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Objectives This study aimed to demonstrate resection of a craniovertebral junction (CVJ) meningioma via the posterolateral approach. Design The study is designed with a two-dimensional operative video. Setting This study is conducted at department of neurosurgery in a university hospital. Participants A 50-year-old woman who presented with lower cranial nerve findings due to a left-sided lower clival meningioma (Fig. 1). Main Outcome Measures Microsurgical resection of the meningioma and preservation of the neurovascular structures. Results The patient was placed in park-bench position and a left-sided retrosigmoid suboccipital craniotomy, followed by C1 hemilaminectomy and unroofing the lip of the foramen magnum, was performed. The dural incision extended from the suboccipital region down to the posterior arch of C2 (Fig. 2). The arachnoid overlying the tumor was incised, revealing the course of the cranial nerve (CN) XI on the dorsolateral aspect of the tumor. The left vertebral artery (VA) was encased by the tumor which was originating from the dura below the jugular foramen. The mass was resected in a piecemeal fashion eventually. At the end of the procedure, all relevant cranial nerves and adjacent vascular structures were intact. Postoperative magnetic resonance imaging (MRI) confirmed total resection and the patient was discharged home on postoperative day 3 safely. Conclusions Microsurgical resection of the lesions of the CVJ are challenging as this transition zone between the cranium and upper cervical spine has a complex anatomy. Since adequate exposure of the extradural and intradural segments of the VA can be obtained by the posterolateral approach, this approach can be preferred in cases with tumors anterior to the VA or when the artery is encased by the tumor.The link to the video can be found at: https://youtu.be/d3u5Qrc-zlM.

Presigmoid girişimler klivusun üst 1/3 ve orta 1/3 bölümlerine ve petröz apekse lateralden yaklaşım için kullanılan girişimlerdir. Bu girişimler transvers-sigmoid sinüs bileşkesini mobilize ederek beyin sapına anterolateralden bakışı mümkün kılarlar. Bu kafa tabanı girişimleri klasik subtemporal ve suboksipital paramediyan girişimlere kıyasla daha geniş bir cerrahi koridor sağlar ve petroklival bölge lezyonlarında daha yüksek oranlarda total rezeksiyonu mümkün kılarlar. Oluşan komplikasyonlar sıklıkla geçici ve tedavi edilebilir olaylardır. Presigmoid approaches are used for lateral access to the upper and middle third of the clivus and the petrous apex. These approaches provide anterolateral visualization of the brain stem after mobilization of the transvers-sigmoid sinus junction. In comparison to classical subtemporal or paramedian suboccipital approaches, these skull base approaches provide safer and wider surgical access to petroclival region lesions and enable more complete resections. In dealing with tumors in the petroclival region the main goal is maximal safe resection. The complications due to presigmoid approaches are generally temporary and manageable.

Sellar-parasellar ve subkiazmal bölgedeki bir tümörlerin optik aparata bası yapması veya bir cerrahi yaklaşım yolu üzerindeki perforanların sayısı, konumları ve optik kiazmanın tipi, nörolojik defisit gelişimini önleme açısından önemlidir. Bu nedenle postoperatif dönemde gelişebilecek nörolojik defisitleri önlemek amacıyla sellar-parasellar bölgenin subkiazmal, suprakiazmal ve parakiazmal anatomisini inceledik. Haziran 2016- Kasım 2016 tarihleri arasında yapılan 30 adet otopsi örneklerinde optik kiazma-sella ilişkisi ve optik kiazmayı besleyen perforan arterlerin köken aldıkları bölge, uzanımları, sayısı incelenmiştir.Çalışmamızda; kiazma tiplerinden; santral 20 olguda (%67), postfiks 6 olguda (%20), prefiks 4 olguda saptanmıştır. Diğer bir çalışma bölgemiz olan optik kiazmanın beslenmesinde; her örnekte, her arterden farklı sayıda perforan arter çıktığı gözlendi. Ortalama 2,6±1,4 adet perforan arter sağ pkomm'dan, 2,1±1,1 adet perforan arter sol pkomm'dan, 0,8±0,8 adet perforan arter sağ anterior koroidal arterden, 0,5±0,6 adet perforan arter sol anterior koroidal arterden çıkarak optik kiazmayı inferiordan beslemekteydi. Ortalama 0,7±1,1 adet perforan arter Akomm'dan, 0,9±1,0 adet perforan arter sağ ASA A1' den, 1±1 adet perforan arter sol ASA A1'den çıkarak optik kiazmayı süperiordan beslemekteydi. Ortalama 0,4±0,8 adet perforan arter sağ IKAsk' den çıkarak, 0,5±0,8 adet perforan arter sol IKAsk' den çıkarak optik kiazmayı lateralden beslemektedir. Prefiks kiazma tipinde ve perforan arterlerin fazla olduğu cerrahi yaklaşım pencerelerinde cerrahi yaklaşımların perforan arter zedelenmeleri nedeniyle zor olacağı sonucu çıkarılabilir. Dolayısıyla, kiazmanın konumuna ve perforan arterin sayısına ve yerleşimine göre, kitlenin total ve defisitsiz olarak çıkartılmasında patolojiye uygun bir cerrahi yaklaşım kararı verilmesi uygun olacaktır. Sellar- parasellar and subchiasmal tumors that compress the optical apparatus or placement and number of the perforating arteries on the surgical approach pathway are critical for preventing new neurological deficit. We investigate sellar- parasellar region subchiasmal, suprachiasmal and parachiasmal anatomy to prevent postoperative new neurological deficit. Thirty autopsy specimens were investigated with Bursa forensic medicine institute for optic chiasm and sellae relationship and number, origination of perforating arteries that were fed the optic chiasm between June 2016 and November 2016. Twenty (67%) central, 6 (20%) postfix and 4 (13%) prefix chiasm were detected at our study. The blood supply of the optic chiasm is an other part of our study. We examined that different number of perforators were originated from different arteries at every specimen. Average number of perforating arteries orginated from right posterior communicating arteries (PComA) were 2,6±1,4. Average number of perforating arteries from left PComA were 2,1±1,1, 0,8±0,8 perforating arteries from right anterior choroidal artery (AChA), and 0,5±0,6 from left AChA were supplied the optic chiasm from inferiorly. Number of perforating arteries that feed the optic chiasm superiorly were avarage 0,7±1,1 from anterior communicating artery, 0,9±1,0 from right anterior cerebral artery A1 segment and 1±1 from left anterior cerebral artery A1 segment. The number of perforating arteries that supplied the lateral optic chiasm were 0,4±0,8 and 0,5±0,8 originated from right and left internal carotid artery respectively.Prefix chiasm and surgical approaches from the gaps that have more perforating arteries have a risk of more perforating arteries injury. However, deciding the surgical route according to the pathology for total excision of the lesion without any deficit due to position of the chiasm and number of position of the perforating arteries is mandatory 51

Türk Nöroşirürji Derneği 30. Bilimsel Kongresi’nde (Antalya, 2016) bildiri olarak sunulmuştur. İntrakranyal hemanjiyoperistom (HPC) dural sinüsler boyunca yerleşen nadir ve agresif seyirli bir tümördür. Tüm intrakraniyal tümörlerin %1’inden azını oluşturur. Bu yazıda HPC nedeniyle kliniğimizde 2015 yılında opere edilen 4 olguyu klinik ve radyolojik açıdan tartışmayı amaçladık. Intracranial meningeal hemangiopericytoma (HPC) is a rare and aggressive intracranial neoplasm located along the dural sinuses. It constitutes less than 1 % of all intracranial tumors. In this manuscript we aim to discuss clinic and radiological features of 4 cerebral HPC cases that were operated in our department in 2015.

