Journal of Nervous System Surgery

May the Presence of Skull Fracture and Pneumocephalus be an Indicator of Spontaneous Resolution in Traumatic Epidural Hematoma? A Case Report

Betül Sulubulut — 2023-07-08

Epidural hematoma is a serious complication of head injury and it may cause important morbidity and mortality. Although the traditional treatment is surgery, cases of spontaneous resolution with close follow-up have also been reported. The underlying pathophysiology of this spontaneous resolution has been the subject of several theories. The patients who can be treated conservatively while being closely monitored are those who have minor, asymptomatic epidural hematomas. This article will discuss a 25-year-old male patient with spontaneous resolution after about 5 hours.

Where are Neurosurgeons in Protective Public Healthcare?

Abdullah Emre Taçyıldız — 2023-07-08

Preventive public health services have demonstrated their importance in previous pandemics. Head and neck injuries are an insidious emergency trauma pandemic in the world. Preventive training programs, which are few in number even in developed countries, should be expanded. Neurosurgeons should be strongly replaced as part of comprehensive preventive healthcare.

Comparison of Non-Contrasted Cranial Computerized Tomographic Images With No Early Radiological Signs and Findings of Ischemic Stroke Patients and The Counterpart Normal Brain Parenchyma Over “Radiomics” Parameters

Törehan Özer — 2023-07-08

Purpose: The purpose of this study was to evaluate the non-contrasted cranial computerized tomography images of ischemic stroke patients with no early radiological signs and findings with texture-tissue analysis over radiomics parameters; and to obtain quantitative data that may contribute to the diagnosis of ischemic stroke.

Materials and Methods: In the present study of ours, the diffusion magnetic resonance imaging (MRI) and non-contrasted computerized tomography (CT) scans of the patients who were admitted to the Emergency Department with clinical symptoms of stroke were reviewed retrospectively. A total of 37 patients (19 females, 18 males) who were between 54-96 years of age, who had diffusion limitation that was consistent with acute ischemic infarction in MR scans, and who did not have early radiological findings and signs in non-contrasted CT scans were included in the study. In the CT images, the infarct area and itscounterpart in the other hemisphere were marked manually with a 1 cm-diameter ROI circle based on Diffusion Sequences and ADC Maps. A total of 106 tissue analysis parameters were obtained with the radiomics add-on of the 3DSlicer Program. A total of 21 parameters that were commonly used in the literature were recorded for statistical evaluation by reviewing similar studies in the literature.
Findings: The following significant differences were found in parameters; glcmjointavarage, glcmjointenergy, glcmcontrast, firstorderuniformity, firstordermedian, firstorderenergy, firstordermax, firstordermean, glrlmrunlengthnonuiformty and ngtdmcontrast. The most significant parameter was ngtdmcontrast: It was found as the parameter, which showed the frequency of gray level variability together with the dynamic range of grayscale levels that showedthe contrast.

Result: In the non-contrasted CT examination, the changes in the parameters of the infarct area appeared in the tissue analysis in the time period when no early radiological findings and signs of stroke were detected.

Endoscopic Third Ventriculostomy in Patients with Idiopathic Normal Pressure Hydrocephalus

Bekir Akgün — 2023-07-08

Objective: High rates of shunt complications in treatment of hydrocephalus has led neurosurgeons to find alternative methods. Endoscopic Third Ventriculostomy (ETV) is the transfer of CSF into interpeduncular and prepontine cisternas by perforating the floor of third ventricle. It is important for obstructive hydrocephalus. Effectiveness in communicating hydrocephalus hasn’t been well elucidated. However success rates approaching 50%, have been reported in Idiopathic Normal Pressure Hydrocephalus (iNPH) (Adams-Hakim Syndrome). Our aim is evaluate the success rates of our patients.

Materials and Methods: 20 patients underwent ETV with diagnosis of iNPH, between April 2017 and January 2023, were included. Ages, duration of symptoms and preoperative Mini-Mental Status Test (MMST) scores were recorded. Ventriculoperitoneal shunt (VPS) was inserted in whose clinical findings didn’t improve during the follow-ups.

