Pituitary adenoma is a common primary brain neoplasm. Pituitary apoplexy (PA) is a rare complication of pituitary adenoma and occurs as the result of sudden tumor growth and following different comorbidities. The authors describe the first case of PA following posterior lumbar fusion surgery performed while the patient was prone. In patients with a preexisting pituitary adenoma, thorough clinical and laboratory investigations should be conducted using an interdisciplinary approach before any planned surgery. In unknown cases of pituitary adenoma, PA should be kept in mind for the differential diagnosis in a case with headache, nausea, vomiting, ophthalmoplegia, visual loss, and electrolyte imbalance concurrent with an ongoing disease state.
Akın Akakın, Baran Yılmaz, Murat Şakir Ekşi and Türker Kılıç
Akın Akakın, Baran Yılmaz, Türker Kılıç and Albert L. Rhoton Jr.
The goal in this study was to examine the cadaveric anatomy of the subthalamic nucleus (STN) and to analyze the implications of the findings for deep brain stimulation (DBS) surgery.
Five formalin-fixed human cerebrums were dissected using the Klingler fiber dissection technique. Digital photographs of the dissections were fused to obtain an anaglyphic image.
The STN was located posteroinferior to the anterior corticospinal fibers, posterosuperior to the substantia nigra, and anteromedial to the red nucleus, lenticular fasciculus, and thalamic fasciculus. The subthalamic region is ventral to the thalamus, medial to the internal capsule, and lateral and caudal to the hypothalamus. The nuclei found within the subthalamic region include the STN. The relationship between the STN and surrounding structures, which are not delineated sharply, is described.
The fiber dissection technique supports the presence of the subthalamic region as an integrative network in humans and offers the potential to aid in understanding the impacts of DBS surgery of the STN in patients with Parkinson disease. Further research is needed to define the exact role of the STN in the integrative process.
Kaya Kiliç, Deniz Konya, Özlem Kurtkaya, Aydin Sav, M. Necmettin Pamir and Türker Kiliç
The authors studied the effect of Gamma Knife irradiation on angiogenesis induced by cerebral arteriovenous malformation (AVM) tissues implanted in the corneas of rats.
Ten AVM specimens obtained from tissue resections performed at Marmara University between 1998 and 2004 were used. A uniform amount of tissue was implanted into the micropocket between the two epithelial layers of the cornea. Gamma Knife irradiation was applied with dose prescriptions of 15 or 30 Gy to one cornea at 100% iso-dose. Dosing was adjusted so that the implanted cornea of one eye received 1.5 Gy when 15 Gy was applied to the other cornea. Similarly, one cornea received 3 Gy when 30 Gy was applied to the other cornea. Angiogenic activity was graded daily by biomicroscopic observations. Forty-eight other rats were used for microvessel counting and vascularendothelial growth factor (VEGF) staining portions of the experiment. Micropieces of the specimens were again used for corneal implantation. Rats from each group were killed on Days 5, 10, 15, and 20, and four corneas from each group were examined.
Gamma Knife irradiation dose dependently decreased AVM-induced neovascularization in the rat cornea as determined by biomicroscopic grading of angiogenesis, microvessel count, and VEGF expression.
The results suggest that Gamma Knife irradiation inhibits angiogenesis induced by AVM tissue in the cornea angiogenesis model. The data are not directly related to understanding how Gamma Knife irradiation occludes existing AVM vasculature, but to understanding why properly treated AVMs do not recur and do not show neovascularization after Gamma Knife irradiation.
Ulaş Yener, Timucin Avsar, Emel Akgün, Aşkın Şeker, Yaşar Bayri and Türker Kılıç
Angiogenesis and the platelet-derived growth factor (PDGF) pathway are active in the pathogenesis of vestibular schwannomas (VSs). The purpose of this study was to test whether imatinib mesylate (Gleevec), a PDGF receptor (PDGFR) blocker, reduces angiogenic capacity in sporadic VS and in VS associated with neurofibromatosis Type 2 (NF2) using a corneal angiogenesis assay.
From 121 VS tissue samples stored in the tumor bank at the Marmara University Institute of Neurological Sciences, 10 samples (6 from sporadic cases, 4 from NF2-associated cases) were selected at random for use in this study. Expression of PDGF-A and PDGF-B and their receptors was evaluated in sporadic and NF2-associated VS as well as in glioblastoma (GBM) and normal brain tissue by means of immunohistochemistry and Western blot analysis. Corneal angiogenesis assay was then used to evaluate the angiogenic capacity of tissue specimens from sporadic and NF2-associated VS with and without imatinib treatment as well as positive and negative controls (GBM and normal brain tissue).
