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Aim: Surgery is the treatment of choice for children who had tethered cord syndrome (TCS). However, a detailed technique for the release of spinal cord is not described yet. The aims of this study are to present our series of TCS in children and to focus on the details of surgical technique. MATERIAL and, Methods: Forty-nine children with tethered cord syndrome underwent surgical treatment for the release of spinal cord between 2004 and 2009. The mean age was 4.6 years (2 days-13 years). Twenty (40.8%) patients were female and 29 (59.2%) were male. Among the 49 children, 41 (83.7%) had different spinal malformations and 8 (16.3%) had no associated lesion. Sectioning of the filum terminale, cutting the arachnoid and fibrous bands, protection of the rootlets and correction of the associated malformations was the standard surgical method to release the spinal cord., Results: Neurological improvement was observed in 4 (8.2%) patients, while the neurological status was unchanged in the others. Cerebrospinal fluid fistula was the main complication and was observed in 3 patients. No mortality or neurological deterioration was encountered., Conclusion: Spinal cord release with appropriate technique seems to be beneficial in maintaining neurological functioning in children with TCS.

We reviewed the clinical, radiological, surgical, and histopathological features of patients with meningiomas to identify factors that can predict tumor recurrence after "microscopic total removal," to improve preoperative surgical planning, and to help determine the need for close radiological observation at shorter intervals or the need for radiotherapy as an adjuvant treatment in the early postoperative period. Clinical data, magnetic resonance imaging studies, angiographic data, operative reports, and histopathological findings were examined retrospectively in 137 patients with a meningioma treated microsurgically and with no evidence of residual tumor on postoperative MR images. Based on univariate analysis, tumor size, a mushroom shape, proximity to major sinuses, edema, osteolysis, cortical penetration, signal intensity on T2-weighted MRIs, pial-cortical arterial supply, presence of a brain-tumor interface in surgery, Simpson's criteria, and histopathological classification were significant predictors for recurrence. However, age, gender, location of tumor, dural tail, calcification, signal intensity on T1-weighted images, and histopathologic subtypes in the benign group were not significant predictors. By Cox regression analysis the most important variables related to the time to recurrence were mushroom shape, osteolysis, dural tail, and proximity to major sinuses. Aggressive surgical therapy with wider dural removal should be considered in the presence of the preoperative predictors of a recurrence. Close radiological observation at shorter intervals or radiotherapy should be considered as adjuvant therapy in high-risk patients based on surgical findings predicting recurrence related to the brain-tumor interface, Simpson's criteria, and histopathological findings in the early postoperative period.

Background: Although there are some cases of cerebellar mutism in adults after posterior fossa surgery for cerebellar tumour it generally occurs in children. Reversible pathophsiology and the anatomical substrate of this syndrome still remain unclear. The predominance of cerebellar mutism in children is suggested to be related to the higher incidence of posterior fossa tumours in children. However, the question regarding the reason for the obvious difference in the incidence of this syndrome between the paediatric and adult population still remaining unanswered. The aim of this study was to evaluate and compare children and adult groups separately to understand the incidence and the clinical characteristics better and to elucidate the pathophysiological basis and predictive factors for this syndrome., Method: We reviewed, analysed, and compared the cases of cerebellar mutism individually in children and in adults reported in the English literature. We found 106 reported cases in children and 11 cases in adults which were suitable for analysis. We added two adult cases to these., Findings: The ages of the patients ranged from 2 to 16 (mean, 6.4 year) in children and from 17 to 74 (mean, 38.7 year) in adults. Although vermis was the main location in both groups, the incidence of vermis lesions was considered higher in the paediatric population (%91.5 versus %69.2). The rate of brain stem invasion was prominent in children (%31.1) when compared with adults (%7.6). The latency for the development of mutism and the duration of the mutism were similar in children and adults (mean, 1.4 d versus 2 d and mean, 5.07 wk versus 4.2 wk respectively). Mutism was transient in all the cases of both groups., Interpretation: Recent concepts of cerebellar physiology disclose the importance of the cerebellum in learning, language, and mental and social functions. Pontine nuclei, the thalamus, motor and sensory areas and supplementary motor areas have been proven necessary for the initiation of speech. It can be hypothesized that uncompleted maturation of the reciprocal links in childhood connecting the cerebellum to these structure makes the children more vulnerable to have postoperative cerebellar mutism in comparison to the adult population.