Results: Success was provided in 12 of 20 patients. In patients achived success, mean age was 67, duration of symptoms 4 months, and preoperative MMST score 19. 7 patients who needed shunt, mean age was 77 years, duration of symptoms 10 months, MMST score 14.

Conclusion: ETV may be an alternative intervention to shunt therapy in iNBH. Patients under 75 years of age, with not very impaired cognitive functions and with symptoms duration less than 6 months are important criterias for the success of ETV. If the patient has over 75 years of age, has poor mental status, symptomatic more than 6 months, ventriculostomy may not be sufficient to improve the decreased perfusion in periventricular microischemic areas. In these cases, VPS should be the first choice.

Brain Stem 3-Dimensional Microsurgical Anatomy, Interior Architecture and Safe Entry Zones

Abdullah Emre Taçyıldız — 2023-07-08

Objective: It is aimed to reveal the 3D microsurgical anatomy of the cranial nucleii, other gray matter assemblies and white matter tracts in the brainstem, and to identify the neighbor structures of all the safe entrance ways to the brainstem and to compare the safe entrance ways with the literature.

Materials and Method: This study was carried out at Istanbul University, Cerrahpaşa Medical Faculty Department of Neurosurgery, Micro-Endo-Neurosurgery and Neuroanatomy Education Research Laboratory. Seven cadaveric human brain stems were fixed according to Klingler J. And Ludwig E. Method and prepared for dissection. The dissections were performed with a microsurgical set under a surgical microscope. Disections were performed from the front, back and lateral. Microsurgical anatomy of brain stem was revealed. Digital photographs and 3D photographs were taken at each stage.

Results: In the literature, 18 safe entry regions were revealed with surrounding boundaries.It has been revealed for the first time in the literature that intramesencephalic fibers of the oculomotor nerve also pass through the lateral aspect of the red nucleus in the anterior mesencephalic region. It has been shown for both infracollicular entry and intercollicular safe entry zones, IV. cranial nerve is under high risk. The proximity of the vestibular nerve and the inferior cerebellar peduncle in the lateral pontin region have been documented for the first time. When moved deeper in the supratrigeminal region the medial and lateral lemniscus are encountered. The dorsolateral border of the olivary region in medulla oblongata is formed by CTT, which has not been mentioned in the literature.

Conclusion: Surgeons who deal with brain stem surgery must know brainstem anatomy with all cranial nerves, descending and ascending pathways in detail. Fiber dissection technique is the best way to gain this knowledge. Surgeons should consider to combine this information with new neuroimaging techniques, in addition to the changes in intraoperative neurophysiology and act accordingly.

Short and Mid-term Results for Intraarticular Lumbar Facet Joint and Anterior Epidural Transforaminal Injections

Ilyas Dolas — 2023-07-08

Objective: Low back pain (LBP) is one of the most common causes of the loss of workforce and restriction of physical activity. Lumbar facet joint injection (FJI) and anterior epidural transforaminal injection (AETI) are minimally invasive techniques that can be useful in managing acute/chronic LBP. This study aimed to analyze short and mid-term results of patients who underwent lumbar FJI and AETI.

Materials and Methods: A single-center retrospective study was performed on 60 patients who received the lumbar FJI and AETIs between January 2022 to April 2022. Patients were evaluated with the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) before and immediately after the procedure, on the 15th day, first, and third months after the procedure. Patients with a score reduction of 20 points or more on the ODI or a score reduction of 2 or more on the VAS were considered to have benefited from the procedure.

Results: This study included 78 AETIs and 244 FJIs performed on 60 patients. Four (6.7%) patients had only AETI, 12 (20%) patients had only FJI and 44 (73.3%) patients had combined AETI and FJIs. Of these patients, 48 (80%) of them have benefited from the procedure in the short term (<1 month). Of these, 30 (50%) patients sustained pain relief during the mid-term follow-ups (1-3 months).

Conclusion: Lumbar FCI and AETI are minimally invasive techniques that can be useful for managing acute/chronic LBP. Lumbar steroid injections can be preferred in selected patients with a high risk for surgical intervention and to provide time for physical therapy.