Publications by authors named "Adem Yilmaz"

44 Publications

A rare case of cervical metastatis of glioblastoma after cranial tumor resection: case report and review of literature.

Br J Neurosurg 2020 Sep 1:1-7. Epub 2020 Sep 1.

Department of Neurosugery, Istanbul Education and Research Hospital, Istanbul, Turkey.

Glioblastoma multiforme (GBM) is the most common and the most malignant primary intracranial tumor in adults. GBM extraneural metastases occur in only approximately 0.2-0.4% of patients. We present a case of a cervical metastasis of glioblastoma after cranial tumor resection. In concord with case presentation, we reviewed the metastatic location and metastasis time of the gliablastomas seen in the literature.
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http://dx.doi.org/10.1080/02688697.2020.1814994DOI Listing
September 2020

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury.

Eur J Trauma Emerg Surg 2020 Aug 3;46(4):919-926. Epub 2020 Jun 3.

Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey.

Background: Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI.

Methods: A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared.

Results: Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047).

Conclusions: Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.
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http://dx.doi.org/10.1007/s00068-020-01409-xDOI Listing
August 2020

Cranio-Orbital Tumors: Clinical Results and A Surgical Approach.

Sisli Etfal Hastan Tip Bul 2019 27;53(3):240-246. Epub 2019 Aug 27.

Department of Neurosurgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Objectives: In this study, we aimed to share the surgical approaches and clinical experiences of cranio-orbital tumors, which are surgically difficult anatomies.

Methods: A total of 22 orbital tumors with extraorbital-transcranial pathology between January 2004 and December 2017 were retrospectively reviewed. Information was obtained from hospital, operation and outpatient records for this study. Preoperative demographic data, ophthalmologic examination findings, clinical and radiological findings were recorded. All patients had cranial magnetic resonance and cranial computerised tomography examinations at this time. The location of the tumor, its size and its relation to neighboring structures were recorded in the light of these examinations.

Results: The lateral approach was performed in 12 cases. The lateral approach was performed with frontotemporal craniotomy. Because of the lateral inferior location of the tumor in three of 12 cases, zygoma osteotomy was added to classical osteotomy. In 10 cases, the anterior approach was applied and the frontal craniotomy was found sufficient in seven cases. In three cases subfrontal craniotomy was added to classical craniotomy.

Conclusion: The findings obtained in this study suggest that high resection rates can be achieved with appropriate surgical intervention in orbital tumors requiring a transcranial surgical approach. The most important factor in surgical planning is the location of the tumor. The size of the tumor and the expectation of the percentage of surgical removal are the other important factors. In our series, it has reached high excision ratio in most cases with low complication rate, good visual field and eye movements results.
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http://dx.doi.org/10.14744/SEMB.2018.82698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192274PMC
August 2019

The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study.

J Clin Neurosci 2019 08 29;66:235-238. Epub 2019 May 29.

Department of Neurosurgery, Medical Faculty of Ataturk University, Erzurum, Turkey.

Aim: Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH.

Material And Methods: Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed.

Results: The average degenerated soma intensity/mm at the C5-6 levels in the spinal cord was 2 ± 1/mm, 13 ± 4/mm, and 56 ± 10/mm for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm, 34 ± 9/mm, and 234 ± 78/mm for Groups I, II, and III.

Conclusion: Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.
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http://dx.doi.org/10.1016/j.jocn.2019.05.039DOI Listing
August 2019

Factors associated with mortality in acute subdural hematoma: Is decompressive craniectomy effective?

Ulus Travma Acil Cerrahi Derg 2019 Mar;25(2):147-153

Department of Neurosurgery, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey.

Background: Despite rapid diagnosis and aggressive neurosurgical intervention, acute subdural hematoma (ASDH) is a severe type of head injury that can result in high morbidity and mortality. Although surgical procedures, such as craniotomy and decompressive craniectomy (DC), can be effective, the preferred approach for treating an ASDH remains controversial. The aim of this report was to evaluate factors associated with mortality in patients with ASDH and determinants of outcome in those with ASDH who underwent DC.

Methods: The demographic details and clinical and radiological characteristics of a total of 93 patients with ASDH who underwent DC during a 60-month period from 2012 to 2017 were evaluated to determine the effect on mortality and any association with the Glasgow Coma Scale (GCS) score recorded on arrival.

Results: Sixty-five male and 28 female subjects with a mean age of 59.82+-19.49 years (range: 16-88 years) were included in the study. Sixteen patients (17.2%) died following the surgery. Older age (p=0.007) and lower GCS scores (p=0.022) were statistically significantly associated with the mortality rate. The mean hematoma thickness was 15.46+-5.73 mm, and the mean midline shift was 9.90+-4.84 mm. The mortality rate was positively correlated with an excessive midline shift (p=0.011; r=0.262) and age (p=0.022; r=0.237) in patients with ADSH. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm was significantly associated with mortality (p=0.014; p=0.039). The etiology of the trauma; comorbidities of subarachnoid, epidural, or intracranial hemorrhage; compression fractures; or contusions were not significantly correlated.

Conclusion: The results indicated that there was a higher mortality rate among older patients and those with a GCS score of <6 on arrival. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm were significantly related to mortality. Our study supports the conclusion that DC may help prevent further midline shift and be associated with a lower mortality rate compared with a craniotomy.
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http://dx.doi.org/10.5505/tjtes.2018.48079DOI Listing
March 2019

Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study.

Br J Neurosurg 2018 Apr 28;32(2):196-200. Epub 2018 Apr 28.

a Marmara University School of Medicine , Istanbul , Turkey.

Purpose: Ventriculoperitoneal shunt (VPS) is the most common treatment modality for hydrocephalus. However, VPS infection is a common and serious complication with high rates of mortality and morbidity. The objective of this study was to investigate causative agents and the management of VPS infections and to identify risk factors for re-infection in children.

Materials And Methods: Retrospective, multicentre study on patients with VPS infection at paediatric and neurosurgery departments in four tertiary medical centres in Turkey between January 2011 and September 2014.