The angiogenic potential of the sporadic and NF2-associated VS tumor tissue differed significantly from that of the positive and negative control tissues (p <0.05). Furthermore, NF2-associated VS showed significantly lower angiogenic potential than sporadic VS (p <0.05). Imatinib treatment significantly reduced the angiogenic potential in both the sporadic VS and the NF2-associated VS groups. The level of PDGF-A and PDGFR-α as well as PDGF-B and PDGFR-β expression in sporadic VS and NF2-associated VS also differed significantly (p <0.05) from the levels in controls. Additionally the level of PDGFR-β was significantly higher in sporadic VS than in NF2-associated VS (p <0.05).
The findings of this study indicate that NF2-associated VS has significantly more angiogenic potential than sporadic VS and normal brain tissue. Additionally, imatinib reduces the angiogenic activity of both sporadic and NF2-associated VS. The authors conclude that imatinib may be a potential treatment for VS, especially for NF2-associated lesions that cannot be cured with resection or radiosurgery.
Ender Koktekir, Zafer Orkun Toktas, Askin Seker, Akin Akakin, Deniz Konya and Turker Kilic
Due to lack of construct stability of the current anterior cervical approaches, supplemental posterior cervical approaches are frequently employed. The use of an anterior-only approach with anterior transpedicular screws (ATPSs) has been proposed as a means of providing 3-column fixation. This study was designed to investigate the feasibility of anterior transpedicular screw (ATPS) fixation of cervical spine, to obtain the morphological measurements for technical prerequisites, and to evaluate the accuracy of the ATPS using fluoroscopy.
The study included both radiological and anatomical investigations. The radiological investigations were based on data from cervical spine CT scans performed in 65 patients. Technical prerequisites of ATPS were calculated using OsiriX for Mac OS. In the anatomical part of the study, 30 pedicles (C3–7) from 6 formalin-preserved cadavers were manually instrumented. Measurements obtained included pedicle width (PW), pedicle height (PH), pedicle transverse angle (PTA), distance of the entry point from the midline (DEPM), and distance of the entry point from the superior endplate (DEPSEP). The authors also analyzed screw position in the manually instrumented vertebrae.
The mean PW and PH values showed a tendency to increase from C-3 to C-7 in both males and females. The means were significantly larger for both PW and PH in males than in females at all levels (p = 0.001). The overall mean PTA value was significantly lower at C-7 (p < 0.0001). The mean value for the distance of entry point from the midline (DEPM) represented a point at the contralateral side of the pedicle for every level except C-7. The mean DEPSEP values showed significant differences between all levels (p < 0.0001). Seven of the 30 screws were identified as breaching the pedicle (23.3%); these screw malplacements were seen at C-3 (3 screws), C-4 (2 screws), and C-5 (2 screws).
The morphological measurements of this study demonstrated that ATPS fixation is feasible in selected cases. They indicate that ATPS insertion using a fluoroscopy-assisted pedicle axis view is safe at the C-6 and C-7 levels, but the results at the other levels did not prove the safety of this technique.
Baran Yılmaz, Zafer Orkun Toktaş, Akın Akakın, Semra Işık, Kaya Bilguvar, Türker Kılıç and Murat Günel
Brain arteriovenous malformations (AVMs) can occur in patients with hereditary hemorrhagic telangiectasia (HHT). However, brain AVM without HHT has also been reported. Using whole exome sequencing, the authors performed comprehensive genomic characterization of a 6-person Turkish family with 3 cases of brain AVM without HHT.
Three siblings with brain AVM, one of whom also had spinal AVM, were evaluated. The parents and the fourth sibling had no AVM on cranial MRI. The authors performed a whole exome capture and Illumina sequencing on blood samples from 2 siblings with AVM.
An ACVRL1 heterozygous mutation (p.Lys332Glu) was identified in 2 patients via whole exome sequencing. Variant segregation was confirmed using direct Sanger sequencing.
Study results suggested that whole exome sequencing analysis is particularly useful in cases of locus heterogeneity and uncertain diagnostic classification schemes in patients with hereditary brain AVM.