period. We observed no complications related to CT cisternography or craniotomy. The leakage area was successfully detected with CT cisternography when the other methods failed. CONCLUSION Bone defect can usually be shown by means of CT. However, when bone-defect cannot be shown or the dura in the defective area is intact, CT cisternography is useful to show the CSF leak. Conventional surgery was very succesful in the treatment of spontaneous rhinorrhea but it was cosmetically problematic. In the patients both treated with galea and galea together with collagen matrix, the repair of the defect was successful.

ObjectAs magnesium is a potent cerebral vasodilator, we have investigated routine supplementation of magnesium (as a potent cerebral vasodilator) in patients presented with aneurysmal subarachnoid hemorrhage (ASAH) to determine whether there has been a reduction in the incidence of cerebral vasospas

Aim To evaluate the clinical success of the en bloc laminoplasty and impact of the arcocristectomy on postoperative axial pain of the patients with cervical spondylotic myelopathy (CSM). Material and methods A retrospective review of 81 patients with CSM who underwent en bloc cervical laminoplasty while preserving posterior structure of the cervical spine during the period from 2007 to 2014 was performed. Arcocristectomy was performed if the C6-7 level was included in the surgery. The posterior spinal elements and muscles attached to the spinous process of C2 and C7 were preserved. Thus, postoperative deformity of the cervical spine could be avoided. The neurological status of the patients was assessed using the modified Japanese Orthopedic Association (JOA) scale. The neurological recovery rate was calculated according to the Hirabayashi method. Results The mean modified JOA scale score was 11.4±2.4 preoperatively and 15.0±3.9 postoperatively. The neurological recovery rate was 68.6%. C7 arcocristectomy was performed in 19 patients. No axial pain was noted in the first 2 postoperative months. Keyhole foraminotomies were performed in 11 patients and radicular pain completely resolved after surgery. Temporary C5 nerve root palsy was observed in 3 patients. Mean cervical spine lordosis was 10.6o±10.5o preoperatively and 8.6o±9.5o postoperatively. No postoperative spinal instability or kyphotic deformity was noted. Conclusion En bloc cervical laminoplasty while preserving posterior structure is useful in preventing postoperative spinal malalignment and axial pain. Arcocristectomy is an effective technique for the prevention of postoperative axial pain in patients with C6-7 spinal stenosis.

INTRODUCTION The goal of this study was to evaluate the efficacy and reliability of neuronavigation and intraoperative microvascular Doppler sonography (MDS) for identifying afferent (feeding) and efferent (draining) vessels as well as for controlling the totality of the surgical resection of arteriovenous malformations (AVMs). METHODS Between June 2000 and November 2005, twenty-five patients with small arteriovenous malformations (grades I-III) underwent microsurgical removal at our institution. A passive-marker-based neuronavigation system (Brain Lab, Munich, Germany), and an intraoperative MDS (Multi Dop X system, DWL, Germany) were used in this surgery. Blood flow velocities (BFV) in afferent and efferent vessels were recorded before and after removal of AVM. The preoperative neurological status and postoperative outcome were recorded. Patient follow-up monitoring ranged from 4 months to 3 years (mean: 16 months). RESULTS The calculated registration accuracy of the neuronavigation computer ranged between 0.2-1.7 mm (mean: 1.1 mm). Before AVM removal the mean BFV of afferent vessels was 56.5+/-13.4 (28-98 cm/s) and the PI varied by 0.40+/-0.11 (0.25-0.66), after AVM removal these values reduced to 4.8+/-0.8 cm/s and 0.26+/-0.05, respectively. Similarly, before AVM removal, the mean BFV of efferent vessels was 13.5+/-4.5 (4-20 cm/s) and PI was 0.4+/-0.2 (0.34-0.56), after AVM removal both BFV and PI were not recorded. Complete removal of the AVMs was accomplished in 24 (96%) out of 25 patients which was confirmed with postoperative digital subtraction angiography (DSA). While there was no mortality, three patients (12%) had a worsening in their neurological status after surgery. CONCLUSION Image-guided microneurosurgery with intraoperative MDS is a safe, effective, and reliable method for identifying the afferent and efferent vessels and for confirming the complete resection of AVMs. These benefits of image-guided microsurgery were most apparent for small, deep-seated AVMs that were not visible on the surface of the brain. In addition these techniques reduce the operative time and blood loss during AVM resection.