The artery of Percheron (AOP) is a single thalamoperforating arterial trunk that provides bilateral supply to the paramedian thalami and the rostral midbrain. As this rare anatomical variant artery may be involved in endovascular procedures or encountered surgically during basilar terminus aneurysms, the present study was warranted. Thirty-four adult (20 male and 14 female) formalin-fixed cadaveric brains underwent dissection of the 68 posterior cerebral arteries. Observations were made of the presence and the variations of the thalamoperforating arteries as well as the presence of the AOP. Thalamoperforating arteries arose from the superior or posterior surfaces of the P1 segment at a mean of a 1.87 mm (range, 0.39-5.25 mm) distance from the basilar apex and entered the brain through the posterior perforated substance. The average number was 4.25 (range 1-9), and the mean diameter was 0.73 mm (range 0.46-1.16 mm). Thalamoperforating arteries were classified into four different types according to their origin at the P1 segment: type I (bilateral multiple, n = 19), 55.8 %; type II (unilateral multiple, unilateral single, n = 4), 11.7 %; type III (bilateral single, n = 7), 20.5 %; type IV [one side with a single branch, the other side with no branches (the AOP), n = 4], 11.7 %. In three separate specimens with ruptured basilar artery aneurysms, the origin of the thalamoperforating arteries was incorporated not only into the posterior aspect of the aneurysm neck but also into the fundus. In about one tenth of cases the possibility of the presence of a single arterial trunk that supplies the two paramedian thalamic territories should be taken into consideration during treatment planning of basilar terminus aneurysms. Furthermore, our data show that the thalamoperforating arteries may take off from both the aneurysm neck and the fundus.

In this case series study, the surgical outcomes of 29 patients with intracerebral hematomas resulting from the rupture of middle cerebral artery aneurysms that were operated on within the first 12 hours after rupture were retrospectively analyzed. Preoperative cerebral angiography could be obtained in 12 (41.3%) of our patients. Outcome was assessed according to the Glasgow Outcome Scale at 6 months after surgery. Overall mortality was 48%. Of 12 patients in good preoperative condition, 6 (50%) had a favorable outcome (Glasgow Outcome Scale, 4 to 5), whereas of the 17 patients in poor preoperative condition only 1 (5.8%) had a favorable outcome (P = 0.042). Our results suggest that despite early surgical treatment of patients with ruptured middle cerebral artery aneurysms associated with massive intracerebral hematoma, mortality continues to be high in patients with poor preoperative grades.

Patients undergoing posterior fossa surgery in sitting position have been reported to suffer from venous air embolism, hemodynamic instability, spinal cord and lower brainstem infarctions, and pneumocephalus. Although parkinsonism has been presented secondary to subdural hematoma or effusion, there are no reports about parkinsonism related to tension pneumocephalus and subdural effusion following to surgical removal of the vestibular schwannoma. Herein, we present two patients with acute onset parkinsonism symptoms that appeared after vestibular schwannoma surgery performed in sitting position. Both patients had no extrapyramidal signs and symptoms on preoperative examination. Our first case had frontal subdural pneumocephalus and effusion, and second one similarly had tension pneumocephalus in the ventricular space. In both cases, the compression of the intracranial air on the frontobasal circuit (frontocortical-striatal-pallidal-thalamic-cortical loop) caused to parkinsonism. We concluded that secondary parkinsonism could occur with dysfunction of the circuits linking the frontobasal pathway resulting in compressive effect of tension pneumocephalus. Oturur pozisyonda arka fossa cerrahisi uygulanan hastalarda venöz hava embolisi, hemodinamik instabilite, spinal kord ve beyin sapı enfarktları ve pnömosefali geliştiği bildirilmiştir. Subdural hematom veya efüzyona bağlı parkinsonizm sunulmuş olmasına karşın vestibüler schwannomanın cerrahi olarak çıkartılmasını takiben tansiyon pnömosefali ve subdural efüzyon gelişimi ile ilişkisi henüz bildirilmemiştir. Biz oturur pozisyonda yapılan schwannoma cerrahisini takiben akut başlangıçlı parkinsonizm semptomları ortaya çıkan iki hasta sunuyoruz. Her iki hasta da operasyon öncesi incelemede ekstrapiramidal bulgu ve semptomlara sahip değildi. İlk olgu frontal subdural pnömosefali ve efüzona sahipti, ve ikinci olgunun benzer olarak ventriküler boşlukta tansiyon pnömosefalisi vardı. Her iki olguda intrakranyal havanın frontobazal çevrim (frontokortikal-striatal-pallidal-talamik-kortikal döngü) üzerindeki baskısı parkinsonizme neden oldu. Biz sekonder parkinsonizmin tansiyon pnömosefalinin kompresif etkileri ile sonuçlanan frontobazal yolak ile bağlantılı çevrimlerin disfonksiyonu ile oluşabileceği sonucuna vardık.

Türk Nöroşirurji Derneği 28. Bilimsel Kongresi’nde bildiri olarak sunulmuştur. Orbitayı penetre eden yabancı cisimler çoğunlukla travma kaynaklıdır. Yabancı cisimler metal, cam plastik, taş parçası gibi inorganik maddelerin yanı sıra, odun parçası gibi organik materyaller de olabilir. Organik yabancı cisimlerin kraniyum içinde saptanmaları zordur. Orbitadan intrakraniyal kompartmana uzanımı ise çok nadirdir ve hasta için ciddi risk taşımaktadır. Bu yazıda çok nadir görülen sivri ve uzun tahta parçası ile olan orbitokraniyal yaralanma olgusunu takdim etmekteyiz. Bu nadir görülen durumun tanı, tedavisi tartışılmıştır. Penetrating intraorbital foreign bodies have generally traumatic source. These foreign bodies can be organic materials like wooden objects besides inorganic materials like metal, glass or sand. Radiological detectinon of organic materials in the cranium are difficult. Penetration of foreign body from orbita to intracranial compartment is so rare and it carries serious risks for the patient. In this manuscript, we presented a case that was injured orbitocranially by a sharp and long wooden piece. We discussed the diagnosis and treatment of this rare condition

Background. The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Method. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). Findings. The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploe (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 +/- 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4-5) and 8 (26.7%) had poor results (GOS 1-3). Conclusions. Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.

