Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rath... more Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rathke's pouch and are located in the sellar, parasellar, and third ventricular regions. Despite major advances in microsurgical techniques, total removal of these tumors is associated with a high risk of death, long-term endocrinological dependence, cognitive dysfunction, and behavioral disorders. For patients with monocystic craniopharyngiomas, encouraging postoperative survival rates and high rates of cyst regression after intracavitary administration of bleomycin have been reported. Moreover, only a few side effects have been reported for this treatment method. We report a patient with a cystic craniopharyngioma who was treated using intracavitary bleomycin administration and died as a result of the direct toxic effects of bleomycin on deep brain structures and the brainstem. A 47-year-old woman with a cystic craniopharyngioma underwent stereotactic insertion of a catheter attached to a subcutaneous reservoir. Five months after the procedure, positive-contrast computed tomographic cystography was performed to confirm the absence of fluid leakage. Daily intracavitary injections of bleomycin were administered through the reservoir into the cyst, until a total dose of 56 mg had been administered in 8 days. After the treatment, the cystic cavity regressed but the patient exhibited neurological deterioration; magnetic resonance imaging scans revealed diffuse edema in the diencephalon and brainstem. The patient died 45 days after completion of the treatment. Intracavitary administration of bleomycin is not a treatment protocol without risks or side effects, even if there is no fluid leakage into the cerebrospinal fluid. Although this is known to be an effective treatment for cystic craniopharyngiomas, previous reports cannot be used to establish a standard treatment method, and more research is needed to yield a safer effective protocol.
Dystonia ؒ Dorsal root entry zone operation ؒ Thalamotomy ؒ Campotomy ؒ Pallidotomy Abstract Seve... more Dystonia ؒ Dorsal root entry zone operation ؒ Thalamotomy ؒ Campotomy ؒ Pallidotomy Abstract Several medical and surgical procedures have been presented for treatment of dystonia. Thalamotomy, pallidotomy, and campotomy are some of the surgical choices. This study presents a patient with dystonia who underwent a cervical dorsal root entry zone (DREZ) operation after thalamotomy and campotomy. A 23-yearold man who was resistant to medical treatment presented with left hemidystonia. Thalamotomy and campotomy were performed. The patient remarkably benefi ted from the procedure but dystonic complaints in his left arm continued. A cervical DREZ operation was performed 5 years after the fi rst operation and the dystonic complaints decreased after the surgery. This article presents a new aspect for the treatment of dystonia. Based on the outcomes of the treatment, DREZ operation may be suggested as an alternative surgical treatment for patients with segmental dystonia located in the extremities.
Percutaneous bilateral cordotomy performed using conventional techniques may cause the patient to... more Percutaneous bilateral cordotomy performed using conventional techniques may cause the patient to develop sleep-induced apnea due to bilateral destruction of the ventrolateral reticulospinal tract. Computerized tomography (CT)-guided percutaneous cordotomy using a newly designed needle electrode system has the advantages of safe, selective, and controlled lesioning under direct visualization in the lateral spinothalamic tract. Given its low complication rate, bilateral selective cordotomy performed with CT guidance using this new needle electrode system may prove to be the treatment of choice for cancer patients with bilateral pain of the lower trunk and extremities. The present series included five cancer patients suffering from intractable pain bilaterally in the lower trunk and extremities. All were treated with CT-guided bilateral selective cordotomy: the results demonstrate that this technique may be used effectively and safely.
Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to ch... more Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to chronic inflammation for which no cause such as infection, specific granulomatous disease, or malignancy is demonstrable. We present a case of IHCP with perifocal brain edema suggesting mass lesion with its magnetic resonance imaging (MRI) and pathologic findings. A 36-year-old woman was admitted to our hospital in August 2001
The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tracto... more The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. METHODS: In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients' pain scores and Karnofsky Performance Scale scores were evaluated pre-and postoperatively (postoperative Day 1).
