Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: A single center-experience

INTRODUCTION AND OBJECTIVES

We aimed to assess the outcomes of patients with trigeminal neuralgia (TGN) who underwent Gamma Knife radiosurgery (GKRS).

MATERIALS AND METHODS

Fifty-three patients with typical TGN underwent GKRS from May 2012 until December 2022. Among these patients, 45 patients who were follow-up for at least 12 months were included in the study. A mean dose of 87.5 Gy (range, 80-90) was administered to the trigeminal nerve. Postoperatively, outcome was considered excellent if the patient was pain- and medication-free.

RESULTS

The mean symtpom duration was 9.53 years, and the mean patient age was 59.8 years (range, 34-85). The mean follow-up period was 46.8 months (range, 12-127 months). 46.7% of patients had a history of previous surgical interventions. A single nerve division was affected in 14 patients (31.1%), and multiple divisions were affected in 31 patients (68.9%). The rate of initial pain relief was 80%. Hypoesthesia in the area of trigeminal nerve developed in 30 (66.7%). Twenty patients (44.4%) exhibited excellent results within 72.4 months. Recurrence occurred in 11 patients (24.4%) with 27.6 months.

CONCLUSIONS

Our results suggest that GKRS is a safe and effective procedure. Thus, it is an attractive first- and second-line treatment choice for TGN.

Combined thalamic and pallidal deep brain stimulation in diabetic hemiballism/hemichorea

Hemiballism/Hemichorea (HH) is a hyperkinetic movement disorder observed mostly after cerebrovascular diseases in elderly patients. Even though the improvement in symptoms would be maintained without treatment, in rare cases, lesioning or DBS (deep brain stimulation) surgery provide a chance on relieving the severe involuntary movements. HH is a more rarely reported entity as a diabetic complication and we encountered very few cases treated with surgical intervention for diabetic HH. A 75-year-old female patient with type-II diabetes mellitus was admitted for left-sided disabling involuntary movement despite being medically treated for six months. A GPi (globus pallidus internus) and thalamic Vim (ventral intermediate) nucleus targeted DBS surgery was performed. Complete resolution was achieved with combined stimulation at 1.7 mA of thalamic Vim nucleus and 2.4 mA of GPi. Combined stimulation of thalamic Vim nucleus and GPi resulted in an effective treatment method for HH secondary to diabetes in our case. Even if the rarity of the cases treated surgically withholds us to come to a certain conclusion, it provides a new option to treat HH to our experience.

Memantine and Q-VD-OPh Treatments in Experimental Spinal Cord Injury: Combined Inhibition of Necrosis and Apoptosis

AIM

To evaluate the effects of NMDA receptor antagonist memantine and pancaspase inhibitor Q-VD-Oph in combination or alone in experimental spinal cord injury.

MATERIAL AND METHODS

45 male Sprague-Dawley rats were divided into five groups. Spinal cord injury was created with the clip compression technique. The drugs were administered either alone of in combination to the subjects according to their groups. Motor function was assessed with Tarlov's motor grading scale and the inclined plane technique. The subjects were sacrificed at the fifth postoperative day. Histopathological examination was done with the use of hematoxylin eosin and TUNEL staining.

RESULTS

The results for TUNEL staining and apoptotic cell counts revealed statistically significant differences in Q-VD-Oph and combined treatment groups. Tarlov motor grading scale and inclined plane test results were also found significantly better in these two groups.

CONCLUSION

Combined use of memantine and Q-VD-OPh provides better histological and clinical results. The combined inhibition of the two major pathways, necrosis and apoptosis, needs to be further assessed with in-vivo or in-vitro studies.

Neuronavigation-assisted percutaneous balloon compression for the treatment of trigeminal neuralgia: The technique and short-term clinical results

BACKGROUND

Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia. However, this technique has a steep learning curve and significant complications were reported that were related to foramen ovale puncturing. The aim of this study was to evaluate the clinical results of a small patient group who underwent neuronavigation-assisted PBC.