Results: A total of 290 patients with VPS infections were identified during the study period. The aetiology of hydrocephalus was congenital malformations in 190 patients (65.5%). The most common symptom of shunt infection was fever in 108 (37.2%) cases. At least one pathogen was identified in 148 VPS infections (51%). The most commonly isolated pathogen was coagulase-negative staphylococci, which grew in 63 cases (42.5%), followed by Pseudomonas aeruginosa in 22 cases (14.9%), Klebsiella pneumoniae in 15 cases (10.1%), and Staphylococcus aureus in 15 cases (10.1). The median duration of VPS infection was 2 months (range, 15 days to 60 months) after insertion of the shunt, with half (49.8%) occurring during the first month. VPS infection was treated by antibiotics and shunt removal in 211 cases (76.4%) and antibiotics alone without shunt removal in 65 patients (23.5%). Among the risk factors, CSF protein level greater than 100 mg/dL prior to VPS insertion was associated with a potential risk of re-infection (OR, 1.65; p =.01).

Conclusion: High protein levels (>100 mg/dL) before the re-insertion of a VPS may be a risk factor for VPS re-infection.
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http://dx.doi.org/10.1080/02688697.2018.1467373DOI Listing
April 2018

Chronic subdural hematoma associated with arachnoid cyst of the middle fossa : Surgical treatment and mid-term results in fifteen patients.

Turk Neurosurg 2017 Oct 18. Epub 2017 Oct 18.

University of Health Sciences, Hamidiye Sisli Etfal SUAM, Department of Neurosurgery, Istanbul, Turkey.

Aim: We report the neurological and radiological features, surgical management and Mid-term outcome in a series of patients with chronic subdural hematoma (CSDH) and associated ipsilateral arachnoid cyst (AC) of the middle fossa.

Material And Methods: Between August 2004 and August 2012, 453 patients were treated with diagnosis of CSDH in our clinic. Of those, 15 patients had ipsilateral arachnoid cyst in the middle fossa. A single burr hole craniostomy was performed to drain the hematoma and the AC left intact at first in 14 patients, one patient had no surgical intervention. Follow-up period ranged from 13 months to 88 months (mean 43.07 ± 23.23 months).

Results: The patients having CSDH with AC were found to be younger than the patients with CSDH alone, the mean age was 13.93 ±12.37 years Eleven patients had head trauma 21 to 50 days before admission. Hematoma evacuation through a single burr hole and closed system subdural drainage 2 to 4 days after surgery improved the symptoms in all patients. Two patients developed subdural fluid collection which is treated by subduroperitoneal shunt placement.

Conclusion: Greater prevalence of ACs in patients with CSDHs has been reported in the literature. We recommend the drainage of the hematoma via a single craniostomy and to leave the AC intact as the first choice of treatment if the associated AC is a Galassi type I or II. Additional subduroperitoneal shunting may be performed in patients with Galassi type III cyst.
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http://dx.doi.org/10.5137/1019-5149.JTN.21513-17.3DOI Listing
October 2017

Inverse Association Between Basilar Artery Volume and Neuron Density in the Stellate Ganglion Following Bilateral Common Carotid Artery Ligation: An Experimental Study.

World Neurosurg 2017 Apr 19;100:138-143. Epub 2016 Dec 19.

Department of Pathology, Medical Faculty of Atatürk University, Erzurum, Turkey.

Objective: This study examined the relationship between neuron density in the stellate ganglion and the severity of basilar artery (BA) enlargement after bilateral common carotid artery ligation.

Methods: Rabbits (n = 24) were randomly divided into 3 groups: unoperated control group (n = 4), experimental group subjected to bilateral common carotid artery ligation (n = 15), and sham-operated control group (n = 5). Histologic examination of the BAs and stellate ganglia was performed 2 months later. Permanent bilateral common carotid artery ligation was induced by ligation of common carotid arteries at prebifurcation levels as a model for steno-occlusive carotid artery disease.

Results: Mean BA volume and neuron density in stellate ganglia for all animals were 4200 μm ± 240 and 8325 μm ± 210. In sham-operated animals, the mean values were 4360 μm ± 340 and 8250 mm ± 250. For the experimental group, mean volume and density in animals with slight dilatation of the BA (n = 6) were 4948 μm ± 680 and 10,321 mm ± 120, whereas in animals with severe dilatation (n = 9), the values were 6728 μm ± 440 and 6300 mm ± 730. An inverse association was observed between degree of BA enlargement and stellate ganglia neuronal density.

Conclusions: High neuron density in stellate ganglia may protect against steno-occlusive carotid artery disease by preventing BA dilatation and aneurysm formation in the posterior circulatory arteries.
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http://dx.doi.org/10.1016/j.wneu.2016.12.034DOI Listing
April 2017

Analysis of diabetes-related cerebellar changes in streptozotocin-induced diabetic rats.

Turk J Med Sci 2016 Nov 17;46(5):1579-1592. Epub 2016 Nov 17.

Neurosurgery Clinic, Şişli Etfal Training and Research Hospital, İstanbul, Turkey.

Background/aim: Diabetic peripheral neuropathy has been extensively studied and reported, but the number of studies that have investigated diabetes-related changes in the central nervous system are limited, with even fewer studies on the cerebellum. The aim of this experimental study was to perform a histologic analysis of the diabetes-related changes in the cerebellums of diabetic rats.

Materials And Methods: Twenty Sprague Dawley rats weighing between 200 and 220 g were included in the study. Diabetes was induced in 14 of these rats by a single intraperitoneal injection of 65 mg/kg streptozotocin dissolved in saline, while 6 animals constituted the control group. The induction of diabetes was confirmed by measuring the blood glucose levels in the tail blood with a glucometer. Levels equal to or above 200 mg/dL were considered diabetic. Induction of diabetes failed in 3 animals, who were then excluded from the study.

