Sezer, Can; Zırh, Selim; Gokten, Murat; Sezer, Aykut; Acıkalın, Rıdvan; Bilgin, Emre; Zırh, Elham Bahador

Background: Traumatic brain injury is still an important health problem worldwide. Traumatic brain injury not only causes direct mechanical damage to the brain but also induces biochemical changes that lead to secondary nerve cell loss. In this study, we investigated the neuroprotective effect of milrinone after traumatic brain injury (TBI) in a rat model. Methods: Forty male Wistar albino rats, were used. Rats were divided into 4 groups: 1) sham, 2) TBI, 3) TBI + Ringers, and 4) TBI + Milrinone. In group 1 (sham), only craniotomy was performed. In group 2 (TBI), TBI was performed after craniotomy. In group 3 (TBI + Ringer), TBI was performed after craniotomy and intraperitoneal Ringers solution was given immediately afterward. Group 4 (TBI + Milrinone), TBI was performed after craniotomy, and milrinone was given 1.0 mg/kg milrinone intraperitoneally directly (0.5 mg/kg milrinone intraperitoneally again 24 hours, 48 hours, and 72 hours after trauma). Tests were performed for neurological and neurobehavioral functions. Immunohistochemistry and histopathology studies were performed. Results: In group 4 compared with group 2 and group 3 groups, tests for neurological functions and neurobehavioral functions were significantly better. In the milrinone treatment used in group 4, plasma and brain tissue tumor necrosis factor, 8-OH 2-deoxyguanosine, and interleukin 6 levels were significantly decreased, and increased plasma and tissue IL-10 levels were detected. Histopathological spinal cord injury and apoptotic index increased in groups 2 and 3, while significantly decreasing in group 4. Conclusions: This study shows for the first time that the anti-inflammatory, antioxidant and antiapoptotic properties of milrinone may be neuroprotective after TBI.

Akturk, Umut Dogu; Tuncer, Cengiz; Bozkurt, Huseyin; Sahin, Omer Selcuk; Bulut, Husamettin; Arikok, Ata; Dinc, Cem; Gurer, Bora; Turkoglu, Erhan

Objective: Vasospasm after subarachnoid hemorrhage (SAH) plays a vital role in the development of delayed cerebral ischemia. Anti- vascular endothelial growth factor (VEGF) antibodies, like bevacizumab (BEV), may attenuate VEGF-stimulated angiogenesis, reduced vascular cell proliferation, and improve vasospasm after SAH. Methods: Thirty-two adult male New Zealand white rabbits were randomly divided into 4 groups of 8 rabbits in each group: group 1 (control); group 2 (SAH); group 3 (SAH + vehicle); and group 4 (SAH + BEV). BEV (5 mg/kg, intraperitoneally) was administered 5 minutes after the intracisternal blood injection and continued for 72 hours once per day in the same dose for group 4. Animals were sacrificed 72 hours after SAH. Basilar artery cross-sectional areas, arterial wall thicknesses, and hippocampal degeneration scores were evaluated in all groups. Results: VEGF is associated with the narrowing of the basilar artery. Treatment with BEV statistically significantly increased the cross-sectional area of the basilar artery when compared with the SAH and the vehicle groups. Basilar artery wall thicknesses in the BEV group was statistically significant smaller than in the SAH and vehicle groups. The hippocampal degeneration scores for the BEV and control groups were similar and significantly lower than those for the SAH and vehicle groups. Conclusions: Cellular proliferation and subsequent vessel wall thickening is a reason to delay cerebral ischemia and deterioration of the neurocognitive function. Intraperitoneal administration of BEV was found to attenuate cerebral vasospasm and prevent delayed cerebral ischemia and improve neurocognitive function after SAH in rabbits.