Objective: We conducted a retrospective study to investigate the prognosis, possible prognostic factors, and long-term natural history of subarachnoid hemorrhage of unexplained cause., Methods: This report contains a retrospective analysis of data for 84 patients with subarachnoid hemorrhage of unknown cause who were monitored for 1 month to 9.5 years, with an average follow-up period of 5.6 years. We evaluated the associations between computed tomographic (CT) scan features, clinical grade, loss of consciousness during hemorrhage, ventricular ratio, angiographic spasm, complications (such as death resulting from ischemia, early rebleeding, late rebleeding, epilepsy, hydrocephalus, and fixed ischemic deficits), and outcomes, using a nonparametric, two-sample, Kolmogorov-Smirnov test. The chi2 test was used to test the independence of two categorical variables., Results: CT class exhibited a significant association with clinical grade (gamma = 0.865, P = 0.006), loss of consciousness during hemorrhage (gamma = 0.69, P = 0.001), and ventricular ratio (gamma = 0.8175, P = 0.01) but a nonsignificant association with angiographic vasospasm (gamma = 0.21, P = 0.2). Death resulting from ischemic complications and fixed ischemic deficits were strongly associated with clinical grade (P = 0.003 and P = 0.008, respectively) but weakly associated with CT class (P = 0.06 and P = 0.084, respectively). Angiographic vasospasm was strongly associated only with fixed ischemic deficits among complications (P = 0.001). Clinical outcome was strongly positively associated with CT class (gamma = 0.685, P = 0.001), clinical grade (gamma = 0.81, P = 0.001), and ventricular ratio (gamma = 0.57, P = 0.002) but weakly positively associated with loss of consciousness during hemorrhage (gamma = 0.459, P = 0.0487) and angiographic vasospasm (gamma = 0.48, P = 0.04)., Conclusion: Our study confirms earlier studies reporting a good prognosis for survival, but it does not confirm the earlier statements regarding low morbidity rates. Although clinical grade and the presence and amount of subarachnoid blood on CT scans are the major prognostic factors related to the incidence of ischemic complications, clinical grade and CT class are also the main parameters, with ventricular ratio, indicating clinical outcomes for patients with subarachnoid hemorrhage of unknown cause.

Background: Perimesencephalic nonaneurysmal hemorrhage is a benign form of subarachnoid hemorrhage with a low risk of rebleeding. The authors conducted a retrospective study to investigate the prognosis, possible prognostic factors, and long-term natural history in perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH)., Methods: This report contains a retrospective analysis of 29 patients with PNSH who were followed from 1 month to 8 years with an average follow-up period of 5.4 years. We evaluated computed tomography (CT) scan features; clinical grade; loss of consciousness during hemorrhage; ventricular ratio; angiographic spasm; complications such as ischemic complications, early rebleeding, late rebleeding, epilepsy, hydrocephalus, and fixed ischemic deficit; and outcome., Results: There were 7 men and 22 women, and the ages ranged from 22 to 69 years (mean 49.5 years). In the group with PNSH 93% of the patients were in grade I-II, as compared to 70.8% of patients with non-PNSH according to the Hunt and Hess system. Loss of consciousness during hemorrhage was detected in 9 patients (31%). We observed acute hydrocephalus in 4 patients (13.7%). The first cerebral four-vessel angiograms disclosed vasospasm in 3 patients (10.3%). Patients with PNSH have the best outcome according to the activities of daily living (ADL) grading system when compared with other groups of patients with negative angiogram (aneurysmal pattern and invisible blood)., Conclusion: This study provides evidence that patients with PNSH have an uncomplicated course and a particularly favorable outcome.