Results: Light and electron microscopic studies revealed that the neurons and glial cells in the diabetic group had degenerative changes, irregularities and disruption in the myelin sheath, disintegration in the presynaptic vesicles, engorged axon terminals, perivascular and mitochondrial swelling, mitochondrial structural changes, and fragmentation of the neurofilaments.

Conclusion: Ultrastructural alterations are observed in the diabetic rat cerebellum.
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http://dx.doi.org/10.3906/sag-1412-125DOI Listing
November 2016

Adding Expansile Duraplasty to Posterior Fossa Decompression May Restore Cervical Range of Motion in Grade 3 Chiari Malformation Type 1 Patients.

World Neurosurg 2017 Feb 2;98:98-103. Epub 2016 Nov 2.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: Few studies have assessed the effect of Chiari malformation type 1 (CM-1) surgical decompression on cervical lordosis and range of motion (ROM). We aimed to assess the effect of expansile duraplasty on postoperative cervical mobility and spinal stability.

Materials And Methods: This was a single-center retrospective review of prospectively collected data. Patients were included if they underwent surgical treatment for symptomatic CM-1 between the years 1999 and 2009. Cervical ROM and lordosis were assessed before and after surgery in all patients. Collected data also included clinical improvement, as well as surgical complications after the procedure. Patients were divided into 2 groups. The first group underwent a posterior fossa bony decompression alone, while the second group additionally received an expansile duraplasty. Patients were further subdivided into 3 subgroups on the basis of the severity of tonsillar herniation.

Results: A total of 76 patients fit our selection criteria. Fifty-five patients belonged to the duraplasty group. Twenty-one patients underwent bony decompression alone. The 2 groups were statistically demographically and clinically similar. There was no difference in clinical outcome or in ROM and cervical lordosis between the groups except for patients with severe tonsillar herniation (CM-I grade 3). These patients had a statistically significant improvement in their postoperative cervical motility without compromising their spinal stability.

Conclusion: Adding an expansile duraplasty to craniovertebral decompression in CM-1 patients with severe tonsillar herniation may restore cervical ROM while preserving stability and alignment. This may relieve postoperative pain and improve clinical prognosis.
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http://dx.doi.org/10.1016/j.wneu.2016.10.127DOI Listing
February 2017

Factors that Affect Postoperative Hydrocephalus Development in Aneurysmal Subarachnoid Hemorrhage: A Clinical Study.

Turk Neurosurg 2017 ;27(3):353-361

Sisli Hamidiye Etfal Research and Education Hospital, Department of Neurosurgery, Istanbul, Turkey.

Aim: Factors affecting the development of postoperative hydrocephalus patients who underwent surgery after aneurysmal subarachnoid hemorrhage were retrospectively assessed.

Material And Methods: 201 cases, who underwent aneurysm surgery in our clinic after subarachnoid hemorrhage between 2008 and 2013, were retrospectively assessed. Twenty-one cases with hydrocephalus development were retrospectively examined according to their age, gender, history (hypertension, alcohol, and smoking), blood type, the number and size of aneurysms, aneurysm localization, the presence of ventricular hemorrhage, baseline-final neurological diagnosis, Fisher grading system, history of vasospasm and meningitis. The initial neurological course and Hunt-Hess, and also final neurological course of the patients were evaluated according to World Federation of Neurosurgical Societies (WFNS) Grading Scale.

Results: Age, history of hypertension, aneurysm localization, Hunt-Hess grading, vasospasm, meningitis and Glasgow Outcome Scale (GOS) are determinative factors in hydrocephalus development due to subarachnoid hemorrhage. It was detected that gender, alcohol and tobacco use, blood group, the size and the number of aneurysm, the presence of intraventricular hemorrhage and Fisher grading were not the determinative factors in the patients.

Conclusion: In patients who underwent surgery for subarachnoid hemorrhage, risk factors for postoperative hydrocephalus should be determined and the patients with these risk factors should be closely monitored.
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http://dx.doi.org/10.5137/1019-5149.JTN.16400-15.1DOI Listing
December 2017

Morphometric Analysis of Lumbar Disc Space in the Turkish Population and Safe Discectomy Distance in Lumbar Disc Surgery.

Turk Neurosurg 2017 ;27(4):603-609

Istanbul Research and Training Hospital, Neurosurgery Clinic, Istanbul, Turkey.

Aim: Lumbar discectomy is a common surgical intervention in neurosurgical practice. Iatrogenic vascular injury during this surgery is a rare, but serious complication. In this study, our aim was to review the average safe depth of discectomy for both sexes.

Material And Methods: This study involved a total of 56 patients between 21 and 79 years old (28 male and 28 female) who had no surgical pathology as documented by lumbar magnetic resonance imaging study. Measurements at L3-4, L4-5, and L5-S1 were performed for both sexes as follows: 1 < sup > st < /sup > measurement, from the furthest lateral part of the dura to the end of the disc (right-left); 2 < sup > nd < /sup > measurement, the anteroposterior length of the cross-section passing through the midline of the disc; 3rd measurement; from the furthest lateral part of the dura to the furthest lateral part of the disc (right-left); 4th measurement, the length from right to left of the cross-section passing through the midline of the disc.

Results: Measurement 1 at L3-4, L4-5, and L5-S1, this value was estimated to be 35.9 and 36.7 mm, 35.9 and 36.9, and 34 and 34.9 mm in the right and left sides respectively, for female subjects. The corresponding values for males were 41.4 and 42.1, 40.6 and 40.9, and 37.4 and 37.7 mm at L3-4, L4-5, and L5-S1, respectively. Measurement 3 in L3-4, L4-5, and L5-S1 disc spaces on the right and left sides in female subjects were 14.8 and 16.3 mm, 15.7 and 17.2 mm, and 14.9 and 17.1 mm, respectively, with corresponding figures of 18.6 and 19.5, 19.7 and 20.6, and 18.2 and 18.6 mm among male participants. Measurement 2 and 4 in females for L3-4, L4-5, and L5-S1 were 38.4 and 52.3 mm, 38.9 and 53.4 mm, and 37 and 51.8 mm, respectively. The corresponding figures for males were 43.2 and 57.6 mm, 43.2 and 58.9 mm, and 40.1 and 56.7 mm, respectively.