Background: Appropriate management of progressive, unverified brain lesions should be guided by c... more Background: Appropriate management of progressive, unverified brain lesions should be guided by conclusive pathological diagnosis. Stereotactic biopsy (SB) is established as a less invasive surgical procedure that provides diagnosis. In this prospective study, we analyzed the diagnostic difficulties and risk of SB in the various brain mass lesions, the rate of conclusive pathological diagnosis, and the rate of and the reasons for discrepancy between the intraoperative smear results and conclusive paraffin diagnosis. Methods: Using computed tomography (CT) and/or magnetic resonance imaging (MRI), 130 cases underwent SB procedure to assess intra-axial brain mass lesions. A CT-MRI fusion and a multiplanar image processing stereotactic program were used in cases who had lesions adjacent to the neurovascular and critical areas. The intraoperative evaluations were made with the smear preparations (SPs) of 1 or 2 biopsy specimens. The conclusive diagnosis was achieved by paraffin preparations of the remainder of the biopsies. The discrepancy between the smear results and the conclusive diagnosis was analyzed. Results: Conclusive histopathologic diagnosis was achieved in 99.23% of the cases. A discrepancy between smear results and conclusive diagnosis was detected in 6.98% of the conclusively diagnosed cases. The major reasons for the discrepancy were necrosis and improper quality of the preparations. There was no mortality, and hemorrhage-related morbidity was observed in 1 case (0.7%). Conclusions: Necrosis and the improper quality of the SPs can cause difficulties in establishing a histopathologic diagnosis in SB. Small tissue samples do not decrease the diagnostic yield with the new stereotactic technologies used by an experienced team consisting of a neurosurgeon, pathologist, and radiologist. D
Primary malignant brain tumor is the second most common cancer in children. To investigate factor... more Primary malignant brain tumor is the second most common cancer in children. To investigate factors affecting children's survival at a population level, data of 3,169 patients (age<15 years) from the Cancer Registry in England and Wales were used. They were diagnosed during 1971-1990 and followed up until 1995. Variables including age, gender, morphology, WHO grade, tumor site, socioeconomic status, geographical region, and period of diagnosis were available for analysis using the Kaplan-Meier method and the Cox hazards ratio (HR) regression. Results showed that the median survival and the 1-, 5-, and 10-year crude survival rate for this population were 8.7 years, 72.4, 54.0, and 49.2% respectively. Survival was influenced by age (HR 0.88/5 years), morphology (ependymoma HR 2.43), WHO grades (HR 1.42/grade), tumor sites (brain stem HR 2.11), and periods of diagnosis (HR 0.88/5 years). Gender, socioeconomic status, and geographical region did not affect their survival. Results from this population-based data are very helpful for comparison with other hospital-based studies and for public health purposes.
Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal n... more Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal neuralgia: vascular decompression of the trigeminal root in the brainstem, percutaneous trigeminal ganglion procedures, and external beam radiosurgery. Percutaneous radiofrequency electrodes target the trigeminal fibers in the gasserian ganglion through the foramen ovale. Several complications of radiofrequency trigeminal rhizotomy (RF-TR) have been described, including puncture of the carotid artery, the cavernous sinus, and the cranial nerves. This study presents a very rare complication of percutaneous RF-TR, rhinorrhea, and attempts to define its mechanism. Of 2375 patients with idiopathic trigeminal neuralgia who underwent 2958 percutaneous RF-TR procedures, 3 developed subsequent rhinorrhea, which resolved spontaneously in 2 to 3 days. Two formalin-fixed cadavers were dissected to demonstrate the relationship between the foramen ovale and the tuba auditiva and the mechanism of rhinorrhea. This article presents a very rare complication of RF-TR. Rhinorrhea and/or cerebrospinal fluid fistulae in the nasopharyngeal cavity are benign complications of RF-TR that result from puncturing both the membranous portion of the tuba auditiva (eustachian tube) and Meckel's cave with the rhizotomy needle.