Cerebral hydatidosis accounts for approximately 1 to 3% of all cases of hydatid disease. Generally, cerebral hydatid cysts are single lesions located in the watershed of the middle cerebral artery. Primary intracranial extracerebral hydatid cysts are extremely rare. Only 2% of hydatid cysts are localized in the skeleton, and of these 3 to 4% are found in the skull. The authors describe the case of a 10-year-old boy who was admitted to their clinic with headache and unilateral focal epileptic seizures. Computerized tomography scanning revealed a right parietal intraosseous hydatid cyst. A case of cranial intraosseous hydatid disease is presented, and the differential diagnosis and treatment are discussed in the light of literature.

Object: The inflammatory cells that accumulate at the damaged site after spinal cord injury (SCI) may secrete interleukin-6 (IL-6), a mediator known to induce the expression of inducible nitric oxide synthase (iNOS). Any increased production of NO by iNOS activity would aggravate the primary neurological damage in SCI. If this mechanism does occur, the direct or indirect effects of IL-6 antagonists on iNOS activity should modulate this secondary injury. In this study, the authors produced spinal cord damage in rats and applied anti-rat IL-6 antibody to neutralize IL-6 bioactivity and to reduce iNOS. They determined the spinal cord tissue activities of Na+-K+/Mg++ adenosine-5'-triphosphatase (ATPase) and superoxide dismutase, evaluated iNOS immunoreactivity, and examined ultrastructural findings to assess the results of this treatment., Methods: Seventy rats were randomly allocated to four groups. Group I (10 rats) were killed to provide normal spinal cord tissue for testing. In Group II 20 rats underwent six-level laminectomy for the effects of total laminectomy alone to be determined. In Group III 20 rats underwent six-level T2-7 laminectomy and SCI was produced by extradural compression of the exposed cord. The same procedures were performed in the 20 Group IV rats, but these rats also received one (2 microg) intraperitoneal injection of anti-rat IL-6 antibody immediately after the injury and a second dose 24 hours posttrauma. Half of the rats from each of Groups II through IV were killed at 2 hours and the other half at 48 hours posttrauma. The exposed cord segments were immediately removed and processed for analysis., Conclusions: The results showed that neutralizing IL-6 bioactivity with anti-rat IL-6 antibody significantly attenuates iNOS activity and reduces secondary structural changes in damaged rat spinal cord tissue.

Background: Gangliogliomas are rare benign tumors of the CNS consisting of differentiated neural elements and low-grade glial cells., Methods: We reviewed our experience of 11 patients with histologically proven ganglioglioma who were surgically treated since 1986 at Cukurova University Medical Center. These patients presented at 18 to 45 years of age. Five were women and six were men. The most common initial symptom was seizures (in nine of 11 patients), which had sometimes persisted over long periods of time. At the time of diagnosis, four patients had focal neurological deficits and three had signs or symptoms of increased intracranial pressure. The cystic and well-circumscribed characteristics of these lesions were detected on computed tomography (CT). Despite their appearance on CT, all but one of the lesions were found to be mostly solid at operation. Magnetic resonance imaging (MRI) in six patients revealed abnormally high signal intensity on T2-imaging. The temporal lobe was the main tumor location (seven patients). All cases were diagnosed according to the Russel and Rubinstein histological criteria for ganglioglioma., Results: Ten patients had radical total resection and one had subtotal resection. No patient underwent postoperative radiation or chemotherapy. Except for one, all are still alive and free of progressive disease 1 to 11 years (mean 6.2) after operation. Six are seizure-free and three have improved seizure control under anticonvulsant therapy., Conclusions: We conclude that ganglioglioma is a distinct histological phenomenon with mildly predictable clinical symptoms (seizures), mildly characteristic radiological features, and long-term survival after surgical resection without the need of adjuvant treatment such as radiotherapy.