METHODS

An intraoperative computed tomography (CT) device (CereTom, Neurologica, Danvers, MA/USA) was used to obtain CT scans with 2-mm slice thicknesses. The data were transferred to a neuronavigation system planning station (BrainLab, Feldkirchen, Germany). A soft touch registration system was used for image registration. With the image guidance, a trajectory was defined and the foramen ovale was cannulated using neuronavigation and Hartel's landmarks.

RESULTS

Sixteen procedures were performed on 13 patients (4 female and 9 male) without complications. The total length of the procedure was not more than 57 min in all instances.

CONCLUSIONS

We believe that image-guided neuronavigation is useful for neurosurgeons who are at the beginning of their PBC learning curve. It may also be an alternative for particular patients with significant anatomic variations that result in an unsuccessful foramen ovale puncture.

A malignant transformation of a spinal epidural mass from ganglioneuroblastoma to neuroblastoma

Ganglioneuromas are benign tumors. Surgical excision is the treatment of choice with very good prognosis. However, neuroblastomatous malignant transformation of ganglioneuromas was previously reported. We report a patient with spinal neuroblastoma recurrent from a ganglioneuroblastoma after disease free survival of 13 years. This is one of the rare examples of spinal neuroblastoma and to our knowledge the second case report with malignant transformation from a ganglioneuroblastoma or a ganglioneuroma. The present case is the only report in the literature with further genetic investigations.

Microsurgical training model for residents to approach to the orbit and the optic nerve in fresh cadaveric sheep cranium

Background:

Neurosurgery and ophthalmology residents need many years to improve microsurgical skills. Laboratory training models are very important for developing surgical skills before clinical application of microsurgery. A simple simulation model is needed for residents to learn how to handle microsurgical instruments and to perform safe dissection of intracranial or intraorbital nerves, vessels, and other structures.

Materials and Methods:

The simulation material consists of a one-year-old fresh cadaveric sheep cranium. Two parts (Part 1 and Part 2) were designed to approach structures of the orbit. Part 1 consisted of a 2-step approach to dissect intraorbital structures, and Part 2 consisted of a 3-step approach to dissect the optic nerve intracranially.

Results:

The model simulates standard microsurgical techniques using a variety of approaches to structures in and around the orbit and the optic nerve.

Conclusions:

This laboratory training model enables trainees to gain experience with an operating microscope, microsurgical instruments and orbital structures.

Unilateral endoscopic optic nerve decompression for idiopathic intracranial hypertension: a series of 10 patients

OBJECTIVE

Several surgical treatment modalities, including lumboperitoneal or ventriculoperitoneal shunt surgery, subtemporal decompression, endovascular venous sinus stenting, optic nerve decompression (OND), were used in the management of idiopathic intracranial hypertension (IIH). Each surgical technique has different advantages and disadvantages. Endoscopic OND is rarely used in the management of IIH. There are only four reported cases. The aim of this study is to describe the surgical results of patients treated with this less invasive surgical technique.

METHODS

A series of 10 consecutive cases of unilateral OND was reviewed. Between December 2008 and December 2012 these patients underwent the endoscopic approach without nerve sheath opening. Presenting symptoms, neurological examination findings, magnetic resonance venography imaging results, fundoscopic and visual acuity examination findings, and automated perimetry test results were recorded. Perioperative results, including complications and length of hospital stay, were evaluated. Findings at follow-up evaluations were also recorded.

RESULTS

This report is the first series of unilateral OND performed using the endoscopic approach. The mean patient age was 34.1 years (range, 9-49 years); there were nine female and one male patients. Visual impairment was the main symptom in this patient group, whereas headache was a secondary complaint. The patients were first managed with medical treatment for at least 3 months. Unilateral endoscopic OND was performed on the side with the most visual failure. Mean follow-up was 28.4 months (range, 8-55 months). The visual field defects and visual acuity improved in eight of nine patients, whereas papilloedema improved in seven of nine patients. Also headaches resolved in four of seven patients. There were no complications in this relatively small series.

CONCLUSIONS

The surgical treatment of IIH by using the unilateral endoscopic OND technique is a safe and effective method in the hands of experienced surgeons with advanced endoscopic skills. A collaboration with the ophthalmology team is needed for the follow-up. Further studies with larger patient numbers is needed to compare unilateral endoscopic OND technique with the current techniques used in the surgical management of IIH.