BACKGROUND The aim of this study was to investigate the protective effects of erythropoietin, dextran/saline and erythropoietin in combination with dextran/saline on brain edema and lipid peroxidation following traumatic brain injury in rats. METHODS In the study, 40 male 3-month-old albino Wistar rats, weighing 250-340 g, were divided into four groups, each consisting of ten rats. Traumatic brain injury was induced in all rats by the weight-drop method, and erythropoietin (5,000 U/kg) and/or dextran and saline (8 ml/kg) solutions were injected intraperitoneally ten minutes after trauma. Control animals received an equal volume of serum physiologic. All rats were sacrificed 24 hours later. Glutathione peroxidase activity and malondialdehyde levels were measured in the left hemisphere, and edema was quantitated by the wet-dry method. RESULTS Brain edema and the levels of malondialdehyde, the last product of lipid peroxidation in tissues, were decreased variably, and the activity of glutathione peroxidase, an antioxidant enzyme, was increased in others compared with the control group. CONCLUSION In this study, it was concluded that the brain edema that developed in rats on which head trauma was induced and the secondary brain damage caused by oxidative stress could be deceased using a combination of erythropoietin, dextran, and saline.

AIM To compare cervical hemilaminectomy with cervical laminoplasty to determine the prognostic significance of both methods in cervical spondylotic myelopathy (CSM). This study is first in the literature to compare the hemilaminectomy and laminoplasty procedures MATERIAL and METHODS: A total of 42 patients who underwent surgery due to CSM and followed for at least 24 months were included in the study. Thirty-four out of 42 patients were males, while 8 were females; the mean age of the patients was 63.6 years (range 41-80). The visual analog scale (VAS) was used in the evaluation of postoperative axial neck pain. Factors known to affect prognosis of CSM such as patients" age, gender, duration of symptoms, pressure level, and T2-hyperintense appearance on magnetic resonance imaging (MRI) were evaluated. Patients were compared in terms of sagittal alignment of the vertebrae (instability), anterior-posterior diameter of the spinal canal, transsectional spinal canal area, axial neck pain, and recovery rate based on the preoperative and postoperative Japanase Orthopaedic Association (JOA) scores. RESULTS The recovery rate in patients who underwent hemilaminectomy was 60.8%±18.8, while in patients that underwent laminoplasty it was 52.8%±11.9. The comparison of both surgical techniques in terms of postoperative recovery rates did not show any significant difference between the techniques (p > 0.05). CONCLUSION There were no significant differences in terms of recovery rate, preoperative and postoperative canal diameter, preoperative and postoperative spinal canal area, and postoperative sagittal alignment (p > 0.05). The VAS evaluating axial neck pain was significantly lower in patients from the hemilaminectomy group compared to patients from the laminoplasty group.

Objective The goal of this study was to evaluate the efficacy and reliability of intraoperative microvascular Doppler sonography (MDS) for the assessment of cerebral haemodynamics in aneurysm surgery. Methods For 40 patients (21 men, 19 women, mean age 54.0 years, range 23-73 years) who underwent surgery for the treatment of 48 intracranial aneurysms, microvascular Doppler sonography with a 20-MHz microprobe was used before and after clip application, to confirm the complete obliteration of the aneurysm. Postoperative angiography was performed to assess the complete occlusion of the aneurysm and the patency of adjacent vessels. The findings of MDS were analysed and compared with the postoperative angiography. Results A 1-mm diameter microprobe was able to insonate all vessels of the circle of Willis and their major branches and perforating arteries were reliably insonated. The aneurysm clip was repositioned on the basis of the MDS findings in 12 out of 48 patients (25%). For 9 aneurysms (18.7%) MDS exposed a relevant stenosis of an adjacent vessel induced by clip positioning that had escaped detection by visual inspection. Clip repositioning resulted in complete occlusion of the aneurysms in 7 of 9 cases (14.5%). In two cases, additional wrapping became necessary as it was not possible to achieve complete clipping. The mean duration of MDS investigations was 5.3 minutes. There were no complications of intraoperative MDS probe use. Conclusion Intraoperative MDS should be used routinely in cerebral aneurysm surgery, especially for large, complicated and giant aneurysms. Intraoperative MDS is a feasible, safe, and very reliable technique in aneurysm surgery. This technique is a valuable tool, in many instances, in place of intraoperative angiography for the surgical treatment of aneurysms.

In this report, the authors describe two cases of growing fracture of the orbital roof. The aim is to draw attention to this rare complication and discuss the role of three-dimensional computed tomography in radiological findings and surgical planning. Relevant literature is also reviewed.

In this study, an extremely rare case of a gigantic cerebral hydatid cyst is presented. A right frontotemporal hydatid cyst was detected by computed tomography and magnetic resonance imag-ing. This lesion was extirpated successfully with intact contents with the aid of a neuronavigation system. The literature is reviewed and possible postoperative complications are discussed with the published reports.