The aim of this study was to evaluate the results of conservative and surgical management options for traumatic cerebrospinal fluid (CSF) leakage complicating skull base fractures. The subjects were 81 patients who were treated between 1996 and 2003 for CSF leaks that had persisted for 24 h or longer after head injury. For each case the medical records were reviewed, and the data collected were as follows: demographic features, clinical and radiological findings, management options, complications and outcome scores. Analysis was done with patients grouped according to Glasgow coma scale (GCS) score at admission (8), and findings for three treatment methods (conservative, CSF drainage, surgery) were evaluated. In 32 cases (39.5%), the CSF leakage resolved spontaneously, and the mean hospital stay for these patients was 14 +/- 11 days. Twenty-four patients (29.6%) were treated by CSF drainage, and seven of these individuals ultimately required surgery to close the leak. Hospital stay was 17 +/- 7 days. Twenty-five patients (30.9%) underwent surgery as the initial treatment step, and the mean hospital stay for these individuals was 15 +/- 9 days. The large majority (74.2%) of patients with admission GCS scores 8 resolved spontaneously. The factors that had a critical influence on outcome in this series were level of consciousness on admission and presence of additional intracranial pathology associated with CSF leakage within cases of traumatic CSF fistulae due to skull base fractures. Treatment decisions should be dictated by the severity of neurological decline during the emergency period and the presence/absence of associated intracranial lesions. The timing for surgery and CSF drainage procedures must be decided with great care and with a clear strategy. The authors offer a treatment algorithm.

Pituitary tumors invade the cavernous sinus via the medial wall. Researchers have speculated that this wall is composed of dura and that substances secreted by tumors might damage this barrier. In contrast to the lateral wall, little is known about the structure of the medial wall of the cavernous sinus (MWCS). This study provides the first detailed quantitative (thickness) and qualitative (histological) assessment of the MWCS. Eighteen sellar-parasellar tissue blocks were obtained from adult human autopsies. Ten specimens were used for microsurgical dissection and macroscopic anatomical description. Eight specimens were used for histopathological study and for recording computer measurements of MWCS thickness. Each of these eight specimens was divided into three approximately equal-sized pieces, with cuts made in the coronal plane from posterior to anterior starting at the anterior level of the pituitary stalk. Wall thicknesses were compared in the three different regions (posterior, middle, anterior), and also on the left vs. the right sides. The investigations showed that the MWCS is a distinct dural layer that forms a barrier between the medial venous space of the cavernous sinus and the pituitary gland. The mean thickness of the 48 total (left and right) MWCS observed in the 24 sections examined was 0.195 +/- 0.066 mm (range = 0.080-0.387 mm). This wall is composed of loosely arranged collagen fibers that comprise a specific layer known as "meningeal dura." The posterior third of the MWCS was significantly thinner than the middle third (P = 0.0014) or anterior third (P = 0.0001). No macro- or microscopic defects were observed in any of the MWCS in the 18 specimens. The thinness of the posterior MWCS suggests that this is the most likely path for extension of pituitary tumors into the cavernous sinus.

The vertebral artery, cervical spinal nerves, spinal nerve roots, and the bony and ligamentous tissue related to the cervical vertebrae are structures whose anatomy determines the path of a surgical approach. Defining the anatomy and, in particular, determining the precise location of vulnerable structures at the intervertebral foramen and the uncovertebral foraminal region (UVFR), a region defined by the uncinate process anteriorly, the facet joint posteriorly and the foramen transversarium laterally, has critical significance when selecting the safest surgical approach. We studied the anatomy of the vertebral artery, cervical spinal nerves, and spinal nerve roots within the UVFR in six cadaver specimens. We also obtained measurements of bony structures in 35 dry cervical vertebral columns, from C3-C7. The uncinate process (UP) projects superiorly from the posterolateral aspect of each cervical vertebral body, except for the first and second vertebrae. Because the posterior part of the UP lies adjacent to the vertebral artery, spinal nerve, and spinal nerve roots, its resection creates sufficient space to decompress these structures directly. The posterolateral surface of the UP is covered by ligamentous tissue that originates from the posterior longitudinal ligament and protects the neural and vascular structures during their decompression in the UVFR.

Two cases of cerebello-pontine angle epidermoid tumour presented with the clinical findings of brain stem stroke. Preoperative imaging showed stretching of branches of the basilar artery. Brain stem stroke as a presenting feature of cerebello-pontine angle epidermoid tumour has not been reported before.

Optik sinirin proksimal kısmı, optik foramen girişinde tümöral ve travmatik patolojiler ile zedelenmeye oldukça yatkındır. Böyle bir durumda, optik sinir proksimal kesimini dekomprese etmek gerekir. Bu nedenle, optik kanal bölge anatomisinin öğrenilmesi önem taşımaktadır. Optik kanalın proksimal kesiminin dekompresyonu esnasında karşılaşılabilecek problemleri ve anatomik sınırları vurgulayan bu çalışmada, optikokarotid bölgenin detaylı anatomisi ve histopatolojik yapısı araştırıldı. Otuz adet sellar ve parasellar örnek yetişkin insan kadavralarından çıkarıldı. Örneklere anatomik diseksiyon ve histopatolojik inceleme yapıldı. Proksimal optik kanalın superior ve lateral duvarı, mikrocerrahi teknik kullanılarak transkraniyal yaklaşım ile; inferior ve medial duvarı ise, endoskopik ve mikroskobik teknik kullanılarak, transsfenoidal yaklaşım ile incelendi. Histopatolojik incelemede optik kanal, internal karotid arter ve optik sinir arasındaki ilişkiler kalitatif ve kantitatif olarak değerlendirildi. Transkraniyal ve transsfenoidal yaklaşım ile benzer oranlarda optik kanal çevresel dekompresyonu yapılabilmesine karşılık, transkraniyal yaklaşımın optik sinirin superiorunun ve lateralinin dekompresyonunda, transsfenoidal yaklaşımın ise optik sinirin inferiorunun ve medialinin dekompresyonunda daha üstün olduğu görüldü. Transkraniyal yaklaşımın optik sinirin daha fazla mobilize edilebilmesi açısından daha uygun olduğu saptandı. Histopatolojik olarak optik sinirin medialde ve inferiorda traksiyon veya basıdan kaynaklanabilecek zedelenmeye daha yatkın olduğu görüldü.Optik sinir dekompresyonuna karar verirken, patolojinin yerleşimine ve bölgenin anatomik-histolojik özelliklerine göre trankraniyal veya transsfenoidal yaklaşımlardan birini seçmek uygun olacaktır.Anahtar Kelimeler: optik sinir, optik kanal Proximal portion of the optic nerve is quite prone to injury in the optic foramen entrance by tumoral and traumatic pathologies. In such a case, it is necessary to decompress the proximal part of the optic nerve. Therefore, it is important to learn the regional anatomy of the optic canal. In this study that emphasizing the problems and anatomic limitations which can be encountered during proximal optic canal decompression, detailed anatomy and histopathology of the opticocarotid region was investigated. Thirty adult sellar and parasellar samples were extracted from human cadavers. Anatomical dissection and histological examination was performed to the samples. Superior and lateral walls of the proximal optic canal were evaluated by using microsurgical transcranial approach; inferior and medial walls were evaluated by using endoscopic and microsurgical transsphenoidal approach. The relationship between the optic canal, the internal carotid artery and the optic nerve were qualitatively and quantitatively examined. Though, similar rates of peripheral optic canal decompression was achieved by transcranial and transsphenoidal approach, transcranial approach was superior in the decompression of the superior and lateral portions, transsphenoidal approach was superior in the decompression of the inferior and medial portions of the optic nerve. Transcranial approach is found to be more appropriate for optic nerve mobilization.It was found that, histopathologically the medial and inferior parts of the optic nerve, was more prone to injury caused by traction or compression.When deciding the optic nerve decompression, either the transcranial or the transsphenoidal approach should be preferred according to the localization of the pathology and anatomical-histological characteristics of the region.Key words: optic nerve, optic canal 55