Ozoner, B.; Aydin, Seckin; Akgun, Mehmet Yigit; Durmaz, Emine Sebnem; Sahin, Serdar; Gazioglu, Nurperi; Kizilkilic, O.; Kadioglu, P.; Tanriover, Necmettin

Objective: Rathke's cleft cysts (RCCs) may have various anatomic, clinical, and radiologic characteristics, which may be related to their differences in texture or consistency. The purpose of the study was to investigate RCCs based on consistency. Methods: We retrospectively reviewed 25 cases of patients with RCCs who underwent endoscopic endonasal transsphenoidal surgery between 2008 and 2018. Cases were divided into 3 types based on cyst consistency: fluid (serous) or type A (n = 4); semi-fluid (mucoid) or type B (n = 17); and non-fluid (caseous) or type C (n = 4). Demographic, clinical, radiologic, and surgical characteristics for each group were analyzed. Results: All type A RCCs (100%) had visual impairment. The mean age (42.8 ± 13 years) and cyst volume (2442.5 ± 533.6 mm3) were higher in these patients. T1-weighted images were hypointense and T2-weighted images were hyperintense on magnetic resonance imaging. Type B RCCs were more frequently encountered (68%). Although headache was the most common (82.3%) symptom, endocrine disorders were also prevalent (52.9%). T1-weighted images were typically isointense or hyperintense on magnetic resonance imaging. Type C RCCs had the youngest patient population (30.3 ± 10.2 years) and T2-weighted images were predominantly hypointense in this group. Conclusions: The proposed novel consistency classification of RCCs will provide a practical tool for more accurately estimating the nature of the pathology, because each type has its own specific characteristics. Furthermore, the new classification of RCCs may aid in planning a consistency-specific surgery.

Kayacı, Selim; Cakir, Tayfun; Dolgun, Muge; Cakir, Ertugrul; Bozok, Şahin; Temiz, Cüneyt; Caglar, Yusuf Sukru

Purpose: Aortic injury by pedicle screw is rare but can cause serious complications. It has not been clearly determined when aortic repair is necessary in cases of screw impingement without perforation of the aortic wall. In this article, we review the treatment and clinical course of pedicle screw aortic impingement and attempt to clarify this issue. Methods: Cases of aortic injury during thoracic screw procedures were found using a MEDLINE search and analyzed together with 3 new cases that we present. Results: Nineteen cases collected from the literature and 3 new cases were included in the study. In 7 of the cases, aortic impingement by the pedicle screw was detected during postoperative follow-up (day 1) radiologic examinations. In the other cases, time to presentation of aortic impingement ranged between 2 weeks and 60 months after fixation. The main indications for thoracic spinal fixation were post-traumatic vertebral fracture and kyphoscoliosis/scoliosis. Repair of the aortic damage ranged from primary repair to stent and tube graft placement by the thoracic endovascular aortic repair method. Conclusions: In cases in which the screw impinges less than 5 mm into the aortic wall, hardware revision without aortic repair may be sufficient if recognized early and there are no sign of aortic leakage in vascular imaging. However, cases with more than 5 mm of screw impingement should undergo aortic repair first, even in the absence of aortic leakage, following by screw revision.

Ozoner, Baris; Cakir, Tayfun; Kayaci, Selim; Aydin, Mehmet Dumlu; Aydin, Seckin; Demirci, Elif

Background: A well-documented association exists between the vasa vasorum and vasopathologies, including atherosclerosis. However, information on the role of the vasa vasorum during vascular degenerative changes of vasospasm after subarachnoid hemorrhage (SAH) is insufficient. Methods: In this study, 34 rabbits were divided into 3 groups: basal group (N = 8), sham group (N = 8), and SAH group (N = 18). Experimental SAH was formed using a double-injection model. During follow-up, the neurologic status of the rabbits was observed. All rabbits were euthanized after 2 weeks, and the vasopathologic degeneration was categorized as normal, mild, moderate, and severe according to the changes in the basilar arteries. The numbers, locations, and spasms of the vasa vasorum and their relation to the vasodegenerative changes of the basilar artery were investigated. Results: The basilar arteries were graded as normal in the basal and sham groups. In the SAH group, 6 rabbits had mild, 7 had moderate, and 5 had severe degeneration. Neurologic deficits were prominent in the SAH group, and deficit grades correlated with vascular degeneration. The number of the vasa vasorum were significantly higher in the SAH group, and an enhanced formation of the vasa vasorum was noted in which severe degenerative changes were present. Moreover, the vasospasm index of the vasa vasorum, which increased with the aggravation of vascular degenerative changes, was significantly higher in the SAH group. Conclusions: The vasa vasorum and their vasospasm play a crucial role in the pathogenesis of basilar artery degeneration in the vasospasm following SAH.