Excessive calcium influx has been implicated in the pathophysiology of ischemic cerebral damage. The effects of nimodipine, a calcium antagonist, on the Na(+)-K+/MG+2 ATPase activity, Ca+2/Mg+2 ATPase, lipid peroxidation, and early ultrastructural findings were examined at the acute stage of ischemia in the rat brain. Ischemia was produced by permanent unilateral occlusion of the middle cerebral artery. In Group I, the rats which had no ischemia and not received medication were used for determining Na(+)-K+/Mg+2 ATPase, Ca+2/Mg+2 ATPase, the extent of lipid peroxidation by measuring the malondialdehyde content and normal ultrastructural findings. In Group II, the rats which had only subtemporal craniectomy without occlusion and received saline solution were used for determining the effect of the surgical procedure on the biochemical indices and ultrastructural findings. In Group III, the rats received saline solution following the occlusion in the same amount of nimodipine and in the same duration as used in Group IV. In Group IV, nimodipine pre-treatment 15 min before occlusion (microgram kg-1 min-1 over a 10 min period) was applied i.v. Na(+)-K+/Mg+2 ATPase and Ca+2/Mg+2 ATPase activities decreased significantly and promptly as early as 10 min and remained at a lower level than the contralateral hemisphere in the same group and at the normal level in Group I. Nimodipine pre-treatment immediately attenuated the inactivation of Na(+)-K+/Mg+2 ATPase (p < 0.05) but there was no change on Ca+2/Mg+2 ATPase activity (p < 0.05). Malondialdehyde content increased significantly in Group III following ischemia as early as 30 min. Nimodipine pre-treatment decreased the malondialdehyde level in Group IV (p < 0.05). This study supports the possibility that nimodipine pre-treatment effects the membrane stabilizing properties via inhibiting the lipid peroxidation and subsequently restoring some membrane bound and lipid dependent enzymes' activity such as Na(+)-K+/Mg+2 ATPase and the ultrastructural findings.

Platelet-derived growth factor (PDGF) released from platelets is one of the mitogens in serum, which plays a major role upon the cell biology, namely enhancing cell division and controlling of the maturation, especially upon the glial cell growth and its differentiation. Trapidil, which is an anti-PDGF agent, inhibits the effect of PDGF, especially the proliferative effects on the glial and tumoral cells in vitro. Previous studies suggested that the astrocytic proliferation stimulated by PDGF was inhibited by trapidil via the selective antagonism. Trapidil was not found to have a considerable effect on the prevention of nonpermissive astrocytes in this study. It should be theorized that trapidil, administered immediately even after the trauma, could not reach the injury site in effective measure because of secondary events such as edema and impairment of blood circulation. This suggestion should be another subject for studies concerning trapidil which is administered prior to the trauma.

The results of percutaneous radiofrequency rhizotomy of lumbar spinal facets in 46 patients followed at least three months (mean 15 months) are reported and compared with those reported previously. Satisfactory pain relief three months after the procedure was achieved in 36.4 percent of patients without operations and in 41.7 percent of patients, with operations other than fusion. No patient had previously undergone fusion. Treatment of low-back pain by using radio-frequency thermocoagulation of spinal facets is a simple, safe, and well-tolerated procedure. It can be used to relief of pain in spite of decreasing rates of success within the follow-up period.

A 43-year-old woman complaining of severe pain of the right side of the face was admitted to the Department of Neurosurgery. It had been present for three months and diagnosed as trigeminal neuralgia. The CT scan without contrast material had been considered normal at that time. Three months later, after a favourable response to carbamazepine, she suddenly developed right occipital headache and drowsiness. On admission, she was alert, and neurological examination revealed only mild neck stiffness. Computed tomographic scan demonstrated an acute hematoma in the right cerebellopontine angle and in the fourth ventricle. Vertebral angiography revealed an aneurysm of the right anterior inferior cerebellar artery (AICA). A posterior fossa approach disclosed a large, nearly totally thrombosed, saccular AICA aneurysm, which showed minimal compression to the pons at the trigeminal root entry zone. The aneurysm was clipped and excised. She showed an excellent recovery and was free of pain in the early postoperative period and at the last examination 16 months later. Aneurysms in the distal AICA are very rare lesions. Only 31 cases have been published so far. Distal AICA aneurysm in an extremely unusual cause of trigeminal neuralgia secondary to aneurysmal compression. The literature concerning AICA aneurysms and their clinical manifestations is reviewed and discussed.