Objective Tumours in the clival region are difficult to remove surgically. Before the 1970s, clival tumours had very high mortality and morbidity rates. Methods An anatomic dissection was performed on 24 spheno-occipital bone blocks obtained from 28 adult cadavers. The internal carotid artery, paraclival carotid tubercle, sixth cranial nerve and dorsum sellae in the upper clival region were analyzed qualitatively and quantitatively. For the histological evaluation, 4 samples were decalcified and sagittal sections were cut. From the eight blocks obtained, 32 incisions were made in the axial plane, and the tissue was analyzed. Results Using microscopy, a clival recess was clearly identified in 15 of the 24 (62.5%) samples. Paraclival carotid tubercles were observed in 19 (79.16%) of the samples. In the upper clival and petroclival region, the sixth cranial nerve had directional changes at the dural porus, the petrous apex and the lateral wall of the cavernous segment of the internal carotid artery. At the dorsum sellae level, the distance between the medial surfaces of both internal carotid arteries was a mean of 15.33 ± 2.12 mm. This distance at the pharyngeal tubercle was a mean of 38.95 ± 4.67 mm. On all the histological sections, the distance of the sixth cranial nerve from the dural porus to the cavernous sinus was within the basilar plexus, along with the subarachnoid membranes around it. On the petrous apex level, the sixth cranial nerve was fixed to the petrous apex and the internal carotid artery with connective tissue formed by dense collagen fibres. The sixth cranial nerve and the internal carotid artery are tightly surrounded by dense collagen connective tissue, and the relative proximity between the carotids on the dorsum sellae level can be easily damaged during the transsphenoidal–transclival approach. Similarly, due to the ligamentous fixation on the dural porus and the petrous apex surfaces, there is a high risk of injury to the carotid artery and sixth cranial nerve. Conclusion This study determines the relationship between the sixth cranial nerve and the internal carotid artery at the upper clivus and to provide morphologic details that is essential for the risks of transclival surgery.

Klivus bölge tümörleri cerrahi çıkartılması zor patolojilerdir. 1970'lerden önce mortalite ve morbidite oranları oldukça yüksek olarak izlenmiştir.Yirmisekiz erişkin kadavradan çıkartılan sfenooksipital kemik bloğun 24'ünde anatomik diseksiyon yapıldı. Üst klival bölgede internal karotid arter, paraklival karotid tüberkül, VI. kranial sinir, dorsum sella, baziller venöz pleksus ölçümsel incelendi. Histopatolojik değerlendirme için 4 örnek dekalsifiye edilerek sagittal planda orta hattan kesildi ve elde edilen toplam sekiz bloktan aksiyel planda 32 kesit elde edilerek incelendi.Klival reses 24 örneğin 15'inde (%62,5) net olarak izlendi. Paraklival karotid tüberkül örneklerin 19 tanesinde (%79,16) belirgin olarak izlendi. VI. kranial sinirin petroklival bölgede 3 yerde yön değişikliğine uğramakta olduğu gözlendi; dural porusta, petroz apekste ve internal karotid arterin kavernöz segmentinin lateral duvarında tespit edildi. Dorsum sella düzeyinde, aksiyel planda her iki internal karotid arter medial yüzlerinin arasındaki mesafe ortalama 15,33±2,12 mm ölçüldü. Farengeal tüberkül düzeyinde, bu mesafe ortalama 38,95±4,67 mm ölçüldü. Histopatolojik tüm kesitlerde VI. kranial sinirin dural porustan kavernöz sinüse kadar olan mesafede etrafındaki subaraknoid membranla birlikte dışında dura ile çevrili olarak baziler pleksus içinde seyrettiği izlendi. Petroz apeks düzeyinde VI. kranial sinirin yoğun kollajen lifler ile kurulu bir bağ doku ile hem petroz apekse hem de internal karotid artere sabitlendiği görüldü.Transsfenoidal-transklival yaklaşım esnasında dorsum sella düzeyinde karotisler arası mesafenin göreceli yakınlığı ve yoğun kollajen bağ doku nedeniyle sabitlenmiş internal karotis arter ve VI. kranial sinirin kolay zedelenebileceği görüldü. Benzer şekilde dural porus ve petroz apeks düzeylerinde ligamentöz fiksasyon nedeni ile VI. kranial sinir ile birlikte internal karotid arterin yaralanma riskinin yüksek olabileceği gözlendi. Clival lesions remain one of the most difficult pathologies to treat surgically. Before 1970s, lesions of this region were considered to have high mortality and morbidity rates.24 sphenooccipital bone-blocks resected from 28 adult cadavers were dissected. Internal carotid artery, paraclival carotid tubercle, CN VI, dorsum sellae, basilar venous plexus at the upper clival region were examined quantitatively. Four specimens were decalcified and resected from midline in sagittal planes for histopahtological examination. A total of 32 cross-sections from eight blocks in the axial plane were obtained and analyzed.Clival recesses were viewed clearly in 15 of 24 specimens (62.5%). Paraclival carotid tubercles were viewed significantly in 19 specimens (79.16%). CN VI was observed changing direction in three different places in petroclival region and detected at dural porus, petrous apex and lateral wall of cavernous segment of internal carotid artery. At the level of the dorsum sellae, the average distance between the medial surfaces of both internal carotid arteries was measured as 15.33±2.12 mm. At the level of the pharyngeal tubercle, that distance was measured as 38,95±4,67 mm. CN VI with its subarachnoid membrane surrounded by dura was observed in the basilar plexus in all histopathological sections. At the level of the petrous apex, CN VI fixed to both petrous apex and internal carotid artery with a connective tissue of dense collagen fibers was determined.During transsphenoidal-transclival approach, due to the relative proximity of internal carotid artery and connective tissue of dense collagen, CN VI and fixed internal carotid artery can be easily damaged at the level of the dorsum sellae. Similarly, at the level of the dural porus and petrous apex there is a high risk of injury of internal carotid artery and CN VI because of ligamentous fixation. 44