Idiopathic inflammatory trigeminal sensory neuropathy (IITSN) is a disorder with the dominant cli... more Idiopathic inflammatory trigeminal sensory neuropathy (IITSN) is a disorder with the dominant clinical features of trigeminal sensory disturbance; this idiopathic condition follows a benign course in most cases. Recent reports have shown that transient abnormalities, which may mimic those of trigeminal neuromas, can be observed in magnetic resonance imaging scans. Presented here is a case of IITSN that was diagnosed, with cytological and histopathological verification, during the active inflammatory phase of the disease (the first such attempt, to our knowledge). A 20-year-old female patient was referred to our hospital with a 2-month history of numbness of the left side of her face, headache, and hemifacial pain attacks. Cranial magnetic resonance imaging scans revealed a mass above and below the foramen ovale, extending into the cavernous sinus. A percutaneous biopsy procedure through the foramen ovale was performed; the pathological examination revealed lymphocytes, macrophages, and endothelial cells but no evidence of neoplastic cells. A few days later, the patient was surgically treated using a cranial base approach, the gasserian ganglion was exposed, and the lesion was removed. Pathological examination of the specimens revealed inflammatory changes and fibrosis of the nerve fibers and ganglion cells. Disruption of the myelin around the nerve bundles was detected. Therefore, IITSN was pathologically confirmed during the early stage of the disease. During 3 months of follow-up monitoring, the patient experienced no serious clinical problems. IITSN should be suspected in cases of tumors involving the cavernous sinus, and a percutaneous biopsy through the foramen ovale should be performed as part of the differential diagnosis in such cases. This procedure might obviate unnecessary aggressive surgery. In the current case, no neoplastic cells were observed during the examination; only lymphocytes, macrophages, and endothelial cells were observed, on a background of erythrocytes. Lymphocyte-dominant inflammatory infiltration, fibrotic changes, and demyelinization are cardinal histopathological findings observed during the active phase of IITSN.
Chiari Type I malformation is an important pathological state in which the brainstem is compresse... more Chiari Type I malformation is an important pathological state in which the brainstem is compressed by the cerebellar tonsil. We present a case of glossopharyngeal neuralgia caused by Chiari Type I malformation. A 50-year-old male patient was admitted with glossopharyngeal neuralgia. Magnetic resonance imaging studies revealed caudal displacement of the left cerebellar tonsil. Small occipital craniectomy and C1 laminectomy were performed. The left cerebellar tonsil was resected. This glossopharyngeal neuralgia was caused by compression of the lower cranial nerves and brainstem by the displaced left cerebellar tonsil. Decompression and pain relief were obtained with resection of the cerebellar tonsil. The patient was pain-free 30 weeks after the operation.
OBJECTIVE: The objective of this study was to evaluate the effectiveness of percutaneous, control... more OBJECTIVE: The objective of this study was to evaluate the effectiveness of percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR). The outcome of 1600 patients with idiopathic trigeminal neuralgia after RF-TR was analyzed after a follow-up period of 1 to 25 years. METHODS: A total of 1600 patients with idiopathic trigeminal neuralgia underwent 2138 percutaneous radiofrequency rhizotomy procedures between 1974 and 1999. Sixty-seven patients had bilateral idiopathic trigeminal neuralgia, and 36 of them were treated with bilateral RF-TR; 1216 patients (76%) were successfully managed with a single procedure, and the remainder were treated with multiple procedures. Benzodiazepines and narcotic analgesics were used for anesthesia because patient cooperation during the procedures was essential so that the physician could create selective, controlled lesions. RESULTS: The average follow-up time was 68.1 ؎ 66.4 months (range, 12-300 mo). Acute pain relief was accomplished in 97.6% of patients. Complete pain relief was achieved at 5 years in 57.7% of the patients who underwent a single procedure. Pain relief was reported in 92% of patients with a single procedure or with multiple procedures 5 years after the first rhizotomy was performed. At 10-year follow-up, 52.3% of the patients who underwent a single procedure and 94.2% of the patients who underwent multiple procedures had experienced pain relief; at 20-year follow-up, 41 and 100% of these patients, respectively, had experienced pain relief. No mortalities occurred. After the first procedure was performed, early pain recurrence (<6 mo) was observed in 123 patients (7.7%) and late pain recurrence was observed in 278 patients (17.4%). Complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1%), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis of Cranial Nerves III and VI in 12 (0.8%). Permanent Cranial Nerve VI palsy was observed in two patients, cerebrospinal fluid leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one. CONCLUSION: Percutaneous, controlled RF-TR represents a minimally invasive, low-risk technique with a high rate of efficacy. The procedure may safely be repeated if pain recurs. (Neurosurgery 48:524-534, 2001)
Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgi... more Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia. Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients. Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC. The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.