Conclusion: Determination of the safe discectomy depth in both males and females, as well as the use of marking disc punches to indicate the safe margins may help clinicians to avoid this unwanted complication.
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http://dx.doi.org/10.5137/1019-5149.JTN.16871-15.0DOI Listing
February 2018

Computerized Tomography-Guided Stereotactic Biopsy of Intracranial Lesions: Report of 500 Consecutive Cases.

Turk Neurosurg 2017 ;27(3):395-400

Sisli Hamidiye Etfal Research and Training Hospital, Clinic of Neurosurgery, Istanbul, Turkey.

Aim: Computed tomography (CT)-guided stereotactic brain biopsy has been performed in our clinic since March 1998. In this prospective study, we examined the patient data undergoing stereotactic biopsy and the results of biopsies in 500 consecutive patients.

Material And Methods: Between the dates of March 1998 and January 2015, CT-guided stereotactic biopsies were performed by using the Leksell stereotactic frame system (Elekta Instruments EU, Sweden) in 500 patients. A total of 512 procedures were performed in patients consisting of 184 females (36.8%) and 316 males (63.2%), ages ranging from 3 to 81 years (mean 50.40±16.67).

Results: Conclusive histopathological diagnosis was not achieved in 17(3.3%) of 512 procedures. Of the others, 173 (33.8%) were high-grade gliomas, 103 (20.1%) were low-grade gliomas, 36 (7%) were malignant lymphomas, 34 (6.6%) were other types of brain tumors, 82 (16%) were metastasis and 67 (13.1%) were non-tumoral lesions. Complications were occurred in ten cases: 3 tumoral bleedings, 2 hypertensive cerebral hematomas, 2 peroperative convulsions, 1 epidural hematoma, 1 myocardial infarction and 1 brain edema. The patients who developed myocardial infarction and hypertensive thalamic hematoma died. The mortality was 0.4% and morbidity was 1.6% in 512 procedures.

Conclusion: CT-guided stereotactic biopsy is a reliable and a safe procedure in cases with intracranial lesions when histopathological diagnosis is required for the appropriate treatment.
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http://dx.doi.org/10.5137/1019-5149.JTN.16280-15.1DOI Listing
December 2017

Nerve sheath myxoma of the dorsal paravertebral space.

Int J Surg Case Rep 2014 16;5(11):858-60. Epub 2014 Oct 16.

Department of Pathology, Sisli Research and Education Hospital Istanbul, Turkey.

Introduction: Nerve sheath myxomas (NSM) are rare benign soft tissue tumors. The dorsal paravertebral placed NMS diagnosis can be difficult.

Presentation Of Case: This article presents clinical, radiological findings and treatment of the NSM of the dorsal paravertebral space in a 32-year-old man presented with a right shoulder and back pain for 4 years.

Discussion: NSM is a rare and benign tumor and that most often occurs in the skin of the head, neck or upper limbs of younger patients. Rare locations such as intracranial, spinal canal, trunk, lower limb and oral cavity were also reported. The appropriate treatment of NSM is surgical excision. Diagnosis is difficult in an uncommon presentation.

Conclusion: Although the most presented case of NMS are dermal tumors, it may also be found extremely rare locations. We conclude that, the definitive treatment of NSM is surgical excision with safe margins even when it is possible.
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http://dx.doi.org/10.1016/j.ijscr.2014.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245665PMC
June 2016

Spinal nerve root compositions of musculocutaneous nerve: an anatomical study.

Turk Neurosurg 2014 ;24(6):880-4

Baskent University, School of Medicine, Department of Orthopedic Surgery, Istanbul, Turkey.

Aim: This study was aimed to investigate the variations in the spinal nerve root compositions of musculocutaneous nerve and to confirm which spinal nerve root is the main ingredient in participating amount.

Material And Methods: A total of 20 fresh cadavers were dissected. Brachial plexus and its branches were extracted. Musculocutaneous nerve stump was traced back to the roots to identify its fascicular origin. The number of fascicles originating from a particular nerve root and their axial location with in the nerve were noted.

Results: The most frequent type of spinal nerve compositions of musculocutaneous nerve was C5, C6, and C7 with incidence of 60%. Musculocutaneous nerve had bundles from C5 root in all specimens, 90% of the specimens had contribution from C6 and only 70% of them had bundles from C7 root. There were a total of 46 (37.7%) bundles in C5 fascicles, 48 (39.3%) bundles in C6 fascicles, and 28 (22.9%) bundles in C7 fascicles.

Conclusions: In electrophysiological studies it should be remembered that C7 or C6 lesions may not impair musculocutaneous nerve functions. The success of musculocutaneous nerve neurotization may be improved if care is taken to ensure whether or not C7 root is contributing to the musculocutaneous nerve.
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http://dx.doi.org/10.5137/1019-5149.JTN.9145-13.1DOI Listing
December 2015

The quality of life and psychiatric morbidity in patients operated for Arnold-Chiari malformation type I.

Int J Psychiatry Clin Pract 2013 Oct 26;17(4):259-63. Epub 2013 Mar 26.

Department of Psychiatry, Sisli Etfal Teaching and Research Hospital , Istanbul , Turkey.

Background: There are some case reports that highlight the association of Arnold-Chiari malformation (ACM) with psychiatric symptoms. We assessed the association between ACM and psychiatric symptoms and risk factors in terms of psychiatric morbidity and evaluated the quality of life after surgery.

Methods: This study consisted of sixteen patients who underwent decompression operation at the Department of Neurosurgery of Sisli Etfal Hospital. The MINI plus, Short-Form McGill Pain Questionnaire and WHOQOL-BREF-TR were administered to patients.