Tüm intrakranial meningiomaların yaklaşık %4-13 kadarı olfaktor oluk bölgesindedir. Olfaktor oluk meningiomaları ön kafa tabanında yerleşir ve etmoid kemik kribrifom çıkıntısı ve krista galliyle, arkada planum sfenoidale üzerine doğru uzanır. Bu makalede 2006-2010 yılları arasında opere edilen 24 olfaktor oluk meningiomalı hasta retrospektif olarak incelendi.18 kadın, 6 erkek hasta, yaşlarının ortalaması 55,7± 8,6 (min. 39, max 75) idi. En sık başvuru şikayeti bilişsel işlev bozukluğu olarak izlendi. Tüm hastalar opere edildi. 6 hasta supraorbital kraniotomi, 17 hasta bifrontal kraniotomi, 1 hastada pterional kraniotomi kullanıldı. Nüks oranı %8,4 (2 hasta) olarak saptandı. Hiçbir hastamızda postoperatif dönemde tedavi gerektiren BOS kaçağı izlenmedi. Ortalama takip süresi 36 ay idi. Olfaktor oluk menengiomalarının cerrahisi anterior serebral arter (ACA) ve optik sinire yakınlığı nedeniyle oldukça zor ve tehlikeli olabilir. Mikrocerrahi tekniklerinin gelişmesi ile eskiye nazaran daha kolay ve güvenli olarak tümör rezeksiyonu yapmak mümkün hale gelmiştir. Olfactory groove meningiomas (OGM) account for 4 to 13% of all intracranial meningiomas. They arise in the anterior fossa over the cribriform plate and crista galli to the planum sphenoidale. 24 patients suffering from OGM operated between 2006 and 2010 in our department is retrospectively reviewed. There were 18 women and 6 men with a mean age of 55,7± 8,6 years (range 39 to 75 yrs) The most common presenting symptom was mental disturbance. The tumor was resected via a supraorbital craniotomy in 6 patients, bifrontal craniotomy in 17 patients, a pterional craniotomy in 1 patient. Recurrance rate was 8.4%. The mean follow-up period was 36 months. None of our patients needed surgery for postoperative CSF leaks, The surgical removal of OGM is difficult due to close anatomical relations among tumor, the anterior cerebral arteries and the optic apparatus. By the improvements in microneurosurgery, the surgical removal can be performed safely.

28 yaşında, boy kısalığı, gelişme geriliği olan ve görme problemleri ile başvuran kadın hastada, sella tursikayı tümüyle dolduran ve parasellar bölgeye uzanım gösteren kitle lezyonu saptandı. Sağ orbitozigomatik kraniotomi ile rezeksiyonu yapılan lezyonun histopatolojik tanısı matür teratom olarak raporlandı. Teratomlar, sella tursikada görülmesi beklenmeyen tümörlendendir. Sella tursika lokalizasyonunda matür teratom oldukça nadir görülür. A 28-year-old woman presented with short stature, growth retardation and visual problems. An intrasellar mass lesion that entirely located in the sella and streamed to the parasellar region was found on imaging studies. Right orbitozygomatic craniotomy was done. Histologic examination diagnosed a mature teratoma. Teratomas arising within the sella turcica are uncommon. Intrasellar teratoma comprising of only mature elements is extremely rare.

Background Determining anatomic landmarks during a transsphenoidal–transethmoidal approach to the optic canal region is of critical importance. Methods Sella–parasella sphenoid bone blocks were extracted from adult cadavers. Anatomic dissections were performed in the optic canal region using a surgical microscope in 30 samples. Quantitative measurements were done using photographic techniques. For histological evaluation, coronal and longitudinal cross-sections were taken from the bilateral optic canal in seven decalcified samples. Results Optic protuberance (OP), carotid protuberance (CP), medial opticocarotid recess (MOCR) and lateral opticocarotid recess (LOCR) were defined as lateral landmarks determining the width of the opening in the extended transsphenoidal–transethmoidal approach. Among all anatomic markers, LOCR was the most determinant lateral marker with tubercular recess the most prominent central marker. OPs showing the optic canal direction and inter-recessal sulci had similar distinguishing rates in the sphenoid sinus base. Inter-recessal sulci formed by OPs and CPs were observed between MOCR and LOCR in most samples. In histologic sections, the dural sheath was thicker inferolaterally to the optic nerve compared to superiorly and medially; collagen arrangement was dense and irregular. Conclusion Although LOCRs and tubercular recesses are safe and prominent markers in extended transsphenoidal–transethmoidal approaches, other anatomic markers should also be taken into consideration to perform an efficient optic canal approach and optic canal decompression. Other factors for safe dissection are the length of the optic canal, bone thickness, adherence of dural structures and the course of the intradural ophthalmic artery.

Gebe kadınlarda meningioma görülme insidansı,normal kadın popülasyonuna göre daha düşüktür fakat gebelikte meningiomaya bağlı semptomlar artabilirler. 34 yaşında bayan hasta gebeliğinin onuncu haftasında; 4 haftadır sol gözünde başlayan görme kaybıyla başvurdu. Kranial MRI görüntülerinde; suprasellar sisterna ve sella içini doldurmuş, dural kuyruğu olan kitle lezyonu mevcuttu.Hasta operasyona alınarak, tuberkulum sella meningioması total çıkartıldı. İmmünohistokimyasal analizinde; meningioma hücrelerinin % 80 olarak progesteron reseptörü taşıdığı gösterildi. Tuberkulum sella meningiomalı gebe kadınlarda; pozitif progesteron reseptörüne ve hipofiz bezinin büyümesine bağlı olarak ani görme kaybı gerçekleşebilmektedir. The incidence of meningioma in pregnant women is lower than non-pregnant women of the same age. However, symptoms may worsen during pregnancy. A 34-years old woman in her fourth pregnancy presented at 10 weeks of gestation with a 4 weeks history of progressive visual loss in her left eye. MRI revealed mass lesion that filled the suprasellar cistern and extended into the sella with dural tail. The patient underwent operation and a tuberculum sellae meningioma was removed totally. The immunohistochemical analysis showed positive staining for progesterone receptors in 80% of meningioma cells. The rapid growth of the mass that stains positive for progesterone receptors and the enlargement of the pituitary gland because of the hormonal changes during pregnancy in cases with tuberculum sellae meningioma can cause sudden visual loss.