Neurodestructive procedures have been used for treating intractable pain for a long time. Pulsed ... more Neurodestructive procedures have been used for treating intractable pain for a long time. Pulsed radiofrequency (RF) is a newly defined energy type. Pulsed RF may be used in the treatment of patients with some pain syndromes in whom the pain could not be controlled by the alternative techniques. The objective of the present study was to examine the histological and electron microscopical changes in rat brain after pulsed RF application. Forty-five male rats were used in these experiments. Lesions were applied stereotactically to the target areas of the rat brains. Two different RF energy type were used as representative models of pulsed-RF and conventional-RF procedures. The rats were kept alive for 21 days and then killed. The effect of pulsed RF lesions on cerebral tissue ultrastructure was studied. In the pulsed RF group, intracytoplasmic edema, clarity of the mitochondrial cristas and opening in the cell membrane pores were observed on the electron microscopic examination. In the conventional RF group, these findings were more prominent. In the pulsed RF group, the ratio of the effected neurons was 5.5% on light microscopic examination. In the conventional RF group, the ratio of the effected neurons was 14.26% and central necrosis was observed additionally. Pulsed RF caused ultrastructural changes in the neurons. The pulsed RF may possibly cause a depression on the cell membrane potential by opening the cell membrane pores and resulting in the ion entrance into the cell cytoplasm and intracytoplasmic edema. However, it seems that all these changes were reversible.
We present a surgical series of 35 patients (25 males and 10 females) with histopathologically ve... more We present a surgical series of 35 patients (25 males and 10 females) with histopathologically verified intracranial cavernous angiomas. The 35 malformations were located as follows: 21 were in the cerebral hemispheres; 4 in the lateral ventricles, 4 in the brain stem; and 6 in the cerebellum. Seizures and focal neurological deficits were the main clinical features observed in patients with intracranial cavernous angiomas. A number of these vascular malformations were misdiagnosed by computerized tomography. In the last 10 years, magnetic resonance imaging has been the most sensitive method for detecting these lesions. Thirty-five cavernous angiomas were treated surgically; in 33 patients a complete excision, and in 2 patients subtotal excision were obtained. One of the patients died one year after the operation. The overall outcome was good in all of the 34 remaining patients, resulting in improved seizure control or neurological deficit. The rationale for neurologic differential diagnosis and surgical treatment and follow up results are discussed.
BackgroundAtypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar regio... more BackgroundAtypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar region, often radiating to the ear, neck, and shoulders. The pain generally is not within any dermatomal or anatomical boundaries. Atypical facial pain is distinct from trigeminal neuralgia and its variants. Therefore, the treatment of AFP should be specified. There is also no consensus in
Malignant mesotheliomas are neoplasms that arise from mesothelial cells and cause intractable pai... more Malignant mesotheliomas are neoplasms that arise from mesothelial cells and cause intractable pain in the chest wall, usually located unilaterally. This local pain can be well controlled by computerized tomography (CT)-guided percutaneous cordotomy (PC). One hundred and fifty-three patients suffering from intractable pain due to malignancy were treated with CT-guided cordotomy between 1988 and 2001. Seventy of the 153 patients had pulmonary malignancy. Among these, 40 had bronchogenic carcinoma, 11 had Pancoast tumors and the remaining 19 had mesothelioma. The latter 19 cases with malignant mesothelioma suffering from unilateral pain were treated with CT-guided PC. In 18 cases, pain was controlled totally and, in one, partial pain control was obtained. Selective pain control was obtained in 15 cases, in whom narcotic drugs were discontinued postoperatively. Post-cordotomy dysesthesia was noted in only one case, and no complication or mortality was observed. In the treatment of intractable pain, CT-guided cordotomy is a perfect method in selected cases with malignancy. This is the most effective and suitable treatment modality for local pain due to malignant mesothelioma.
Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rath... more Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rathke&#39;s pouch and are located in the sellar, parasellar, and third ventricular regions. Despite major advances in microsurgical techniques, total removal of these tumors is associated with a high risk of death, long-term endocrinological dependence, cognitive dysfunction, and behavioral disorders. For patients with monocystic craniopharyngiomas, encouraging postoperative survival rates and high rates of cyst regression after intracavitary administration of bleomycin have been reported. Moreover, only a few side effects have been reported for this treatment method. We report a patient with a cystic craniopharyngioma who was treated using intracavitary bleomycin administration and died as a result of the direct toxic effects of bleomycin on deep brain structures and the brainstem. A 47-year-old woman with a cystic craniopharyngioma underwent stereotactic insertion of a catheter attached to a subcutaneous reservoir. Five months after the procedure, positive-contrast computed tomographic cystography was performed to confirm the absence of fluid leakage. Daily intracavitary injections of bleomycin were administered through the reservoir into the cyst, until a total dose of 56 mg had been administered in 8 days. After the treatment, the cystic cavity regressed but the patient exhibited neurological deterioration; magnetic resonance imaging scans revealed diffuse edema in the diencephalon and brainstem. The patient died 45 days after completion of the treatment. Intracavitary administration of bleomycin is not a treatment protocol without risks or side effects, even if there is no fluid leakage into the cerebrospinal fluid. Although this is known to be an effective treatment for cystic craniopharyngiomas, previous reports cannot be used to establish a standard treatment method, and more research is needed to yield a safer effective protocol.
Dystonia ؒ Dorsal root entry zone operation ؒ Thalamotomy ؒ Campotomy ؒ Pallidotomy Abstract Seve... more Dystonia ؒ Dorsal root entry zone operation ؒ Thalamotomy ؒ Campotomy ؒ Pallidotomy Abstract Several medical and surgical procedures have been presented for treatment of dystonia. Thalamotomy, pallidotomy, and campotomy are some of the surgical choices. This study presents a patient with dystonia who underwent a cervical dorsal root entry zone (DREZ) operation after thalamotomy and campotomy. A 23-yearold man who was resistant to medical treatment presented with left hemidystonia. Thalamotomy and campotomy were performed. The patient remarkably benefi ted from the procedure but dystonic complaints in his left arm continued. A cervical DREZ operation was performed 5 years after the fi rst operation and the dystonic complaints decreased after the surgery. This article presents a new aspect for the treatment of dystonia. Based on the outcomes of the treatment, DREZ operation may be suggested as an alternative surgical treatment for patients with segmental dystonia located in the extremities.
Percutaneous bilateral cordotomy performed using conventional techniques may cause the patient to... more Percutaneous bilateral cordotomy performed using conventional techniques may cause the patient to develop sleep-induced apnea due to bilateral destruction of the ventrolateral reticulospinal tract. Computerized tomography (CT)-guided percutaneous cordotomy using a newly designed needle electrode system has the advantages of safe, selective, and controlled lesioning under direct visualization in the lateral spinothalamic tract. Given its low complication rate, bilateral selective cordotomy performed with CT guidance using this new needle electrode system may prove to be the treatment of choice for cancer patients with bilateral pain of the lower trunk and extremities. The present series included five cancer patients suffering from intractable pain bilaterally in the lower trunk and extremities. All were treated with CT-guided bilateral selective cordotomy: the results demonstrate that this technique may be used effectively and safely.
Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to ch... more Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to chronic inflammation for which no cause such as infection, specific granulomatous disease, or malignancy is demonstrable. We present a case of IHCP with perifocal brain edema suggesting mass lesion with its magnetic resonance imaging (MRI) and pathologic findings. A 36-year-old woman was admitted to our hospital in August 2001
The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tracto... more The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. METHODS: In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients' pain scores and Karnofsky Performance Scale scores were evaluated pre-and postoperatively (postoperative Day 1).