Results: About 43.8% of the patients had a psychiatric disorder. About 50% of the patients had co-existing syringomyelia of which 50% with syringomyelia had a psychiatric disorder. Patients with syringomyelia without any psychiatric disorder had significantly lower scores on physical domain of WHOQOL-BREF-TR (p = 0.02) than the patients without syringomyelia and psychiatric disorder. Subjects with a psychiatric disorder had lower scores on four domains of WHOQOL-BREF-TR. The patients with psychiatric diagnoses had significantly higher scores on affective pain index (p = 0.021) and total pain index (p = 0.037) than the patients without any psychiatric disorder.

Conclusion: The presence of a psychiatric condition influences not only the physical aspect but also deteriorates the psychological and social relations and environmental aspect. Moreover the presence of a psychiatric disorder increases the perception of pain and causes more discomfort.
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http://dx.doi.org/10.3109/13651501.2013.778295DOI Listing
October 2013

Giant osteoid osteoma of the ethmoid bone with unusual large nidus.

J Neurosci Rural Pract 2012 Sep;3(3):383-5

Department of Neurosurgery, Clinic of Neurosurgery, ŞişliEtfal Education and Research Hospital, Istanbul, Turkey.

Osteoid osteoma (OO) is a benign bone neoplasm which is seen in the long bones of appendicular skeleton. It is rarely seen in the cranium. Ethmoid bone OO has been very rarely reported so far. We report another case of giant osteoid osteoma involving the ethmoid bone with intraorbital and intracranial extension in a 3O year old female patient. This case with unusual anatomical location was presented. It is first time reporting a giant osteoid osteoma of ethmoid bone with such a large nidus.
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http://dx.doi.org/10.4103/0976-3147.102637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505348PMC
September 2012

Clip ligation of unruptured intracranial aneurysms: a prospective midterm outcome study.

Acta Neurochir (Wien) 2012 Jul 29;154(7):1135-44. Epub 2012 May 29.

Clinic of Neurosurgery, Şişli Etfal Education and Research Hospital, Istanbul, 34077, Turkey.

Background: We conducted a prospective study to investigate the clinical and radiological outcome in a surgical case series of 176 patients with 203 unruptured intracranial aneurysms (UIA).

Methods: The success of aneurysm obliteration was assessed within 2 weeks after surgery by digital subtraction angiography (DSA). Patients also underwent angiography 5 years after surgery. Clinical outcomes were assessed using the modified Rankin Scale (mRS). All predictors of poor surgical outcomes were assessed using an exact logistic regression.

Results: Overall, 83 % of the patients had a good outcome (mRS score 0 or 1); 10.8 % of the patients had a slight disability (mRS score 2), and 6.2 % of the patients had a moderate or moderate-severe disability (mRS score 3 or 4). The mortality rate was 0 % overall. The most important predictors of outcome were presence of history of ischemic cerebrovascular disease and postoperative stroke. Complete aneurysm occlusion was achieved in 93.5 % of all aneurysms. Sixty percent of treated aneurysms were checked with late follow-up DSA. No cases of hemorrhage from a surgically obliterated UIA were documented in this series during the 7.3 ± 1.4 (SD)-year follow-up period.

Conclusions: If patients are carefully selected and individually assigned to their optimum treatment modality, IUAs can be obliterated by surgery with a low percentage of unfavorable outcomes.
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http://dx.doi.org/10.1007/s00701-012-1397-yDOI Listing
July 2012

Clinical outcomes of myelomeningocele defect closure over 10 years.

J Clin Neurosci 2012 Jul 16;19(7):984-90. Epub 2012 May 16.

Clinic of Neurosurgery, Şişli Etfal Education and Research Hospital (Şişli Etfal Eğitim ve Araştırma Hast.), Beyin ve Sinir Cerr, Kliniği, Şişli, Istanbul 34381, Turkey.

We report our surgical procedures for the closure of myelomeningocele defects. A retrospective analysis of 162 patients (74 male [45.7%], 88 female [54.3%]) with myelomeningocele was performed and the relationship between hydrocephalus, neurological status and the level and size of the myelomeningocele was described according to type of defect closure. Patients were divided into four groups according to the size of the defect, which was classified into ranges of 0-24 cm(2), 25-39 cm(2), 40-60 cm(2) and >60 cm(2). Myelomeningocele occurred in the lumbar region in 114 patients (70%). The minimum defect size was 3×2 cm, and the maximum defect size was 15×15 cm (mean defect size=34.64 cm(2)). We found that primary closure can be performed on clean, small defects with an intact sac that contains cerebrospinal fluid and the neural placode. For defects larger than 25 cm(2) that contained perforated sacculas, more soft tissue for well-vascularized coverage was required. Bilateral V-Y fasciocutaneous flaps are a good choice for immediate coverage of myelomeningocele defects.
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http://dx.doi.org/10.1016/j.jocn.2011.09.026DOI Listing
July 2012

A cross sectional observational study on the influence of chronic obstructive pulmonary disease on activities of daily living: the COPD-Life study.

Tuberk Toraks 2012 ;60(1):1-12

Faculty of Medicine Hospital, Adnan Menderes University, Aydin, Turkey.

Introduction: This study was designed to identify the impact of chronic obstructive pulmonary disease (COPD) on activities of daily living, life styles and needs in patients.

Patients And Methods: Participants of this national, multi-centered, cross-sectional observational study included 497 stable COPD patients from 41 centers. The mean age (standard deviation; SD) was 63.3 (9.3) years with 59.0% of the patients under the age of 65, and 89.9% of the participants were male. Sociodemographic and COPD-related data were gathered at enrollment and during the 1-month telephone follow-up.

Results: The mean (SD) COPD duration was 7.3 (6.5) years in the overall population while 5.4 (4.6) years for patients who recieved COPD diagnosis at least one year after the onset of symptoms. Dyspnea was the most common (83.1%) symptom and walking up stairs (66.6%) was the most difficult activity to be performed. Majority of the patients were aware of COPD as a chronic disease (63.4%), requiring ongoing treatment (79.7%), mainly caused by smoking (63.5%). 59% of the patients were under the age of 65 years-old. In 84% of patients, graduation from at least a primary school was identified. Results revealed an average number of two dependants that were obliged to look after per patient, ability to go on an outing in 91% of the patients, and going grocery shopping with ease in more than two-thirds of the study population. There was no significant difference in regular use of medication device across different educational or age groups. The top three COPD treatment expectations of the patients were being able to breathe (24.1%), walking (17.1%), and walking up stairs (11.7%), while shortness of breath (43.3%) was the first priority treatment need.