Neuroanatomical structures that form the floor of the third ventricle (FTV) and neighboring tissues are important in the context of third ventriculostomy (TV) procedures. Thorough knowledge of the anatomical and histological organization of the region would be useful in understanding and preventing surgical complications. Taking the third ventricle region as a model, we aimed to simulate TV and make measurements of 23 cadaver brains, as well as perform histological examinations of the third ventricular floor on five cadaver brains. During the endoscopic TV, we examined the degree to which the structures surrounding the FTV were affected by surgical simulation. To make a clinical comparison, the distance between the center of the FTV and the basilar apex was measured on cranial magnetic resonance images (MRIs) of 15 subjects with normal ventricular systems and 15 subjects with moderately enlarged ventricles. Histological examination revealed that the ependynnal cells and arachnoid membrane formed the inner and outer surfaces of the third ventricle floor, respectively, whereas the stroma was made up of glial cells exclusively. This region was gliotic and avascular. When cadaver brains with normal and hydrocephalic ventricles were compared, there were significant differences in the distance between the center of the floor and the basilar apex (P < 0.001). On the basis of our study, the optimal site for TV fenestration and balloon inflation is just anterior to the mamillary bodies to avoid injury to neighboring structures.

BACKGROUND: The significance of medial and lateral opticocarotid recesses and the planum sphenoidale region in skull base pathologies for the transsphenoidal-transplanum approach were evaluated. METHODS: The sphenoid bone block samples were extracted from adult cadavers. Dissections and measurements in the opticocarotid and planum sphenoidale regions were performed in 29 samples using a surgical microscope. For histologic evaluation, oblique sections through the bilateral opticocarotid regions were obtained and examined in eight samples. RESULTS: Optic, carotid prominences, and medial and lateral opticocarotid recesses can be identified as lateral markers intraoperatively to the extent of the exposure. The lateral opticocarotid recess was observed to be prominent in all samples. In all samples, the groove formed by optic and carotid prominences between the medial and lateral opticocarotid recesses was seen. This groove was designated the inter-recess sulcus. In the transsphenoidal-transplanum approach, the area needed for a reliable bone resection was measured as a mean of 237.32 +/- 30.96 mm(2). The mean angle between optic nerves was 115.41 +/- 18.39 degrees. The mean anteroposterior length of the planum sphenoidale was 14.84 +/- 1.52 mm. In histologic sections, collagenous ligaments between the anterior part of cavernous sinus and the adventitia layer of internal carotid artery were more frequent and regular than the inferior part of optic nerve. CONCLUSIONS: The lateral opticocarotid recess is a reliable and persistent indicator for extended transsphenoidal surgery. To approach the opticocarotid region near the internal carotid artery and optic nerve, a careful dissection is needed to minimize surgical injuries to the optic nerve and carotid artery. Other factors determining a reliable bone resection are the anteroposterior length of the planum sphenoidale and the distance and width of the angle between optic nerves. Attention should be given to individual anatomic variations of the region when planning and performing transsphenoidal-transplanum surgery.

Suprasellar ve perisellar bölge lezyonları optikokarotid ve planum sfenoidale bölgesine yerleşebilir veya uzanım gösterebilirler. Bu tür patolojilerde transsfenoidal transplanum yolunu kullanmak, minimal invaziv olması nedeniyle popüler hale gelmiştir.37 erişkin kadavradan çıkartılan sfenoid kemik blok örneklerinin 29'unda anatomik diseksiyon yapıldı. Sfenoid sinüsün anterior duvarı çıkarılarak optikokarotid bölge ve planum sfenoidale bölgesindeki anatomik belirteçler operasyon mikroskobu altında değerlendirildi. Mikrodiseksiyon yapılan örneklerde optikokarotid bölgede optik sinir, internal karotid arter ve planum sfenoidale bölgesinin ölçümsel anatomik ilişkileri bilateral olarak incelendi. Histopatolojik değerlendirme için sekiz örnek dekalsifiye edildi ve bilateral optikokarotid bölgeyi çaprazlayan aksiyel, koronal, sagital ve oblik toplam 48 kesit elde edildi. Masson trikrom ile boyanan kesitlerde, optikokarotid bölgenin anteroinferior kısmının ligamentöz ve kemik yapısı ve optik sinir ile karotid arter arasındaki ilişki incelendi. Lateral optikokarotid reses örneklerin tamamında belirgin olarak izlendi. Tüm örneklerde, medial optikokarotid reses ile lateral optikokarotid reses arasında optik ve karotid prominensin oluşturduğu oluk izlendi ve bu oluk interresesal sulkus olarak isimlendirildi. İnterresesal uzunluk ölçümü 3 mm'nin altında ise grup tip 1, 3 mm'nin üzerinde ise grup tip 2 olarak sınıflandırıldı. Transsfenoidal transplanum yaklaşımında emniyetli kemik rezeksiyonu için gereken alan ortalama 237.32±30.96 mm² ölçüldü. Optik sinirler arası açı ortalama 115.41±18.39 derece idi. Planum sfenoidalenin ön arka uzunluğu 14.84±1.52 mm idi. Histopatolojik kesitlerde kavernöz sinüsün anterior kısmı ile internal karotid arterin adventisya tabakası arasındaki kollajenöz bağların, inferiora göre daha sık ve düzenli olduğu; optik sinirin inferior kısmında dural kılıfın kalınlığının medial ve lateral kısmına göre daha fazla, kollajen diziliminin ise daha sık ve düzenli olduğu görüldü.Lateral optikokarotid reses genişletilmiş transsfenoidal cerrahi için güvenilir bir belirteçtir. Optikokarotid bölgede internal karotid arter ve optik sinire yaklaşımda tip 1 ve tip 2 olgularda, cerrahi yaralanmaları en aza indirmek için dikkatli yaklaşmak gerekir. Transsfenoidal transplanum yaklaşımında emniyetli ve yeterli kemik rezeksiyonunu belirleyen diğer faktörler planum sfenoidalenin ön arka uzunluğu, optik sinirler arası mesafe ve açının genişliğidir. The lesions in suprasellar and perisellar regions can be placed or extend in opticocarotid and planum sphenoidale regions. For such kind of pathologies, the use of transsphenoidal transplanum approach has been popular as it is minimally invasive.In 29 of 37 sphenoid bone block samples extracted from adult cadavers, anatomic dissection was done. Extracting anterior wall of sphenoidal sinus, anatomical indicators in opticocarotid region and planum sphenoidale region were evaluated under surgical microscope. In the samples subjected to microdissection, optic nerve, internal carotid artery in opticocarotid region and measurable anatomical relationship of planum sphenoidale region were evaluated bilaterally. For histopathological evaluation, eight samples were decalcified and totally 48 axial, coronal, sagittal and oblique sections crossing through bilateral opticocarotid regions were obtained. In the sections dyed with Masson's trichrome stain, ligamentous and bony structures of anteroinferior part of opticocarotid region and the relationship between optic nerve and carotid artery were examined. Lateral opticocarotid recess was observed to be prominent in all samples. In all samples, the groove formed by optic and carotid prominences between medial opticocarotid recess and lateral opticocarotid recess was seen and this groove was called as inter recesses sulcus. If inter recesses length measure was under 3 mm, group was classified as type 1; if it was over 3 mm, group was classified as type 2. In transsphenoidal transplanum approach, the area needed for a reliable bone resection was measured as a mean of 237.32±30.96 mm². The angle between optic nerves was a mean of 115.41±18.39 degrees. Antero-posterior length of planum sphenoidale was 14.84±1.52 mm. In histopathological sections it was seen that collagenous ligaments between anterior part of cavernous sinus and adventitia layer of internal carotid artery were more frequent and regular compared to inferior; at the inferior part of optic nerve, thickness of dural sheath was much more than that in medial and lateral parts and collagen arrangement more frequent and regular.Lateral opticocarotid recess is a reliable indicator for extended transsphenoidal surgery. In opticocarotid region to approach to internal carotid artery and optic nerve, a careful approach is needed to minimalize surgical injuries in type 1 and type 2 cases. The other factors determining a reliable and adequate bone resection in transsphenoidal transplanum approach are antero-posterior length of planum sphenoidale, distance between optic nerves and width of angle. 47