Background: Appropriate management of progressive, unverified brain lesions should be guided by c... more Background: Appropriate management of progressive, unverified brain lesions should be guided by conclusive pathological diagnosis. Stereotactic biopsy (SB) is established as a less invasive surgical procedure that provides diagnosis. In this prospective study, we analyzed the diagnostic difficulties and risk of SB in the various brain mass lesions, the rate of conclusive pathological diagnosis, and the rate of and the reasons for discrepancy between the intraoperative smear results and conclusive paraffin diagnosis. Methods: Using computed tomography (CT) and/or magnetic resonance imaging (MRI), 130 cases underwent SB procedure to assess intra-axial brain mass lesions. A CT-MRI fusion and a multiplanar image processing stereotactic program were used in cases who had lesions adjacent to the neurovascular and critical areas. The intraoperative evaluations were made with the smear preparations (SPs) of 1 or 2 biopsy specimens. The conclusive diagnosis was achieved by paraffin preparations of the remainder of the biopsies. The discrepancy between the smear results and the conclusive diagnosis was analyzed. Results: Conclusive histopathologic diagnosis was achieved in 99.23% of the cases. A discrepancy between smear results and conclusive diagnosis was detected in 6.98% of the conclusively diagnosed cases. The major reasons for the discrepancy were necrosis and improper quality of the preparations. There was no mortality, and hemorrhage-related morbidity was observed in 1 case (0.7%). Conclusions: Necrosis and the improper quality of the SPs can cause difficulties in establishing a histopathologic diagnosis in SB. Small tissue samples do not decrease the diagnostic yield with the new stereotactic technologies used by an experienced team consisting of a neurosurgeon, pathologist, and radiologist. D
Primary malignant brain tumor is the second most common cancer in children. To investigate factor... more Primary malignant brain tumor is the second most common cancer in children. To investigate factors affecting children&#39;s survival at a population level, data of 3,169 patients (age&lt;15 years) from the Cancer Registry in England and Wales were used. They were diagnosed during 1971-1990 and followed up until 1995. Variables including age, gender, morphology, WHO grade, tumor site, socioeconomic status, geographical region, and period of diagnosis were available for analysis using the Kaplan-Meier method and the Cox hazards ratio (HR) regression. Results showed that the median survival and the 1-, 5-, and 10-year crude survival rate for this population were 8.7 years, 72.4, 54.0, and 49.2% respectively. Survival was influenced by age (HR 0.88/5 years), morphology (ependymoma HR 2.43), WHO grades (HR 1.42/grade), tumor sites (brain stem HR 2.11), and periods of diagnosis (HR 0.88/5 years). Gender, socioeconomic status, and geographical region did not affect their survival. Results from this population-based data are very helpful for comparison with other hospital-based studies and for public health purposes.
Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal n... more Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal neuralgia: vascular decompression of the trigeminal root in the brainstem, percutaneous trigeminal ganglion procedures, and external beam radiosurgery. Percutaneous radiofrequency electrodes target the trigeminal fibers in the gasserian ganglion through the foramen ovale. Several complications of radiofrequency trigeminal rhizotomy (RF-TR) have been described, including puncture of the carotid artery, the cavernous sinus, and the cranial nerves. This study presents a very rare complication of percutaneous RF-TR, rhinorrhea, and attempts to define its mechanism. Of 2375 patients with idiopathic trigeminal neuralgia who underwent 2958 percutaneous RF-TR procedures, 3 developed subsequent rhinorrhea, which resolved spontaneously in 2 to 3 days. Two formalin-fixed cadavers were dissected to demonstrate the relationship between the foramen ovale and the tuba auditiva and the mechanism of rhinorrhea. This article presents a very rare complication of RF-TR. Rhinorrhea and/or cerebrospinal fluid fistulae in the nasopharyngeal cavity are benign complications of RF-TR that result from puncturing both the membranous portion of the tuba auditiva (eustachian tube) and Meckel&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s cave with the rhizotomy needle.