Lipid peroxidation (LP) and brain edema are important factors that produce tissue damage in head injury. The purpose of this study was to investigate the effect of mexiletine, gingko biloba extract (EGb 761), and their combination on LP and edema after moderate head trauma. Forty rats were randomly and blindly divided into four groups of ten animals each: control group (bolus injection of physiological saline), mexiletine group (50 mg/kg per injection), EGb 761 group (30 mg/kg per injection), and mexiletine plus EGb 761 group (50 mg/kg and 30 mg/kg per injection, respectively). The injections were given intraperitoneally at 1 h, 9 h, and 17 h after trauma. Twenty-four hours after injury, the rats were killed, and malondialdehyde (MDA) levels and brain water content were determined. Rats treated with mexiletine, EGb 761, and mexiletine plus EGb 761 had significantly lower MDA levels than the control group (P0.05). These findings show the usefulness of mexiletine and its combination with EGb 761 as a cerebroprotective agent in this model of experimental head injury.

Aim Despite different surgical treatment protocols at different centers for spondylodiscitis due to lumbar surgery, there is no consensus on its surgical indications. In this study, we aimed to clarify the steps to be followed in the management and treatment of postoperative spondylodiscitis. Material and methods The data of 20 cases with postoperative spondylodiscitis were evaluated. C-reactive protein (CRP) was used for diagnosis and follow-up. According to culture results of the infected material obtained from the operated cases, appropriate antibiotic treatment was initiated. In non-operated cases, parenteral empirical antibiotic treatment was implemented. Surgical treatment was planned for cases with clinical and radiological instability, abscess on imaging and those who were nonrespondent to empirical antibiotic treatment. For the cases that clinically recovered and had normal CRP levels, oral antibiotic treatment was continued after parenteral antibiotic treatment. Results Of the cases; 13 were male (65%) and 7 were femals (35%). The mean age was 56.3 years (32-74). The most prevalent complaints in referral were waist and leg pain. Except one, all cases had increased CRP levels. All patients had spondylodiscitis on magnetic resonance imaging. Seven had radiological and clinical instability and 3 had epidural abscess. The most commonly growing microorganism in culture was Staphylococcus aureus. Surgical treatment was applied to seven cases and medical treatment to 13 cases. Conclusion In cases with waist pain in the postoperative period, the first potential diagnosis to be considered is spondylodiscitis. Surgical treatment should be implemented for cases resistant to empirical antibiotic treatment, with abscess on imaging, or with lumbar instability.

The surgical approaches for spinal tumors, to a great extent, have been developed in accordance with the developments in medical technology. Today, many surgical techniques are implemented as anterior, anterolateral, posterior, posterolateral and combined approaches. Due to its low morbidity, the posterior approach is the more preferred one. Laminectomy is a widely used technique, especially in neoplastic lesions. However, following laminectomy, there are numerous complications such as instability, kyphotic deformity and scar formation. In this paper, the excision of a tumor that was located intradural-extramedullary at the C3-C7 level with the cervical hemilaminoplasty technique is described. A 47-year-old female patient presented to our clinic with increasing complaints of neck and left arm pain, left arm numbness and searing pain for the last 10 years. On examination, hypoesthesia at the C4-7 dermatomes in the left upper extremity, an increase in deep tendon reflexes, and bilateral positive Hoffmann reflexes were observed. C3-C7 laminae were opened unilaterally on the right side with a midline skin incision. The laminae were drilled with a high-speed drill to provide a wide opening, both on the midline obliquely and from the border of the lamina-facet joint. After the tumor was totally excised, hemilaminae were placed into the previous position and reconstructed with mini-plates and screws. Cervical hemilaminoplasty provides a wide field of vision in tumor surgery of this region. Besides, the reconstruction of hemilaminae is important for stability. As the integrity of the spinal canal is preserved during reoperations of this region, the risk of complications is decreased.

Objective: To investigate the contribution of the use of neuronavigation together with intraoperative ultrasonography in the surgical treatment of cavernous hemangiomas to the decrease of mortality and morbidity. Materials and Methods: A total of 73 cases with cavernous hemangiomas, operated on under the guidance of neuronavigation and intraoperative ultrasonography between June 2000 and September 2010 in the Neurosurgery Department of the University of Erciyes, were investigated retrospectively. The cases were evaluated from the point of neurological deterioration due to surgery. Results: The lesions were mostly located supratentorially, especially in the temporal region. The most common complaint of supratentorially located lesions was epilepsy. Such findings and symptoms as bleeding, headache, and focal neurological deficits were observed mostly in the lesions of infratentorial region; 80 cavernous hemangiomas in 73 cases were removed in total. In 3 of the cases, a temporary increase in the neurological deficits was observed; however, in the late periods, no persistent morbidity or mortality due to surgery was observed. Conclusion: By using neuronavigation together with intraoperative ultrasonography, the inconsistency between real location and the navigation image of the lesion resulting from the brain shift due to cerebrospinal fluid drainage can be restored; so, the morbidity and mortality can be decreased.