Conclusion: In contrast to the common view that COPD prevalance is higher in old age population, this study showed that the rate of the disease is higher among younger patients than expected; indispensability of out of the house activities in majority of patients; and use of regular medication device to be independent of educational level and the age of COPD patients. Our findings indicate that the likelihood of COPD patient population to be composed of younger and active individuals who do not spend majority of their time at home/in bed as opposed to popular belief. Therefore, availability of a portable and easy to use device for medication seems to be important to enhance daily living.
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http://dx.doi.org/10.5578/tt.3414DOI Listing
June 2012

Risk factors for recurrent shunt infections in children.

J Clin Neurosci 2012 Jun 18;19(6):844-8. Epub 2012 Apr 18.

Department of Neurosurgery, Sisli Etfal Training and Research Hospital, Halaskargazi Street, Istanbul 34100, Turkey.

Risk factors for recurrent shunt-related cerebrospinal fluid (CSF) infections were analyzed. A total of 58 children were treated for initial shunt infections (ISI): all children were treated with antibiotics and CSF drainage, either by removal of the shunt system and insertion of an external ventricular drainage (EVD) catheter (44 children, 75.9%) or by externalization of the existing ventricular catheter (14 children, 24.1%). Recurrent shunt infections (RSI) were detected in 15 children: nine had been treated with shunt removal and insertion of a new EVD catheter and six had been treated with externalization of the existing ventricular catheter. There was a statistically significant increase in the number of RSI in children treated with externalization of the existing ventricular catheter. Thus, to reduce the risk of RSI, total shunt removal and insertion of a new EVD catheter is preferred.
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http://dx.doi.org/10.1016/j.jocn.2011.07.054DOI Listing
June 2012

Unilateral frontal interhemispheric transfalcial approaches for the removal of olfactory groove meninjiomas.

Turk Neurosurg 2012 ;22(2):174-82

Sisli Etfal Research and Education Hospital, Department of Neurosurgery, Istanbul, Turkey.

Aim: A unilateral subfrontal interhemispheric transfalcial approach for the removal of olfactory groove meningiomas (OGM) was evaluated in terms of surgical technique, complications, clinical outcomes, and recurrence rate.

Material And Methods: Twenty-four females and eighteen males with a mean age of 59 years were operated on for OGM within a 12- year (1996-2008) period. The pre- and post-operative Mini-Mental Test (MMT) scores, visual impairment scores (VIS), pre-operative clinical symptoms (headache, epileptic seizure and anosmia), Karnofsky performance scores (KPS), tumor size and tumor extensions were evaluated. The effects of the pre-operative parameters on post-operative MMT, VIS and KPS were investigated.

Results: Tumor size and pre-operative MMT significantly affected pre-operative KPS. Mean tumor diameter was 5.6±0.8 cm. Total excision was achieved in 97.6% of all cases. No peri-operative mortality was seen. Ten patients (23.8%) experienced surgery-related complications. The mean follow-up period of cases was 52 months, and the rate of residual tumor re-growth was 2.3%. No parameter showed any effect on post-operative KPS, as no significant difference was seen between pre- and post-operative KPS. A significant positive difference was detected between pre- and post-operative MMT and VIS.

Conclusion: A unilateral subfrontal interhemispheric transfalcial approach can be the preferred modality for treating OGM.
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http://dx.doi.org/10.5137/1019-5149.JTN.4749-11.1DOI Listing
July 2012

Recurrent cerebral arteriovenous malformation with a posterior inferior cerebellar artery aneurysm.

Turk Neurosurg 2011 ;21(4):674-9

Şişli Etfal Education and Research Hospital, Clinic of Neurosurgery, Istanbul, Turkey.

Aim: Cerebral arteriovenous malformations (AVMs) are congenital lesions which rarely recur after complete microsurgical excision.

Material And Methods: This case report presents a 35-year-old woman who had been referred with a hemorrhagic AVM five years ago. This patient has recently undergone microsurgical excision for her left parieto-occipital Grade II AVM and surgical clipping of the left posterior inferior cerebellar artery (PICA) aneurysm which was concomitantly detected. She is the oldest case reported whose AVM recurred as Grade III, which is bigger than her first AVM associated with an aneurysm.

Conclusion: Although some authors do not propose routine additional follow-up in adults after the initial negative postoperative angiogram, we believe that such patients should be followed clinically and radiologically.
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http://dx.doi.org/10.5137/1019-5149.JTN .3059-10.2DOI Listing
April 2012

The effect of degenerated neuron density of petrosal ganglion on the development of blood pressure variabilities after subarachnoid hemorrhage in a rabbit model: an experimental study.

Turk Neurosurg 2011 ;21(4):559-66

Sisli Research and Education Hospital, Department of Neurosurgery, Istanbul Turkey.

Aim: The aim of this study was to determine the relationship between ischemic neurodegeneration, of the petrosal ganglion of the glossopharyngeal nerve, and BP fluctuations, after subarachnoid hemorrhage (SAH).

Material And Methods: Twenty-four rabbits had their blood pressure and heart rhythms studied daily over 20 days. Then, the histopathology of the petrosal ganglion was examined in all animals. Normal and apoptotic neuron density of the petrosal ganglion and blood pressure values were compared statistically.

Results: Mean total volume of the petrosal ganglia was calculated as 0.9 ± 0.34/mm3. BP level of control group was 96.1 ± 2.1 mmHg; 116.5 ± 4 mmHg of mild hypertension (HT) group and 128.1 ± 3.6mmHg in the severe HT group. When the groups were compared to each other they were significantly different. The level of normal-apoptotic neuron in control group was 11,240 ± 802/mm³ -40 ± 6.3/mm³; 9730 ± 148.7/mm³ - 1560 ± 256.2/mm³ in the mild HT group and 6870 ± 378.8/mm³-4240 ± 628.2/mm³ in the severe HT group. When the groups were compared to each other there was significantly difference.