Idiopathic inflammatory trigeminal sensory neuropathy (IITSN) is a disorder with the dominant cli... more Idiopathic inflammatory trigeminal sensory neuropathy (IITSN) is a disorder with the dominant clinical features of trigeminal sensory disturbance; this idiopathic condition follows a benign course in most cases. Recent reports have shown that transient abnormalities, which may mimic those of trigeminal neuromas, can be observed in magnetic resonance imaging scans. Presented here is a case of IITSN that was diagnosed, with cytological and histopathological verification, during the active inflammatory phase of the disease (the first such attempt, to our knowledge). A 20-year-old female patient was referred to our hospital with a 2-month history of numbness of the left side of her face, headache, and hemifacial pain attacks. Cranial magnetic resonance imaging scans revealed a mass above and below the foramen ovale, extending into the cavernous sinus. A percutaneous biopsy procedure through the foramen ovale was performed; the pathological examination revealed lymphocytes, macrophages, and endothelial cells but no evidence of neoplastic cells. A few days later, the patient was surgically treated using a cranial base approach, the gasserian ganglion was exposed, and the lesion was removed. Pathological examination of the specimens revealed inflammatory changes and fibrosis of the nerve fibers and ganglion cells. Disruption of the myelin around the nerve bundles was detected. Therefore, IITSN was pathologically confirmed during the early stage of the disease. During 3 months of follow-up monitoring, the patient experienced no serious clinical problems. IITSN should be suspected in cases of tumors involving the cavernous sinus, and a percutaneous biopsy through the foramen ovale should be performed as part of the differential diagnosis in such cases. This procedure might obviate unnecessary aggressive surgery. In the current case, no neoplastic cells were observed during the examination; only lymphocytes, macrophages, and endothelial cells were observed, on a background of erythrocytes. Lymphocyte-dominant inflammatory infiltration, fibrotic changes, and demyelinization are cardinal histopathological findings observed during the active phase of IITSN.
Chiari Type I malformation is an important pathological state in which the brainstem is compresse... more Chiari Type I malformation is an important pathological state in which the brainstem is compressed by the cerebellar tonsil. We present a case of glossopharyngeal neuralgia caused by Chiari Type I malformation. A 50-year-old male patient was admitted with glossopharyngeal neuralgia. Magnetic resonance imaging studies revealed caudal displacement of the left cerebellar tonsil. Small occipital craniectomy and C1 laminectomy were performed. The left cerebellar tonsil was resected. This glossopharyngeal neuralgia was caused by compression of the lower cranial nerves and brainstem by the displaced left cerebellar tonsil. Decompression and pain relief were obtained with resection of the cerebellar tonsil. The patient was pain-free 30 weeks after the operation.
OBJECTIVE: The objective of this study was to evaluate the effectiveness of percutaneous, control... more OBJECTIVE: The objective of this study was to evaluate the effectiveness of percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR). The outcome of 1600 patients with idiopathic trigeminal neuralgia after RF-TR was analyzed after a follow-up period of 1 to 25 years. METHODS: A total of 1600 patients with idiopathic trigeminal neuralgia underwent 2138 percutaneous radiofrequency rhizotomy procedures between 1974 and 1999. Sixty-seven patients had bilateral idiopathic trigeminal neuralgia, and 36 of them were treated with bilateral RF-TR; 1216 patients (76%) were successfully managed with a single procedure, and the remainder were treated with multiple procedures. Benzodiazepines and narcotic analgesics were used for anesthesia because patient cooperation during the procedures was essential so that the physician could create selective, controlled lesions. RESULTS: The average follow-up time was 68.1 ؎ 66.4 months (range, 12-300 mo). Acute pain relief was accomplished in 97.6% of patients. Complete pain relief was achieved at 5 years in 57.7% of the patients who underwent a single procedure. Pain relief was reported in 92% of patients with a single procedure or with multiple procedures 5 years after the first rhizotomy was performed. At 10-year follow-up, 52.3% of the patients who underwent a single procedure and 94.2% of the patients who underwent multiple procedures had experienced pain relief; at 20-year follow-up, 41 and 100% of these patients, respectively, had experienced pain relief. No mortalities occurred. After the first procedure was performed, early pain recurrence (<6 mo) was observed in 123 patients (7.7%) and late pain recurrence was observed in 278 patients (17.4%). Complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1%), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis of Cranial Nerves III and VI in 12 (0.8%). Permanent Cranial Nerve VI palsy was observed in two patients, cerebrospinal fluid leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one. CONCLUSION: Percutaneous, controlled RF-TR represents a minimally invasive, low-risk technique with a high rate of efficacy. The procedure may safely be repeated if pain recurs. (Neurosurgery 48:524-534, 2001)
Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgi... more Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia. Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients. Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC. The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.