Emergency management of an acute tension pneumocephalus following ventriculoperitoneal shunt surgery for normal pressure hydrocephalus

Tension pneumocephalus is a rare and life threatening complication of intracranial surgical procedures, and requires immediate recognition and surgical intervention. Tension pneumocephalus following ventriculoperitoneal shunt surgery is extremely rare and commonly seen as a delayed complication. To our knowledge, early postoperative tension pneumocephalus after shunt surgery was reported only in one other publication. We present a case of acute tension pneumocephalus following ventriculoperitoneal shunt surgery for normal pressure hydrocephalus, which was managed well with close neurological follow-up and rapid surgical intervention. The use of the portable CT scanner in this case saved significant time, without the transport of the patient to the radiology unit, made early surgical intervention possible, and prevented morbidity and mortality.

Primary multiple cerebral hydatid disease: still symptomatic despite pathologically confirmed death of the cyst

Hydatid disease is a life-threatening parasitic infestation caused by Echinococcus granulosus. Infection with E. granulosus typically results in the formation of hydatid cysts in liver, lungs, kidney and spleen. Majority of the intracranial cysts are secondary and solitary. Multiple primary cerebral cysts are uncommon. Surgical and medical management of a 14-year-old boy with multiple primary hydatid cysts are presented. 14 cysts, which were symptomatic due to their mass effect, were surgically removed, whereas a deep-seated asymptomatic cyst was followed-up with medical treatment. Despite proper antibiotic regimen the patient was admitted with epileptic seizures six months later. The deep-seated lesion was also surgically removed. Intraoperative observations and pathological examination demonstrated different characteristics, with pericystic gliosis, gel-like cyst content and death scolices within the cavity. In addition to the fact, that the presented case is an additional example for the rare primary multiple cerebral hydatid cysts, to our knowledge it is the first case of a dead cerebral hydatid cyst, causing symptoms despite effective medical treatment.

Effects of sodium hyaluronate and methylprednisolone alone or in combination in preventing epidural fibrosis

OBJECTIVE

Epidural fibrosis and leptomeningeal adhesion formation are common causes of failed back surgery syndrome (FBSS). We employed a rat model of lumbar laminectomy to evaluate the histopathological effects of sodium hyaluronate (HA) and methylprednisolone (MP) alone or in combination on post-laminectomy epidural fibrosis.

METHODS

Thirty-two male Sprague-Dawley rats were divided into four groups. All rats underwent three-level lumbar laminectomy. In the treatment groups, HA solution, MP, or a combination of both was applied locally to the epidural spaces of the laminectomy fields. No neurological deficits or pathological wound site changes were observed in any of the groups. At the end of the sixth week, all rats were sacrificed, and the laminectomy vertebral column areas were removed en-bloc. Specimens were evaluated by an expert neuropathologist according to histopathological criteria.

RESULTS

The results of the three treatment groups were separately compared with the control group to assess epidural fibrosis. Minimal reduction in the rate of epidural fibrosis was observed in the groups treated with HA or MP compared with the control group. However, no significant difference in epidural fibrosis was noted between the combined treatment group and the control group.

CONCLUSIONS

Our study showed that MP and HA, given separately, significantly reduce post-laminectomy epidural fibrosis; however, the combination of these drugs is not effective. Further investigation is needed to address the causative drug interactions.

Peroneal and tibial intraneural ganglion cysts in children

BACKGROUND/AIMS

Intraneural ganglion cyst is a rare and underrecognized clinical entity in the pediatric population, which may cause pain as well as motor and sensory neurological deficits. This study presents 4 pediatric patients harboring ganglion cysts involving the peroneal and tibial nerves.

METHODS

Data encompassing pre- and postoperative analyses of 4 pediatric patients with intraneural ganglion cyst was evaluated.