An extremely rare case of a thalamic hydatid cyst is presented and the literature is reviewed. A right thalamic hydatid cyst without rim enhancement or perifocal edema was detected by computed tomography and magnetic resonance. This lesion was extirpated successfully with intact contents via contralateral transcallosal approach. To our knowledge, this is the second hydatid cyst of the thalamus, an unusual location, and the first hydatid cyst to be removed completely with intact contents reported in the literature.

Open third ventriculostomy (OTV) was performed on 4 infants with noncommunicating hydrocephalus and intractable shunt infections. All patients were resistant or relapsed after treatment with intravenous and intraventricular antibiotics along with change of the shunt apparatus. We performed phase-contrast cine magnetic resonance imaging (MRI) for preoperative and postoperative evaluation of cerebrospinal fluid (CSF) flow at the aqueduct of Sylvius. All patients required a second OTV approximately 3 weeks after the first OTV due to closure of the patency. Our experience led us to view OTV as an unsuccessful procedure in infantile noncommunicating hydrocephalus due to an insufficiently developed subarachnoid space. The patients’ data, operative findings and probable causes of failure are presented here.

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological findings are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86 % of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2 %, but only patients with an acute course died (20 %). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Four cases of migration of the ventriculoperitoneal (V-P) shunt tip through patent processus vaginalis resulting in scrotal hydrocele are presented. These cases are considered a rare complication of V-P shunts and causal mechanisms are discussed with a review of the literature.

Syringomyelia is a not infrequent pathology that develops related to changes in cerebrospinal fluid dynamics due to many etiological factors. The development of syringomyelia through a spinal arachnoid cyst is quite rare and has been defined in only 31 cases in the literature. A case due to thoracic epidural lipomatosis has also been reported. There have been no previous reports of thoracic region epidural lipomatosis with underlying arachnoid cyst and syringomyelia as in our case. We present a 27-year-old patient who developed thoracic arachnoid cyst and underlying syringomyelia because of the pressure of the thoracic epidural fat tissue and also evaluate the characteristics of patients with syringomyelia by virtue of an arachnoid cyst previously reported in the literature.

Gergi omurilik serbestleştirilmesi pediatrik nöroşirurjide yaygın olarak yapılmaktadır. Günümüzde minimal invazif yöntemler gittikçe artan bir ilgi görmektedir. Cerrahi uygularken giriş yollarına en az hasar verilmesi ve normal dokunun azami korunması amaç olmuştur. Bizde günümüzde gergin omurilik sendromunun cerrahi tedavisinde uygulanan pek çok yöntemlerden farklı olarak olgudan hiçbir doku çıkartılmadan kordun serbestleştirilmesini sağlayan bir yöntemi tanıtmayı amaçladık. Bu yaklaşımın temel avantajı işlemin 2 cm kesi ile yapılması, ligamentum flavum ve lamina gibi kemik yapıların korunması ve buna bağlı gelişebilen skar dokusunun azalmasıdır.Teknik not: Olgu sitting-prone pozisyonda operasyon masasına alındı ve skopi ile L5-S1 mesafesi belirlendi. Orta hattın 0.5 cm lateralinden 2 cm vertikal kesi sonrasında cilt ve cilt altı dokular geçildi. L5 laminası rehberliğinde L5-S1 mesafesi ve mesafeyi örten ligamentum flavum ortaya kondu. Mikroskop çekildi ve Williams Ekartörü mesafeye yerleştirildi. Buraya kadarki işlemler disk cerrahisiyle aynıydı. Mikroskop altında flavum'a vertikal kesi yapılarak her iki dudağı sırtlarındaki dokuya basit sütür ile asılarak duranın rahat görünümü sağlandı. 0.5 cm'lik vertikal kesi ile tekal sak açıldı. Sinir oku yardımıyla filum bulunarak serbestleştirildi. Dura primer olarak mikro cerrahi enstrümanları ile dikildi ve üzerine flavum tekrar serildi., Tethered cord release is commonly performed in pediatric neurosurgery. Nowadays, minimally invasive procedures are created growing interest due to its highly tolerable nature for surgery. It has been main purpose a minimal damaging on access route and maximum protection of normal structures in surgery. We present a surgical treatment of tethered cord syndrome, by which is provided the cord releasing unlike the many methods being applied with tissue removal. The main advantage of performing this surgery through 2 cm hole is to avoid removing ligamentum flavum and bony structure like lamina in addition to reduce the length of the incision and the related scar tissue. J Clin Exp Invest 2014; 5 (1): 115-117Technical note: the patient was taken on the operating table in the sitting-prone position, and L5-S1 distance was determined by fluoroscopy. The skin and subcutaneous tissues was passed via a 2 cm vertical incision settled in 0.5 cm laterally from midline. L5-S1 distance and its covering ligamentum flavum are displayed by the guidance of L5 lamina. Williams's retractor was placed in the distance after fetching microscope. The foregoing procedures are the same with microdiscectomic surgery. By a vertical incision made on the flavum, its both layer was lifted up and hanged with simple suture on the back tissue for a comfortable exposure of the Dura. Thecal sac was opened by 0.5 cm long vertical incision on the Dura after obtaining secure CSF drainage with the help of yellowtipped syringe needle. With finding by a nerve hook, the phylum was burned and released securely. Then the Dura was sutured primarily for the closure by means of microsurgery instruments, and flavum was laid on it again.