Kayacı, Selim; Çakir, Tayfun; Aydın, Mehmet Dumlu; Kanat, Ayhan; Omeroglu, Muhammed; Levent, Akin; Kantarci, A. Mecit; Diyarbakırlı, Semih; Demirci, Elif

Purpose: Subarachnoid hemorrhage (SAH) may lead to vasospasm in various vessels. The cervical nerves have a vasodilatory effect on the upper extremity arteries. The aim of this study was to investigate if there is a relationship between C6 dorsal root ganglion (DRG) degeneration and brachial artery (BA) vasospasm after spinal SAH. Methods: This experimental study was conducted on 23 rabbits. The animals were divided into 3 groups: control (n = 5), SHAM (n = 5), and study group (n = 13). One cubic centimeter (cc) of serum saline was injected into the cisterna magna of animals of the SHAM group; the same procedure was performed by 1 cc of homologous blood in the study group. Degenerated neuron densities (DNDs) of DRGs (n/mm3) at C6 levels and BA vasospasm indexes (VSI; wall surface/lumen surface) of all animals were determined and results were analyzed statistically. Results: Mean VSI values of BAs and DNDs of C6DRGs of the control, SHAM, and study groups were estimated as 10 ± 3/1.12 ± 0.11 n/mm3, 34 ± 9/1.27 ± 0.24 n/mm3, and 1031 ± 145/2.93 ± 0.78 n/mm3, respectively. Mean DNDs and VSI values were statistically significantly different between the control and study groups (P < 0.0001). Conclusions: C6DRG degeneration may be considered as an important factor in the etiopathogenesis of severe BA vasospasm after SAH.

Çakır, Tayfun; Kayacı, Selim; Aydın, Mehmet Dumlu; Özöner, Barış; Çalık, İlknur; Altınkaynak, Konca

Objective: We created a neck trauma model by injecting blood into the sheath of rabbits' carotid bodies (CBs). Then we determined the relationship between neuronal degeneration of the CB due to hemorrhage of this organ and its clinical effects such as blood pH and heart rhythm. Methods: The present study included 24 adult male New Zealand rabbits. The animals were divided into 3 groups: control (n = 5); sham (0.5 mL saline injected into CBs; n = 5); and study (CB trauma model; n = 14). pH values and heart rhythms were recorded before the experiment to determine the values under normal conditions, and measurements were repeated thrice in the days following the experiment. The number of normal and degenerated neuron density of CBs was counted. The relationship between the blood pH values, heart rhythms, and degenerated neuron densities was analyzed. Results: Heart rhythms were 218 ± 20 in the control group, 197 ± 16 in the sham group (P = 0.09), and 167 ± 13 in the study group (P < 0.0005). pH values were 7.40 ± 0.041 in the control group, 7.321 ± 0.062 in the sham group (P = 0.203), and 7.23 ± 0.02 in study group (P < 0.0005). Degenerated neuron densities were 12 ± 4/mm3 in the control group, 430 ± 74/mm3 in the sham group (P < 0.005), and 7434 ± 810/mm3 in the study group (P < 0.0001). Conclusions: A high degenerate neuron density in the CB can decrease blood pH and hearth rhythm after neck trauma, and there might be a close relationship between the number of degenerated neurons and clinical findings (such as heart rhythm and blood pH). This relationship suggests that injury to the glossopharyngeal nerve−CB network can cause acidosis by disturbing the breathing-circulating reflex and results in respiratory acidosis.