This is a prospective, randomized, controlled trial that compared the efficacy of different protocols of local tissue infiltration with levobupivacaine or levobupivacaine-methylprednisolone at the surgical site for pain relief after lumbar discectomy. The objective of the study was to determine the efficacy of preemptive wound infiltration with levobupivacaine and levobupivacaine-methylprednisolone at the surgical site for pain relief. Patients usually suffer significant pain after lumbar discectomy. Wound infiltration with local anesthetics with or without corticosteroids is one method to address this. A total of 100 patients were randomly allocated to five equal groups as follows: Group I had the musculus multifidi near the operated level infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone just before wound closure; Group II had the same region infiltrated with 30 mL 0.25% levobupivacaine alone before closure; Group III had this region infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone before the incision was made; in Group IV this region was infiltrated with 30 mL 0.25% levobupivacaine alone before incision; and in Group C (controls) this region was infiltrated with 30 mL 0.9% NaCl just before wound closure. Demographics, vital signs, postoperative pain scores and morphine usage were recorded. All four treatment groups showed significantly better results than the control group for most parameters. The treated groups had lower parenteral opioid requirements after surgery, lower incidences of nausea and shorter hospital stays. Further, the data indicate that, compared with infiltration of these drugs at wound closure, preemptive injection of levobupivacaine or levobupivacaine-methylprednisolone into the muscle near the operative site provides more effective analgesia after lumbar discectomy. Our data suggest that preemptive infiltration of the wound site with levobupivacaine alone or combined with methylprednisolone provides effective pain control with reduced opiate dose after unilateral lumbar discectomy.

Background: It is unusual to encounter hemorrhagic complications caused by arterial or venous damage during TSS. Problems with these structures can lead to permanent disability or death. Our aim was to quantitatively analyze anatomical and radiologic relationships among the BCS, the CCA, and the pituitary gland, as these structures are accessed during TSS. Methods: Forty-nine formaldehyde-fixed, sellar-parasellar tissue blocks from adult cadavers were used to simulate accessing the BCSs via TSS. In each specimen, size of the pituitary gland and specific characteristics of each BCS and the horizontal segment of each CCA were recorded. Nine other specimens were used for histologic investigation and microanatomical measurements. To attest correlation between clinical data and cadaveric measurements, coronal MRI scans of 22 healthy adults as well as of 28 patients with macroadenomas were analyzed. Results: In cadaveric specimens, distances between both CCAs in the BCS were 17.1 +/- 4.0 mm anteriorly, 20.3 +/- 4.2 mm medially, and 18.8 +/- 4.6 mm posteriorly. In this study, the anterior medial space of the BCS was dominant in 12 specimens on the right side and in 5 specimens on the left; the posterior medial space of the BCS was dominant in 23 specimens on the right side and in 9 specimens on the left side. The right medial BCS was dominant in 35 specimens. On histologic coronal sections, some part of the carotid artery's (CA's) diameter was located below the line passing from the basal dural layer ranging from 5.3% to 65.4%. In normal-sella images, distances between both CCAs were 15.4 +/- 1.8 mm anteriorly, 16.0 +/- 2.8 mm medially, 16.2 +/- 3.4 mm posteriorly. On coronal normal-sella images, some part of the CA's diameter was located below the line passing from the basal dural layer ranging from 16.4% to 66.7%. In macroadenomas, distances between both CCAs were 22.0 +/- 3.6 mm anteriorly, 21.5 +/- 3.8 mm medially, and 20.7.2 +/- 3.7 mm posteriorly. On coronal images, in only 6 of 28 macroadenomas, some part of the CA's diameter was located below the line passing from the basal dural layer ranging from 12.5% to 100%. Conclusions: Our results indicate that a working area of 15.0 +/- 2.6 x 10.3 +/- 2.1 mm is safe during TSS. The position of the CCA posterior segment was notably more caudal than the anterior segment with respect to the basal dura, which should be taken into account during extended exposure. Also, preoperative recognition of the anatomical variations is beneficial for detection of the boundaries of dissection, which is particularly important in the BCS, where variable course of CCAs may transform the anatomical configuration. Slowly growing pituitary adenomas stretch out both CCAs considerably from medial to lateral directions, and they cause widening of intercarotid distances in all segments. Processing of fixation, decalcification, and paraffin embedding for the cadaveric tissue in contrast to physiologically hydrated tissues may change the accuracy of measurements. These measurements are significantly different than those in the radiologic images when arterial blood under pressure is in the CCA as well as when venous blood fills the cavernous sinus as is the case in vivo. In clinical practice, these facts must be taken into consideration in the cadaveric measurements.