Vertebral hemangiomas are benign vascular lesions of the vertebral column; only 0.9-1.2% of all vertebral hemangiomas cause spinal cord compression. We report a 34-year-old female who was admitted to the neurosurgery clinic with a history of back pain, poor quality of life and easy fatigability for 1.5 years. Her medical history revealed a fall from a height of 2 meters 1.5 years ago. Neurology examination revealed bilateral hypoesthesia below the T8 level and hyperactive deep tendon reflexes in her left leg. Computed tomography scan of the thoracic spine showed T8 vertebral hemangioma, and magnetic resonance imaging showed a T8 hemangioma compressing the spinal cord. Surgical intervention was planned and T8 total laminectomy was performed. The tumor extending into the anterior spinal cord was resected, and T8 vertebroplasty with short segment posterior stabilization and fusion was performed. We aimed to present a new treatment approach for symptomatic vertebral hemangiomas and reviewed the relevant literature.

Background Intracranial hemorrhage (ICH) is a life-threatening situation in childhood. Congenital factor deficiencies (CFD) like hemophilia may cause ICH, and ICH may be the initial presentation in some cases., BACKGROUND: Intracranial hemorrhage (ICH) is a life-threatening situation in childhood. Congenital factor deficiencies (CFD) like hemophilia may cause ICH, and ICH may be the initial presentation in some cases.METHODS: From 2000 to 2010, 107 children with CFD from Erciyes University, Faculty of Medicine, Department of Pediatric Hematology, were evaluated. The ICH episodes were identified by medical history, general physical examination, detailed neurological examination, and CT or MR scan. The management strategies, surgical intervention, and outcome were noted.RESULTS: Twenty-one episodes of ICH were seen in 18 patients (16.8%) out of 107 CFD patients. The mean age of the patients was 42.1 months. Fourteen out of 18 patients were male, and four were female. Twelve (57.1%) out of 21 ICH episodes were caused by trauma, and nine (42.9%) were non-trauma related. Epidural hematoma was most frequently observed. All patients survived, but four had decrease in intellectual capacity and motor deficit.CONCLUSION: The optimal management of ICH in children with CFD depends on immediate recognition and prompt replacement therapy to ensure hemostatic balance with adequate surgical intervention.PMID:21748400[PubMed - indexed for MEDLINE]

Objective In the surgery for a distal anterior cerebral aneurysm which is applied with a vertical head position, the dome of the aneurysm makes it difficult the expose the neck and the proximal artery. This study was performed to evaluate the applicability of the alternative contralateral interhemispheric approach with a horizontal head position for clipping these aneurysms. Method The head of the patient was placed in the horizontal position such that the aneurysm side remained at the top and then tilted 45 degrees superiorly. On the contralateral side, the craniotomy, interhemispheric dissection and clipping were performed in 12 patients with 13 aneurysms. Results All aneurysms were clipped successfully. Problems in the standard supine position such as the obstruction of the access to the aneurysm neck and the proximal artery by the dome were not encountered. Vasospasm developed in 4 patients and akinetic mutism in 1 patient; postoperative convulsion due to an inadvertent cortical venous injury in one patient resolved with medical treatment. Hydrocephalus developed in 2 patients; one patient needed placement of a ventriculoperitoneal shunt while the other responded to occasional lumbar punctures. Mortality or permanent morbidity did not occur. Conclusion The horizontal head position may be an alternative for circumventing difficulties posed by the location of distal anterior cerebral artery aneurysms.