Conclusion: Blood pressure variability observed in this study may be explained by ischemic neurodegeneration of petrosal ganglia caused by SAH. The results of this study suggest that petrosal ganglion ischemia has potential implications for the development of hypertension. These findings suggest that new treatment strategies should be considered for the treatment of SAH.
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http://dx.doi.org/10.5137/1019-5149.JTN .4553-11.1DOI Listing
April 2012

The effect of choroidal artery vasospasm on choroid plexus injury in subarachnoid hemorrhage: experimental study.

Turk Neurosurg 2011 ;21(4):477-82

Sisli Etfal Education and Research Hospital, Department of Neurosurgery, Istanbul, Turkey.

Aim: We examined whether vasospasm of choroidal arteries (ChAs) may be resulted in ischemic injury in choroid plexus (CP) after subarachnoid hemorrhage (SAH).

Material And Methods: This study has been conducted on 30 rabbits. Eight, fourteen and eight of them were used as control, SAH and SHAM groups, respectively. The volumes of choroidal arteries were examined and measured by using the micrometric microscope barr. Ischemic morphological changes of the choroid plexus cells and villus were examined as follows: cellular shrinkage (1 point), cytoplasmic condensation (2 points), angulation (3 points) and villus desquamation (4 points) were considered as 1st, 2nd, 3rd, 4th degree downward choroid plexus degeneration criteria. Degeneration scores of 1 to 4 criteria were calculated by summing the exacerbated ones with the existing one.

Results: Choroidal artery diameter&volume, and CP degeneration scores in three groups were evaluated: The mean volumes were 1.080 ± 0.650 mm³, 0.907 ± 0.330 mm³, 0.480 ± 0.175 mm³ and the degeneration scores of choroidal plexuses were scored as 0 and 1- 1, and 4- 3 and 10 in the control, SHAM and SAH groups respectively. A significant correlation between the degree of vasospasm and CP degeneration was found.

Conclusion: Vasospasm of choroidal arteries may be at a serious degree in cases with SAH incurs damages on choroid plexuses, and affects structures which play important roles in immune, endocrine, detoxifying, thermoregulatory, and secretory functions of the brain resulting in worsened prognosis.
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http://dx.doi.org/10.5137/1019-5149.JTN .4204-11.1DOI Listing
April 2012

Midterm outcome after a microsurgical unilateral approach for bilateral decompression of lumbar degenerative spondylolisthesis.

J Neurosurg Spine 2012 Jan 26;16(1):68-76. Epub 2011 Aug 26.

Clinic of Neurosurgery, Şişli Etfal Education and Research Hospital, Istanbul, Turkey.

Object: The aim of this study was to evaluate the results and effectiveness of bilateral decompression via a unilateral approach in the treatment of lumbar degenerative spondylolisthesis (DS).

Methods: Operations were performed in 84 selected patients (mean age 62.1 ± 10 years) with lumbar DS between the years 2001 and 2008. The selection criteria included lower back pain with or without sciatica, neurogenic claudication that had not improved after at least 6 months of conservative treatment, and a radiological diagnosis of Grade I DS and lumbar stenosis. Decompression was performed at 3 levels in 15.5%, 2 levels in 54.8%, and 1 level in 29.7% of the patients with 1 level of spondylolisthesis. All patients were followed up for at least 24 months. For clinical evaluations, a visual analog scale, Oswestry Disability Index (ODI), and Neurogenic Claudication Outcome Score (NCOS) were used. Spinal canal size and (neutral and dynamic) slip percentages were measured both pre- and postoperatively.

Results: Neutral and dynamic slip percentages did not significantly change after surgery (p = 0.67 and p = 0.63, respectively). Spinal canal size increased from 50.6 ± 5.9 to 102.8 ± 9.5 mm(2) (p < 0.001). The ODI decreased significantly in both the early and late follow-up evaluations, and good or excellent results were obtained in 64 cases (80%). The NCOS demonstrated significant improvement in the late follow-up results (p < 0.001). One patient (1.2%) required secondary fusion during the follow-up period.

Conclusions: Postoperative clinical improvement and radiological findings clearly demonstrated that the unilateral approach for treating 1-level and multilevel lumbar spinal stenosis with DS is a safe, effective, and minimally invasive method in terms of reducing the need for stabilization.
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http://dx.doi.org/10.3171/2011.7.SPINE11222DOI Listing
January 2012

Surgical results of large and giant pituitary adenomas with special consideration of ophthalmologic outcomes.

World Neurosurg 2011 Jul-Aug;76(1-2):141-8; discussion 63-6

Department of Neurosurgery, Sisli Research and Education Hospital, Baskent University Medical School, Istanbul, Turkey.

Objective: To analyze functioning and nonfunctioning pituitary adenomas (PAs)>3 cm, with special emphasis on preoperative and postoperative visual functions.

Methods: The cases consisted of 49 women and 54 men with mean age of 43.2 years (range 19-66 years). All cases had a macroadenoma >3 cm in diameter. The transsphenoidal approach was performed in 117 procedures, and the transcranial approach was performed in 8 procedures. Radical tumor excision was achieved in 50 of 103 patients. Postoperative evaluation was done in 88 patients. Preoperative and postoperative visual acuity, visual field, and ocular fundi and their relationship with the pattern and duration of the symptoms and the size of the tumor were evaluated.

Results: Normalization of visual acuity was obtained in 71.5% of patients, improvement occurred in 13.6%, symptoms persisted in 13.6%, and symptoms worsened in 1%. Postoperative improvement of visual field defects (VFDs) was observed in 74.1% of patients, and visual impairment score improved postoperatively in 92% of patients. Patients operated on <6 months before the onset of vision loss had better and more sustained visual improvement. One patient died, and 15.5% of patients experienced surgery-related complications.