We produced retrobulbar hematoma in both orbits of 10 pigs in order to assess the effects of blood elements and pressure created by the hematoma on the optic nerves. Ten other pigs were used as a control group. Following decompression in the right orbits, ocular movements, fundi, and intraocular pressure were evaluated for 6 weeks. At the end of the 6th week the optic nerves of 20 pigs were dissected bilaterally for measurements of ATP-ase activity and ultrastructural examination. The results of the ultrastructural examination of the optic nerves of the control group were normal. Optic nerves with decompressed retrobulbar hematoma showed minimal degeneration, whereas the nerves subjected to retrobulbar hematoma with no decompression showed significant degenerative changes. For all groups ATP-ase activities were measured and evaluated. Na+, K+ ATP-ase activities decreased, while Ca+2, Mg+2 ATP-ase activities increased with the extent of degeneration. Optic nerve damage can develop after trauma. Decompression procedures are not among the causes of optic nerve degeneration but retrobulbar hematoma can result in optic neuropathy caused by the compression from the hematoma and the direct effect of blood waste products on the optic nerve.

The authors describe a case of giant fusiform aneurysm of the basilar artery presenting with ischemic symptoms. Angiography and CT revealed vertebro-basilar fusiform aneurysmal dilatation. Fusiform vertebro-basilar aneurysm is associated with various complications particularly brain stem infarction. Similar lesions in the literature are reviewed and the relationship between this clinical entity and cerebral ischemia, particularly brain-stem infarction are discussed.

A patient with a giant intracavernous carotid aneurysm usually has symptoms and signs of a space-occupying lesion, producing one of a variety of types of cavernous sinus syndromes. Epistaxis is an unusual feature in these patients. A patient who noted the onset of repeated arterial epistaxis 2 years after a severe head injury was found to have a traumatic aneurysm of the cavernous portion of internal carotid artery. After angiography, he suddenly developed profuse, pulsatile, arterial epistaxis and had a cardiopulmonary arrest. This case and a review of previously reported cases emphasize the importance of early cerebral angiography in patients with posttraumatic recurrent epistaxis.

Since computerized tomography scanning became available at the Division of Neurosurgery in July, 1979, 13 patients have undergone removal of colloid cysts of the third ventricle by transfrontal or transcallosal routes. Computerized tomography has increased the number of colloid cysts detected in the foramen of Monro during neurological diagnostic workups. The clinical and diagnostic aspects and changing concepts in the treatment of colloid cysts are reviewed.

Reduced glutathinone (tau-glutamylcysteinglycine, GSH) is a scavenger for oxygen radicals and plays in important role in protection of cells from ischemia and from the harmful effects of free oxygen radicals. Free oxygen radicals due to cerebral vasospasm increase in both vasospasm and proliferative vasculopathy. This experiment was performed to determine whether GSH plays a role in cerebral vasospasm after subarachnoid hemorrhage by preventing the harmful effects of free oxygen radicals. In this study, GSH was administered intraarterially and intracisternally following vasospasm of the canine basilar artery. Less vasospasm was observed in the group treated with GSH intraarterially following subarachnoid hemorrhage than in the one treated with GSH intracisternally and in the control group. The arterial wall was investigated ultrastructurally. We evaluated the effect of the anti-oxidating substance through the activity of superoxide dismutase in the arterial wall. We compared the effect of glutathione reductase in the two groups treated with GSH intraarterially and intracisternally. Arterial degeneration was more prominent in the group in which GSH was used intracisternally, while the superoxide dismutase levels were low. In contrast, arterial degeneration was less in the other group in which GSH was used intraarterially, while the superoxide dismutase levels were high.

Subependymomas are uncommon and relatively benign tumors with a distinctive histological appearance. They are generally asymptomatic and most of them are found incidentally at postmortem examination. These tumors are usually located in the fourth and lateral ventricle, and sometimes in the spinal cord. The authors present a series of 5 pure subependymomas of the central nervous system all of which were symptomatic and all of which were treated by microsurgical removal. The clinico-pathological findings and the results of microsurgical treatment in this series are presented.

Penetrating and perforating periorbital puncture wounds by lead pencils are not rare, but ones that reach the brain stem are extremely unusual. We recently treated a patient with of this type of injury. A newly sharpened lead pencil was accidentally introduced through the subconjunctiva at the inner canthus of the right eye. It passed along the medial border of the globe transorbitally and went through the superior orbital fissure into the temporal fossa, then continued through the lateral side of the sella and posterior clinoid, reaching the brain stem. The entire pencil was removed inch by inch without incident under CT control. Meanwhile, the operative team remained ready in case of emergency bleeding. The patient's postoperative course was uneventful, but the initial neurologic deficit of the patient remained fixed.