Kotil, Kadir; Ozdogan, Selcuk; Kayaci, Selim; Duzkalir, Hanife Gulden

Background: The treatment options for patients with Chiari malformation type 1 (CM1) and Chiari malformation type 1.5 (CM1.5) have not yet been standardized. In these malformations, the main factors include obstruction at the level of the foramen magnum and dural and ligamentous thickening. Here we present our outcomes of surgery and decompression using a minimally invasive surgery (MIS) technique. Methods: Sixty-one patients admitted to our clinics between 2009 and 2016 due to CM1 or CM1.5 and who had undergone MIS were investigated retrospectively. All patients were followed up for a mean period of 55 months, both clinically and radiologically, and the outcomes were recorded. Results: All 61 patients underwent foramen magnum decompression through a 1.5-cm mini-open incision, C1 laminectomy and C2 medial inner side tour, posterior atlanto-occipital membrane removal, external dural delamination, and widening of the internal dura with longitudinal incisions. Fifty-six patients (91.8%) were satisfied with the outcome, 4 patients (6.5%) remained the same, and 1 patient (1.6%) reported a poor outcome. Forty-five percent of the patients with syringomyelia demonstrated resolution within 2 years, and 92% demonstrated resolution in 5 years. Scoliosis was seen in 5 patients (8.1%). The rate of benefit from the surgical procedure was statistically significant (P = 0.0045), and no patient required additional surgery because of poor decompression. Conclusions: MIS is effective for uncomplicated cases of CM1 and CM1.5 due to its minimal connective and muscular tissue damage, short surgical duration, short recovery time, early mobilization, effective posterior foramen magnum widening, lack of liquor fistula development, and better clinical and radiologic improvement during long-term follow-up.

Taydas, Onur; Ogul, Hayri; Ozcan, Halil; Kantarci, Mecit

Background: Electroconvulsive therapy (ECT) is a safe method that has been applied for many years in medical treatment−resistant depression treatment. In this case report, contrast extravasation due to deterioration of the blood-brain barrier after ECT mimicking subarachnoid hemorrhage (SAH) on magnetic resonance imaging (MRI) is discussed. Case Description: A 70-year-old male patient who underwent ECT presented with sulcal hyperintensities suggesting subarachnoid hemorrhage on fluid-attenuated inversion recovery sequence of MRI obtained after ECT. However, there was no evidence to suggest SAH on nonenhanced brain computed tomography. Conclusion: It should be kept in mind that patients may have contrast extravasation due to deterioration of the blood-brain barrier after ECT, and other alternative methods should be used for the diagnosis of SAH in these patients, not MRI.

Ulu, Mustafa Onur; Aydin, Seckin; Kayhan, Ahmet; Ozoner, Baris; Kucukyuruk, Baris; Ugurlar, Doga; Sanus, Galip Zihni; Tanriover, Necmettin

Objective: To review the results of sphenoid sinus lateral recess (SSLR) cerebrospinal fluid (CSF) leaks treated with the endoscopic endonasal minimal transpterygoid approach (EEMTPA) and to discuss the surgical technique and outcomes. Methods: We performed a retrospective analysis of 13 cases who underwent SSLR CSF leak repair through the EEMTPA in our clinic between September 2008 and December 2017. Demographic and etiological features with reconstruction and surgical outcomes were examined. Mean follow-up time was 6.1 years. Results: In regard to etiology, the SSLR CSF leaks included 9 patients with spontaneous, 2 patients with traumatic, and 2 with iatrogenic causes. CSF leak was at the left lateral recess in 8 cases and at right lateral recess in 5 cases. Nine patients had empty sella syndrome, and 11 patients had meningoencephaloceles in addition to SSLR CSF leaks. All patients underwent surgery through the EEMTPA, and a multilayer closure with tissue overlay grafts were used for reconstruction. A pedicled nasoseptal flap and/or pedicled middle turbinate flap were applied to the area of the leak in all cases. One patient had a persistent CSF leak and another had recurrence, both of which required revision surgery. Our overall success rate was 100%. Conclusions: EEMTPA is a safe and effective method that can be used to treat challenging pathologies at the SSLR, including CSF leaks accompanying meningoencephaloceles. Furthermore, the success rate of EEMTPA for SSLR CSF leaks can be increased by applying endoscopic skull base reconstruction techniques such as the pedicled nasoseptal flap and pedicled middle turbinate flap.