We prospectively investigated the complications associated with intraparenchymal intracranial pressure (ICP) monitoring using the Camino intracranial pressure device. A fiberoptic ICP monitoring transducer was implanted in 631 patients. About half of the patients (n = 303) also received an external ventricular drainage set (EVDS). The durations (mean +/- SD) of ICP monitoring in patients without and with an EVDS were 6.5 +/- 4.4 and 7.3 +/- 5.1 days, respectively. Infection occurred in 6 patients with only an ICP transducer (6/328, 1.8%) and 24 patients with an EVDS also (24/303, 7.9%). The duration of monitoring had no effect on infection, whereas the use of an EVDS for more than 9 days increased infection risk by 5.11 times. Other complications included transducer disconnection (2.37%), epidural hematoma (0.47%), contusion (0.47%), defective probe (0.31%), broken transducer (0.31%), dislocation of the fixation screw (0.15%), and intraparenchymal hematoma (0.15%). In conclusion, intraparenchymal ICP monitoring systems can be safely used in patients who either have, or are at risk of developing, increased ICP.

Pituitary adenomas extend to the suprasellar region via diaphragmal passage and extend to the cavernous sinus via the medial wall (MW). Better understanding of the dynamics of suprasellar and parasellar extension of sellar region pathologies requires microanatomical comparison of diaphragma sellae (DS) and the MW of the cavernous sinus. This study provides the first detailed quantitative assessment between DS and MW of the cavernous sinus. Microanatomical details and histopathological examinations of the DS and MWs of the cavernous sinus were studied in sphenoid block samples obtained from adult cadavers, and the thicknesses of the DS and the MW of the cavernous sinus were measured. Mean thickness of the DS was 216.73 +/- 51.26 microm in the center and 367.33+/-133.66 microm in the periphery. Mean thickness of the lower third of the MW was 161.53+/-53.86 microm and that of the upper third was 278.46+/-162.79 microm. Difference between the thicknesses of the upper and lower thirds was significant (P

Objectives: The selection of patients and treatment criteria for acute hydrocephalus and intracranial pressure (ICP) after intracranial hemorrhage remains unclear. In general neurosurgical practice, there is a tendency to use external ventricular drainage (EVD) for the patients. This study was undertaken to analyse the complications and efficiency of the different treatment modalities. Methods: The effects, complications and outcome of ventricular drainage on high ICP and hydrocephalus were analysed retrospectively in 109 patients with intracranial hemorrhage. All the patients were assessed using the Glasgow Coma Scale, computed tomograph and ICP monitoring. We excluded patients over the GCS of 8. All patients underwent a procedure for ICP monitoring plus ventricular cerebrospinal fluid (CSF) drainage. Sixty-one patients were managed with one (single) EVD system; 12 patients needed two EVD systems consecutively, while 23 patients underwent an EVD procedure followed by permanent ventriculoperitoneal (VP) shunt insertion. Thirteen patients were treated only by VP shunt for ventricular drainage. The infection rate and outcome 9 months after hemorrhage were analysed. Results: The infection rates were 8.1% in the one-EVD group, 33.3% in the two-EVD group (one EVD versus two EVD, p < 0.05), 8.6% in the EVD-VPgroup and 7.7% in the VP shunt group. The mortality rates were 73.7% in the one-EVD group, 83.8% in the two-EVD group, 47.8% (p < 0.05) in the EVD-VPgroup and 53.8% (p < 0.01) in the VP shunt group. Discussion: This study indicates that single and short-term use of EVD and/or early VP shunting are associated with a low risk of infection. Furthermore, early VP shunting may protect the brain from the irregular control of intracranial hypertension and may allow more time for resolution of CSF circulation and significantly lowers the mortality rates.

Background: Glutamergic excitotoxicity has been shown to play a deleterious role in the pathophysiology of ischemic spinal cord injury (ISCI). The aim of this study was to investigate the neuroprotective effect of a single dose of MK-801, an antiexcitotoxic drug, in a rat model of ISCI. Methods: Ischemic spinal cord injury was induced for 17 minutes in Sprague-Dawley rats using direct aortic arch, just proximal to the left common carotid artery, plus left subclavian artery cross-clamping through a left-sided limited thoracotomy. Study groups were as follows: control group (n = 8) receiving only vehicle and experimental group (n = 8) receiving a single dose of MK-801 (1 mg/kg IV) 10 minutes before aortic clamping. Neurological examination was performed at 6 hours, 24 hours, and daily up to 96 hours. Rats were sacrificed at 96 hours, and spinal cords were removed for histopathology. Results: All the control rats had severe permanent neurological deficits after ISCI, whereas the MK-801-treated rats had statistically (P

Intracranial lipomas are rare benign congenital neoplasms accounting for 0.1 to 0.5% of all primary brain tumours. Approximately 50% are associated with other cerebral developmental disorders. These slow growing benign lesions are usually asymptomatic and rarely require surgery. We report the case of a 37 year old woman presented with signs of raised intracranial pressure. Computerized tomography and magnetic resonance imaging demonstrated a quadrigeminal cistern lipoma compressing the aqueduct of Sylvius. The patient underwent surgery and a distinct plane of cleavage between the lipoma and the adjacent neural structures was found, allowing total removal of the lesion. Postoperatively, the patient was relieved of her original symptoms but developed akinetic mutism which lasted for two weeks. Intracranial lipomas rarely become symptomatic and surgery is seldom required. If the lesion progresses and causes symptoms of raised intracranial pressure or compression of neural structures, surgical intervention is indicated. Total removal should not be attempted unless a plain of cleavage between the lesion and adjacent neural structures is present. Surgical manipulation should be minimised to avoid complications.

Brown tumors are the end stage of primary or secondary hyperparathyroidism. Such lesions are rare because hyperparathyroldism is now usually diagnosed and treated before they develop. Skeletal bone is most frequently involved, whereas sellar-parasellar involvement is extremely rare. We report a patient with a brown tumor involving the sellar-parasellar region associated with primary hyperparathyroidism. The patient's clinical history and biochemical and radiological tests were used for the diagnosis. Excision of the sellar-parasellar mass enabled histopathological confirmation and surgical decompression of neural structures. After the transsphenoidal surgery, excision of a parathyroid adenoma normalized the patient's metabolic status. Brown tumors are rarely associated with complications but occasionally may compress neural structures such as the optic nerve as they enlarge.

Sarcoidosis is a systemic, idiopathic granulomatous disorder with occasionally surprising clinical presentations. A primary involvement of the optic nerve is particularly important due to visual prognosis. We report here a patient with occult sarcoidosis who presented to us with progressive visual loss as the first and primary manifestation of the disease. The patient underwent surgery for histopathological diagnosis and decompression of the optic nerve. This case demonstrated that sarcoidosis should be considered in the differential diagnosis of any lesion involving the optic nerve.