RESULTS

Out of these 4 patients, 3 had an intraneural ganglion cyst involving the peroneal nerve, and 1 patient had his tibial nerve involved. Two patients were operated for recurrent ganglion cysts with severe postoperative neurological deficits, after preceding operations in other institutions. The other 2 patients had no history of previous surgery, and they had their initial surgical treatment in our institute for primarily diagnosed ganglion cysts. With a mean follow-up of 24 months, all patients experienced pain relief. Significant improvement of motor deficits was achieved in 3 patients. No recurrences were encountered during the 24-month follow-up.

CONCLUSION

Intraneural ganglion cysts in children can be treated with excellent outcome in experienced and dedicated centers, which specialize in peripheral nerve microsurgery.

Cervical intradural glass fragment: a rare cause of neuropathic pain

Intradural foreign bodies after penetrating injuries are seen very rarely. Limited number of cases of glass fragments in the spinal canal were reported previously. Migration of foreign bodies and delayed onset of neurological symptoms due to foreign bodies were also reported. In this report a 33-year-old male patient was presented, who had penetration of glass fragments through oropharyngeal mucosa in to the spinal canal after crashing into a glass door. Glass fragment, which migrated through an unusual route, and reached cervical spinal intradural space, caused neuropathic pain with radicular symptoms, 21 years after the initial injury. This case report emphasize that after penetrating injuries of spine, foreign bodies may remain silent until the patient became symptomatic years after the initial injury and these foreign bodies may migrate to extreme distant and unexpected locations in the central nervous system.

Posterior fossa epidural hematomas in children: clinical experience with 40 cases

OBJECT

Traumatic posterior fossa epidural hematoma (PFEDH) is rare, but among children it may have a slightly higher incidence. With the widespread use of CT scanning, the diagnosis of PFEDH can be established more accurately, leading to an increased incidence of the lesion and possibly to a better patient prognosis. This study presents 40 pediatric cases with PFEDH.

METHODS

The authors assessed the type of trauma, clinical findings on admission, Glasgow Coma Scale scores, CT findings (thickness of the hematoma, bone fracture, compression of the fourth ventricle, and ventricle enlargement), type of treatment, clinical course, and prognosis. Early postoperative CT scans (within the first 6 hours) were obtained and reviewed in all surgical cases.

RESULTS

Twenty-nine patients underwent surgery and 11 patients received conservative therapy and close follow-up. All patients fared well, and there was no surgical mortality or morbidity.

CONCLUSIONS

Based on the data in this large series, the authors conclude that PFEDH in children can be treated in experienced centers with excellent outcome, and there is no need to avoid surgery when it is indicated.

Ascending transaqueductal cystoventriculoperitoneal shunting in Dandy-Walker malformation: technical note

The optimal treatment for Dandy-Walker malformation is still controversial. Ventriculoperitoneal shunting, cystoperitoneal shunting or combinations are the most common surgical options in the management of this clinical entity. Endoscopic procedures like ventriculocystostomy, 3rd ventriculostomy or endoscopy-assisted shunt surgeries have become the focus of recent publications. We describe a new transcystic endoscopic technique, with the usage of a single ascending transaqueductal shunt catheter with additional holes, whereby both the posterior fossa cyst and supratentorial ventricular compartments are drained effectively. By using this new technique complications associated with combined shunting can be avoided. In addition, by equalizing the pressure within the supra- and infratentorial compartments, the upward or downward herniations associated with single-catheter shunting can be prevented.

Bone marrow necrosis secondary to imatinib usage, mimicking spinal metastasis on magnetic resonance imaging and FDG-PET/CT

Imatinib mesylate has become the treatment of choice for gastrointestinal stromal tumors (GISTs) and has made a revolutionary impact on survival rates. Bone marrow necrosis is a very rare adverse event in malignant GIST. Bone metastases are also rarely encountered in the setting of this disease. The authors report on a patient with malignant GIST who developed a bone lesion, mimicking spinal metastasis on both MR imaging and FDG-PET/CT. Corpectomy and anterior fusion was performed, but the pathology report was consistent with bone marrow necrosis. Radiological and clinical similarities made the distinction between metastasis and bone marrow necrosis challenging for the treating physicians. Instead of radical surgical excision, more conservative methods such as percutaneous or endoscopic bone biopsies may be more useful for pathological confirmation, even though investigations such as MR imaging and FDG-PET/CT indicate metastatic disease.