Neurodestructive procedures have been used for treating intractable pain for a long time. Pulsed ... more Neurodestructive procedures have been used for treating intractable pain for a long time. Pulsed radiofrequency (RF) is a newly defined energy type. Pulsed RF may be used in the treatment of patients with some pain syndromes in whom the pain could not be controlled by the alternative techniques. The objective of the present study was to examine the histological and electron microscopical changes in rat brain after pulsed RF application. Forty-five male rats were used in these experiments. Lesions were applied stereotactically to the target areas of the rat brains. Two different RF energy type were used as representative models of pulsed-RF and conventional-RF procedures. The rats were kept alive for 21 days and then killed. The effect of pulsed RF lesions on cerebral tissue ultrastructure was studied. In the pulsed RF group, intracytoplasmic edema, clarity of the mitochondrial cristas and opening in the cell membrane pores were observed on the electron microscopic examination. In the conventional RF group, these findings were more prominent. In the pulsed RF group, the ratio of the effected neurons was 5.5% on light microscopic examination. In the conventional RF group, the ratio of the effected neurons was 14.26% and central necrosis was observed additionally. Pulsed RF caused ultrastructural changes in the neurons. The pulsed RF may possibly cause a depression on the cell membrane potential by opening the cell membrane pores and resulting in the ion entrance into the cell cytoplasm and intracytoplasmic edema. However, it seems that all these changes were reversible.
We present a surgical series of 35 patients (25 males and 10 females) with histopathologically ve... more We present a surgical series of 35 patients (25 males and 10 females) with histopathologically verified intracranial cavernous angiomas. The 35 malformations were located as follows: 21 were in the cerebral hemispheres; 4 in the lateral ventricles, 4 in the brain stem; and 6 in the cerebellum. Seizures and focal neurological deficits were the main clinical features observed in patients with intracranial cavernous angiomas. A number of these vascular malformations were misdiagnosed by computerized tomography. In the last 10 years, magnetic resonance imaging has been the most sensitive method for detecting these lesions. Thirty-five cavernous angiomas were treated surgically; in 33 patients a complete excision, and in 2 patients subtotal excision were obtained. One of the patients died one year after the operation. The overall outcome was good in all of the 34 remaining patients, resulting in improved seizure control or neurological deficit. The rationale for neurologic differential diagnosis and surgical treatment and follow up results are discussed.
BackgroundAtypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar regio... more BackgroundAtypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar region, often radiating to the ear, neck, and shoulders. The pain generally is not within any dermatomal or anatomical boundaries. Atypical facial pain is distinct from trigeminal neuralgia and its variants. Therefore, the treatment of AFP should be specified. There is also no consensus in
Malignant mesotheliomas are neoplasms that arise from mesothelial cells and cause intractable pai... more Malignant mesotheliomas are neoplasms that arise from mesothelial cells and cause intractable pain in the chest wall, usually located unilaterally. This local pain can be well controlled by computerized tomography (CT)-guided percutaneous cordotomy (PC). One hundred and fifty-three patients suffering from intractable pain due to malignancy were treated with CT-guided cordotomy between 1988 and 2001. Seventy of the 153 patients had pulmonary malignancy. Among these, 40 had bronchogenic carcinoma, 11 had Pancoast tumors and the remaining 19 had mesothelioma. The latter 19 cases with malignant mesothelioma suffering from unilateral pain were treated with CT-guided PC. In 18 cases, pain was controlled totally and, in one, partial pain control was obtained. Selective pain control was obtained in 15 cases, in whom narcotic drugs were discontinued postoperatively. Post-cordotomy dysesthesia was noted in only one case, and no complication or mortality was observed. In the treatment of intractable pain, CT-guided cordotomy is a perfect method in selected cases with malignancy. This is the most effective and suitable treatment modality for local pain due to malignant mesothelioma.
Uploads
Papers by Ali Savas