The case of a 24-year-old man with a juvenile-type spinal arteriovenous malformation is reported. Spinal angiography and magnetic resonance image revealed a juvenile (Type III) AVM at the cervical spine. This spinal malformation was successfully resected with a posterior and anterior surgical approach in two stages following partial embolization.

Objective Computer-assisted neuronavigation was used in 87 cases of skull base lesions (SBLs). Preoperative planning and intraoperative identification of anatomic landmarks is especially important in SBLs since it helps to avoid or minimize surgical morbidity and mortality. In this study, we assessed the accuracy and the clinical usefulness of a frameless system based on the optical digitizer in SBLs. Patients and methods Between April 2000 and March 2003, eighty-seven patients with SBLs were operated on in our department using cranial neuronavigation. A passive-marker-based neuronavigation system was used for intraoperative image guidance. There were 56 women and 31 men. The patient's ages ranged from 4 to 76 years (average: 45.7 year). The locations of the tumors reported in this series were as follows: frontobasal, 24 cases; sellar/parasellar, 32 cases; petroclival, 16 cases; tentorial/subtemporal, 15 cases. Results The computer-calculated registration accuracy ranged between 0.3 and 1.7 mm (mean, 1.1 mm). Gross total removal of the SBLs was accomplished in 82 out of 87 patients as was confirmed on postoperative CT and MRI scans. The follow-up period ranged from 1 month to 48 months (average: 20.1 months). Overall mortality and severe morbidity (meningitis, permanent cranial nerve deficits, and cerebrospinal fluid fistulae) rates were 4.6 % and 33.3 %, respectively. Conclusion The image-guided surgery is a valuable aid for safe, helpful and complete removal of SBLs of the brain where accurate localization of the lesion is critical. Although our preliminary series is not large, interactive image guidance provides a constant display of surgical instrument position during surgery and its relationship with the SBLs components, surrounding normal brain, and vascular structures, providing valuable guidance to the surgeon during an operation. Our experience with the neuronavigation suggests that image guidance is helpful in this type of lesions, providing better anatomic orientation during skull base surgery, delineating tumor margins and their relation to critical neurovascular structures.

An unusual case of traumatic C6 - 7 total spondyloptosis with neurologically intactness at the time of injury is reported in a 35-year-old man. The patient was treated with a single-stage combined anterior-posterior and anterior operation to restore the cervical spondyloptosis, and creation of a three-column stabilization of the spine without neurological deficits. To the best of the authors' knowledge, there is no case report of traumatic spondyloptosis of cervical spine, presenting without neurological deficits in the pre- and postoperative periods. A brief summary of the clinical presentation, the surgical technique, and a review of the relevant literature are presented.

Oblique corpectomy (OC) is an alternative technique for the resection of spondylotic spurs ventral to the cervical spinal cord contributing to cervical spondylotic myelopathy (CSM) and cervical spondylotic radiculopathy (CSR). To evaluate the efficacy of OC for the treatment of cervical spondylotic myeloradiculopathy, we reviewed our experience with OC. Twenty-six patients, 18 males and 8 females, were studied. They averaged 51.3 years of age (range 30-72), Thirteen had myelopathy and 13, radiculopathy. Both magnetic resonance (MR) imaging and computed tomography (CT) were performed preoperatively to define the extent of pathology. The Modified Japanese Orthopedic Association (JOA) score was used to grade the quality of the outcome. Neurologic and radiologic results were assessed. Good and excellent results were observed in 76.9% of the cases with myelopathy. Improvement of radicular symptoms was noted in 84.6% of the cases with radiculopathy. Neuroimaging studies confirmed satisfactory anatomical decompression in all patients. Sagittal alignment decreased from 13 degrees to 12 degrees. The degree of postoperative recovery seemed to be directly related to the age and severity of the preoperative myelopathy. This surgical technique has shown excellent clinical outcomes with fast recovery and adequate anatomical decompression in patients with CSM and CSR.