Between 1981 and 1991, 11 adults over 16 years of age were treated for medulloblastoma at the authors' institutions. These patients were studied retrospectively. The patients were managed uniformly, and the treatment included extensive surgical resections and radiation therapy. Chemotherapy was used on only three patients with recurrence. Probable prognostic factors, including tumor location, extent of surgical resection, dose and extent of radiation therapy, and histological characteristics of the tumor such as neuronal or glial differentiation and desmoplasia were investigated. The classical form of medulloblastoma was present in seven cases while the desmoblastic subtype was found in four cases. All patients with the desmoplastic form had the tumor in cerebellar hemisphere. Gross total removal of the tumor was achieved in seven patients and subtotal excision in four patients. There was no surgical mortality in our series. The extent of surgical resection and location of the tumor had an important effect on longterm survival. The extent and dose of radiation therapy had a major effect on recurrence-free survival. Survival rates were best for patients receiving high-dose irradiation to the entire neuroaxis. Other factors such as age and sex had no major effect on prognosis.

Arachnoid cysts of the middle cranial fossa may manifest themselves in several different ways. Most often they remain asymptomatic and are only diagnosed incidentally on computed tomography or at autopsy. When they are symptomatic, headache, nausea, vomiting and seizures are most common in the patients with increased intracranial pressure. Increased intracranial pressure is caused by the ball-valve mechanism of the cyst's membrane which is in communication with the general subarachnoid space or arachnoid cells which contain specialized membranes and enzymes which have secretory activity. A significant number of middle cranial fossa arachnoid cysts are associated with subdural hematoma which may, in turn, be associated with intracystic hemorrhage. We report an unusual case with posttraumatic, isolated intracystic hemorrhage of the arachnoid cyst in the sylvian area without subdural hematoma.

From 1980 through 1991, 78 patients with brain abscess were treated at the Cukurova University School of Medicine Department of Neurosurgery by surgical excision and antimicrobial therapy. Males predominated in all age groups. Although only 17 percent had a predisposing conditions such as local sinus infection, cyanotic heart disease, the majority of the cases had some evidence of a systemic infection such as peripheral leucocytosis and elevated erythrocyte sedimentation rate. The correct diagnosis was commonly not considered despite to these clues of an infective process on admission. The operative mortality was 20% which was similar to the other series reported in the literature. However in spite of significant progress with the advent of computerized tomography, microbiology and antibiotic treatment, difficulties in early diagnosis are held to be responsible for the residual high mortality. Although the appropriate antibiotic therapy, adjuvant medical therapies to control perioperative brain swelling, and the application of reliable surgical techniques have decreased the mortality and morbidity rates, the best result can only be obtained to a wider number of patients if the physician remains alert to the possibility of an intracranial abscess.

Cerebral vasospasm is one of the most important factors influencing morbidity and mortality of intracranial operations or diseases. Platelet aggregation and adhesion is increased in spastic vessels. Degradation of platelets liberates mediators, which in turn increase vasospasm, thus creating a vicious cycle. Healthy vessels cope with this by increasing the synthesis of prostacyclin. The purpose of this study was to increase experimentally the levels of arterial prostacyclin and adenosine triphosphate (ATP) in animals through intraarterial injection of these substances because they are lower in spastic vessels. Prostacyclin promotes antiaggregation and dilatation, increases blood flow, inhibits thromboxane A2, and prevents synthesis of angiotensin II. Most of these effects were done by increasing cyclic adenosine monophosphate (cAMP). After injecting autogenous blood into the cisterna magna of male dogs, both the acute and chronic phases of vasospasm and the degenerative changes in the arterial wall were observed. Injecting ATP increased the severity of vasospasm. During vasospasm it was found that when prostacyclin is used intraarterially, vasodilatation began, but degeneration of the arterial wall could not be prevented. In the group of animals in which both ATP and prostacyclin were used, there was no degeneration of the arterial wall and the basilar artery was seen to be normal when viewed under the electron microscope.