Conclusions: This study shows that patients with severe visual impairment may have remarkable improvement if surgical decompression is done early. The transsphenoidal approach should be performed to correct the patient's visual impairment and to relieve the pressure on the optic apparatus caused by macroadenoma of any size.
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http://dx.doi.org/10.1016/j.wneu.2011.02.009DOI Listing
October 2011

Trigeminal ganglion neuron density and regulation of anterior choroid artery vasospasm: In a rabbit model of subarachnoid hemorrhage.

Surg Neurol Int 2011 15;2:77. Epub 2011 Jun 15.

Department of Neurosurgery, Sisli Research and Education Hospital, Istanbul, Turkey.

Background: Subarachnoid hemorrhage (SAH) is associated with severe vasospasm caused by a variety of neurochemical mechanisms. The anterior choroid arteries (AChAs) are innervated by vasodilated fibers of the trigeminal ganglion (TGG). The goal of this study was to determine whether there is a relationship between the neuron density of the TGG and the severity of AChAs vasospasm with SAH.

Methods: Thirty-two rabbits were used for the study; eight served as the baseline control group, seven as a SHAM group, with injections of 1 cc of isotonic saline solution, and 17 rabbits were included in the experimental SAH group, with injection of homologous blood into the cisterna magna. After 10 days, the histopathology of the AChAs and TGGs were examined. The AChAs vasospasm index (VSI) of the external/internal diameter and the neuron density of the ophthalmic root of the TGGs were evaluated stereologically. The AChAs VSI was preferred -- a measure of the degree of vasospasm. As the VSI increased, the degree of arterial vasospasm increased. The results were statistically analyzed.

Results: The mean AChAs VSI was significantly higher and the mean neuronal density of the ophthalmic root of the TGG was significantly lower in the group with severe vasospasm associated with SAH compared to the controls, SHAM, and the group with mild vasospasm associated with SAH (P< 0.05). The ophthalmic root of the TGG neuron density in the 7 rabbits that developed severe vasospasm was statistically less than that observed in the 10 rabbits with mild vasospasm. There was a linear relationship between the low neuronal density in the ophthalmic root of the TGG and the severity of the AChA vasospasm.

Conclusions: The trigeminal ganglion neuron density may be an important factor in the regulation of AChAs diameter and cerebral blood flow. Low neuron density of the ophthalmic root of the TGG may play a role in the pathogenesis of AChAs vasospasm associated with SAH.
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http://dx.doi.org/10.4103/2152-7806.82084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130438PMC
November 2011

The correlation between hematoma volume and outcome in ruptured posterior fossa arteriovenous malformations indicates the importance of surgical evacuation of hematomas.

Turk Neurosurg 2011 ;21(2):152-9

M.H. Sisli Etfal Research and Education Hospital, Department of Neurosurgery, Istanbul, Turkey.

Aim: The correlation between hematoma volume and outcome in ruptured arteriovenous malformations (AVM) with accompanying posterior fossa hematoma was retrospectively evaluated.

Material And Methods: Microsurgery operations were performed on 127 patients with intracranial AVM between January 1998 and January 2009 at our clinic. Fifteen (11.8%) patients were identified as suffering from posterior fossa AVM, and twelve of these patients presented with a cerebellar hematoma. All patients were clinically evaluated according to the following criteria: modified Rankin Scale (mRS) prior to surgery, Spetzler-Martin grade (SMG) of the AVMs, hematoma volume prior to surgery, and mRS following surgery.

Results: Postoperative mRS scores were significantly lower than preoperative scores (p=0.0001). Postoperative outcomes were concordant with the SMG of the AVMs (r=0.67, p=0.033), hematoma volume (r=0.537, p=0.072) and preoperative mRS scores (r=0.764, p=0.004). These analyses show that the postoperative mRS score is strongly correlated with a preoperative mRS score, hematoma volume and SMG.

Conclusion: Posterior fossa AVMs present an increased risk for hemorrhage and for increased morbidity and mortality. Cases with hematoma should be operated on an urgent basis. We conclude that hematoma volume is a factor that impacts postoperative results and prognosis. SMG and preoperative mRS scores were also correlated with outcome.
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http://dx.doi.org/10.5137/1019-5149.JTN.3401-10.0DOI Listing
September 2011

When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale?

World Neurosurg 2011 Feb;75(2):307-13

Department of Neurosurgery, Sisli Research and Education Hospital, Istanbul, Turkey.

Objective: To evaluate the effect of duraplasty based on cerebellar tonsillar descent (CTD) grade in the surgical treatment of Chiari malformation type I (CM-I).

Methods: Medical records and magnetic resonance imaging (MRI) scans of 82 patients with surgical correction of CM-I performed at the authors' clinic from 1998-2009 were reviewed. The preoperative CTD grading scale was obtained. Patients were divided two groups: duraplasty group (group 1) and nonduraplasty group (group 2). The preoperative and postoperative size of the syringomyelia cavity, Japanese Orthopaedic Association (JOA) scores, recovery rate, and postoperative complications were determined.

Results: There was 58 patients in group 1, who underwent combined foramen magnum decompression, C1 (and C2 if necessary) laminectomy, and duraplasty; the 24 patients in group 2 underwent posterior fossa decompression (PFD) alone with no dural opening performed. There were no statistically significant differences between preoperative and postoperative size of the syringomyelia cavity and JOA scores of duraplasty (group 1) and nonduraplasty (group 2) groups in CTD grades 1 and 2; in CTD grade 3, the decrease in syrinx cavity and clinical improvement were statistically better in group 1 compared with group 2 (P < 0.05). Complications in group 1 were statistically significantly increased compared with group 2 (P < 0.05).

Conclusions: This study shows that PFD and duraplasty for the treatment of CTD grade 3 Chiari malformation may lead to a more reliable reduction in the volume of concomitant syringomyelia and JOA scores. In CTD grade 1 and 2 patients, PFD without duraplasty may be performed.
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http://dx.doi.org/10.1016/j.wneu.2010.09.005DOI Listing
February 2011