Fractures in the clivus region are usually associated with blunt head trauma. They may cause many cranial nerve deficits and vascular complications. The mortality rate is high because of brainstem trauma or vertebrobasilar occlusion. The diagnosis of clivus fracture (CF) is difficult with routine cranial radiography due to the presence of dense petrous temporal bones. Because of this, few cases have been described in the past. In this study, we report nine cases of CF observed and treated in our department during the last 5 years. Computed tomographic (CT) scanning revealed CF in nine of 2500 patients with head trauma (0.36%). The patients ranged in age from 17 to 68 years (mean 38.3). Five patients had had motor vehicle accidents, three were injured in falls, and one was a pedestrian injured by a motor vehicle. Five patients had longitudinal fractures and four had transverse fractures. Cranial nerve deficits were recorded in all patients. Deficits of cranial nerves VI and VII were the most frequently observed (six patients, 66.6%). We review the literature to highlight the differences in clinical presentation and the course in cranial nerve deficits. The diagnosis of CF is made by high-resolution, fine-cut CT using standard and bone window settings. Its presence should alert clinicians to the potential complications.

Anterior cervical foraminotomy (ACF) was developed under the concept of functional spine surgery, which directly eliminates compressive pathological factors while preserving functional anatomic features. The authors reviewed their results to determine the efficacy of the approach for unilateral cervical spondylotic radiculopathy (CSR). Nineteen patients were treated with the ACF with a follow-up from 12 to 36 months. There were 10 men and 9 women (mean age 49.8). Fourteen patients had a single ACF, and 5 had procedures at adjacent levels. The procedure involves microsurgical removal of the lateral portion of the uncinate process to identify the nerve root. Seventeen patients (89.5 %) were symptom-free or clearly improved, one (5.3 %) was unchanged and one patient (5.3 %) was worse in the visual analogue scale (VAS) score for radicular pain. One patient had developed contralateral foraminal stenosis at the level of the surgery and had undergone anterior discectomy and fusion. ACF provided good or excellent outcomes, with minimal morbidities, for patients with CSR. The advantages of ACF include direct decompression of the nerve root, and the preservation of the intervertebral disc and the motion segment. Thus, fusion-related sequelae, including graft-related complications, graft site complications and the adjacent level disease are avoided. The ACF procedure appears to be a good alternative for carefully selected patients with unilateral CSR.

High-grade gliomas are the most common primary brain tumors in adults. Twenty-seven patients with histopathologically proven anaplastic astrocytoma and glioblastoma multiforme were enrolled in this study from November 1998 to August 2002. Radiotherapy was administered after surgery and fotemustine (100 mg/m(2)) was sequentially administered every 3 weeks for 6 cycles. Overall, 111 cycles were administered to the 27 patients (median, 5 cycles; range, 1 to 6 cycles). Myelosuppression was mild to moderate. The median overall survival and progression free survival were 11 +/- 3.1 months (95%CI, 4.9-17.1) and 8 +/- 0.5 months (95%CI 7.1-8.9), respectively. One-year and two-year survivals were calculated at 48% and 7%, respectively. Significant prognostic factors (P

We report the case of an adult with a posttraumatic intradiploic pseudomeningocele which caused an expanded osteolytic skull lesion. Local pain and swelling, the only symptoms of the lesion, regressed after surgery. Intradiploic pseudomeningocele must be distinguished from intradiploic leptomeningeal cyst, which is of traumatic origin or arachnoid cyst and epidermoid cyst, which are of congenital origin. We also discuss the development of intradiploic pseudomeningoceleafter head trauma without skull fracture in adulthood and suggest a possible mechanism.

Nocardia brain abscess is a rare intracranial lesion and has been reported in immunocompromised patients. An optimal treatment approach has not been established. However, early diagnosis and appropriate antimicrobial therapy are very important factors for a good outcome. We report two unusual cases of Nocardia brain abscess simulating brain tumour in immunocompetent patients. One of the cases was presumed to be a primary brain tumour and the other a metastatic brain tumour. They underwent surgical gross total resection. After Nocardia asteroides was seen on Gram’s stain and subsequently identified by culture, appropriate antibiotic therapy was initiated.

Lesions involving the anterior skull base and sphenoclival region are difficult surgical problems. This paper presents surgical details, pitfalls, avoidances and our experiences in the surgical treatment of lesions of the anterior skull base using neuronavigation. Between 1999 and 2003, 33 patients with pathology of the anterior skull base were operated on via the traditional transbasal and the extended transbasal approach. A passive-marker-based neuronavigation system has been used for intraoperative image guidance since April 2000. The patients consisted of 11 men and 22 women. Their ages ranged from 3 to 76 years, with a mean of 41 years. The lesions for which the approach was used included 9 cerebrospinal fluid (CSF) fistulae and 24 neoplastic lesions including meningioma (16 cases), metastasis (3 cases), chordoma (3 cases), plasmacytoma. (I case), and osteoma (1 case). Gross total removal of the tumors was accomplished in 22 out of 24 patients with tumor (91.6%). Postoperative complications include CSF leakage (2 cases), infection (2 cases) and transient impaired vision (1 case). One patient (3%) died postoperatively from hypothalamic dysfunction after removal of a benign tumor extending to the anterior third ventricle. Despite the incidence of postoperative infection and the high rate of CSF leakage and death, it is possible to obtain long-term survival for patients with tumors previously considered challenging and difficult surgical problems.

Acute management of deep-seated hematomas remains controversial. Since patients with these hematoma. later tend Po develop severe edema and necrosis around the lesion, when surgery is indicated it should be done as early as possible. The purpose of this study was to compare whether early surgical removal and conservative treatment of primary thalamic hematoma correlated with improved neurological outcome. Last year, 61 patients with primary thalamic hematomas were admitted to our institution. Of these, 21 underwent surgery via contralateral transcallosal approach during the ultra-early stage (within 6 hours) after the apoplectic attack, and 24 patients were treated conservatively. Another 16 patients were excluded from the study due to systemic disease, mild hematoma (1.93 versus 9.50 +/-2.10, P>0.05). In the operated group, two patients had good recoveries and returned to normal life (Glasgow Outcome Score, or GOS, I), four had moderate disability and needed partial care (GOS II), six had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). However, in the nonoperated group, one patient had good recovery and returned to normal life (GOS I), two had moderate disability and needed partial home care (GOS II), three had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). In this group, the 30-day mortality rate was 50%. Mortality was markedly lower in the operated group (14.3%) than the nonoperated group, and this difference was statistically significant (chi (2)=3.33, P

A case of type IIA odontoid fracture with posterolateral dislocation accompanied by spinal cord injury is presented. Cervical traction was employed but reduction could not be achieved with up to 8 kg of traction. The patient was treated with intraoperative reduction and C1-2 posterior transarticular screw fixation with supplemental bone-wire fusion, and rigid fixation was obtained without any complication.

Intradural lumbar disc herniation (ILDH) is a rare pathology. The pathogenesis of ILDH is not known with certainty. Adhesions between the ventral wall of the dura and the posterior longitudinal ligament (PLL) could act as a preconditioning factor. Diagnosis of ILDH is difficult and seldom suspected preoperatively. Prompt surgery is necessary because the neurologic prognosis appears to be closely linked to preoperative duration of neurologic symptoms. Despite preoperatively significant neurological deficits, the prognosis following surgery is good. We report on two new cases of ILDH of high lumbar locations L1-2 and L2-3 with difficult differential diagnoses, and the possible pathogenic factors are discussed.

Objective: We evaluated 20 patients with spinal lesions with respect to the value of unilateral hemilaminectomy at the Department of Neurosurgery, Erciyes University, Medical Faculty, Kayseri, Turkey. The operative technique of the limited approach for spinal lesions is described. Methods: The study is based on 20 prospective consecutive patients with spinal lesions who had unilateral hemilaminectomy. There were 12 women and eight men. Age ranged from 17 to 63 years mean (42 years) with a slight preponderance of women patients (60%). Spinal lesions were cervical in three cases, lumbar in five cases, and thoracic in 12 cases. Hemilaminectomy was performed by using a high speed drill. Results: Postoperative neurological status was unchanged in six cases, improved in 11 cases, and worsened in three cases. We only observed two cases of wound infections that were not related to our surgical approach. At the follow-up evaluation, which occurred approximately 25 months after surgery none of the patients showed spinal deformity or spinal instability. Conclusion: The rationale of attempting unilateral approach is to avoid damage to the dorsal static structures of the vertebral column. With the precise preoperative definition of the relationship of tumor to the surface of the spinal cord by contrast enhanced MRI, unilateral approaches might be more applicable to spinal lesions except invasive extradural lesions. Spinal Cord (2000) 38, 92–96.

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome. Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively. Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9-15) and 23% of patients with a low GCS score (3-8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21-40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion. Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.

Spinal epidural abscess, if especially caused by Brucellosis is a very rare disease which is usually a consequence of spondylodiscitis. The spinal column can be affected at any joint; however, the lumbar spine is the most common region, especially at the level of the L4-5 and L5-S1. The frequency of spinal involvement usually seen at the lumbar, thoracic and cervical spine respectively. As an occupational disease in farmers, veterinaries, butchers, laboratory staff and shepherds, brucellosis can also occur by direct contact to animals and infected materials or ingestion of raw cheese, milk or unpasteurized milk products. In this study, we presented two cases with cervical spinal epidural abscess caused by brucella melitensis, which was successfully treated by surgical approach. Initial treatment was combined with antibiotic therapy after the surgery for 3 months.