Abstracts of selected publication of our division of Pediatric Neurosurgery

Selected Abstracts

Epidemiology of pediatric central nervous system tumor: a meta-analysis or review? 

Erşahin Y. Child's Nerv Syst 18:8-8,2002 [No abstract available]

Acquired Chiari I malformation changes postendoscopic third ventriculostomy.

Erşahin Y, Gökçay A. Pediatr Neurosurg 36:54-54,2002 [No abstract available]

Orbital growing fracture

Erşahin Y.. Pediatr Neurosurg 35:50-50,2001. [No abstract available]

Is meningocele really an isolated lesion? 

Erşahin Y, Barçın E, Mutluer S. Child's Nerv Syst 17:487-490, 2001.  

OBJECT: We designed this study to elucidate the associated occult spinal lesions in patients with simple dorsal meningocele. METHODS: The study population was comprised of two groups. Group I comprised newly diagnosed patients with dorsal spinal meningocele, and group II comprised patients who had had surgery for meningocele and presented with progressive neurological deficits. Magnetic resonance imaging (MRI) scans of the whole spinal column were done. The associated spinal cord malformations were also treated at the same operation. There were 14 boys and 8 girls, with an age range from birth to 4 years (mean 3.9 months), in group I. Of 20 patients (90%) with associated spinal lesions, 6 had more than one lesion, excluding hydromyelia. Group II was made up of 6 patients who had been previously operated on for a meningocele and who presented with tethered cord syndrome. These were 4 boys and 2 girls, who ranged in age from 4 to 10 years (mean 6 years). RESULTS: The level of the conus terminalis was lower than L3 in all patients. The other findings on MRI, besides low conus, were as follows: tight filum, split cord malformation, epidermoid, dorsal lipoma and hydromyelia. CONCLUSIONS: Meningocele frequently camouflages a second, occult, spinal lesion. MRI of the whole spinal column should be performed. An intradural exploration performed with a microneurosurgical technique is needed to detect the fibrous bands that may lead to spinal cord tethering and to release the entrapped nerve roots. The other associated spinal anomalies should be operated on during the same operation.
 

Child abuse in Turkey: an experience in overcoming denial and a description of 50 cases. 

Oral R, Can D, Kaplan S, Polat S, Ates N, Cetin G, Miral S, Hanci H, Erşahin Y, Tepeli N, Bulguc AG, Tiras B. Child Abuse Negl25:279-90, 2001.  

OBJECTIVE: To share the experiences of the first clinical multidisciplinary child abuse and neglect (CAN) team in Turkey with international child abuse community. METHODS: The authors established the first Turkish CAN follow-up team at Dr. Behcet Uz Children's Hospital. Following a training program in five teaching hospitals in Izmir, the authors kept a record of every case diagnosed with CAN from these hospitals between 1996 and 1998. The demographic, epidemiologic, and medical features of this case series are summarized. RESULTS: Fifty cases were diagnosed and followed-up. Seventy-six percent of patients were reported from Dr. Behcet Uz Children's Hospital. Age and sex distribution was 9.2 +/- 6.7 years and 46% male, 54% female, respectively. The offenders were only father in 38%, only mother in 28%, and multiple in 34%. More than three CAN risk factors were present in 94%. Of the children reported 44% survived, 14% died, and 42% were lost to follow-up. Sixteen percent were free of reabuse, and 42% survived with handicaps. CONCLUSIONS: Child abuse and neglect is a reality in Turkey. The team's work increased pediatricians' awareness of CAN. Reporting these cases to Social Affairs Bureau was established for the first time in Turkey. Physicians in Turkey need training to diagnose and properly report CAN. The implemen tation of a national CAN prevention program is an urgent need for Turkey

Tethered cord syndrome in adults. 

Akay KM, Erşahin Y, Çakır Y. Acta Neurochir (Wien) 142: 1111-1115, 2000.  

BACKGROUND: The tethered cord syndrome (TCS) consists of an abnormally low conus medullaris tethered by a thickened filum terminale or various forms of spinal dysraphism. The adult variant of the syndrome seems not to be as rare as once thought. METHOD: This study includes 11 patients with a TCS. Clinical, radiological findings and outcome were reviewed in these adult patients with TCS. FINDINGS: The patients ranged in age from 18 to 34 years (mean 24.09 years). There were 7 men and 4 women. The presenting symptoms in order of frequency were as follows: low back pain radiating to legs, urinary complaints, weakness in legs and impotence. All patients had magnetic resonance imaging scans. Physical exercise in 8, birth delivery in 1 and carrying heavy objects in 1 patient were determined as the precipitating factors. No precipitating factor could be defined in one of the patients. All patients were operated on, except for one. None of the patients worsened after surgery. INTERPRETATION: The patients presenting with low back pain and sciatica responded to surgery better than those with sphincter problems.
 

Growing skull fractures (craniocerebral erosion). 

Erşahin Y, Gülmen V, Palalı İ, Mutluer S. Neurosurg Rev 23: 139-144, 2000.  

The incidence of growing skull fractures ranges from less than 0.05% to 1.6%. We reviewed 22 growing skull fracture patients retrospectively. There were 15 boys and seven girls ranging in age from newborn to 6 years (mean: 12.4 months) at the time of injury. Falling was the most frequent cause of injury. In total, 17 patients presented with a scalp mass. The scalp was sunken over the bone defect in three patients. Other symptoms and signs were seizure in five patients, hemiparesis in four, recurrent meningitis in one, and pulsatile exophthalmus in one. The most common location was the parietal region. The extent of dural defect was always greater than that of bony defect, except in one case that had been previously shunted for hydrocephalus. In another patient with a growing fracture in the posterior cranial fossa, the dural edges could not be exposed, although a wide craniotomy was performed. Therefore, a cystoperitoneal shunt was inserted. Gliotic tissue was present in all the patients. Cyst or cystic lesions were observed in only nine patients, duraplasty was performed in 21, 16 were neurologically intact, and six had minor deficits. All patients under the age of 3 years with a diastatic skull fracture should be closely followed up. A sustaining diastatic fracture and brain herniation through the skull defect shown on CT or MRI imply a growing skull fracture

Book review: Key hole concept in neurosurgery with endoscope assisted neurosurgery and case studies.

 Erşahin Y.  Pediatr Neurosurg 32: 329-330, 2000. [No abstract available]

Complications of subduroperitoneal shunting. 

Erşahin Y, Tabur E, Kocaman S, Mutluer S. Child's Nerv Syst 16:433-436, 2000.  

OBJECTS: Subduroperitoneal (SP) shunts have been widely used in the management of pediatric subdural fluid collections. METHODS: We retrospectively reviewed the complications of SP shunting in 73 boys and 24 girls, who ranged in age from 1 to 180 months (median 7 months). Subdural fluid collection was bilateral in 75 and unilateral in 22 patients. The most common complication was shunt obstruction (13 patients). Shunt migration was seen in 8 patients. Migration occurred only with unishunts without a reservoir and with peritoneal catheters. However, the shunts with a reservoir or flushing valve led to skin necrosis in 4 patients (P=0.003). Unilateral drainage though bilateral collections were present, infection, bowel perforation, and ileus occurred in 5, 4, 1 and 1 patients respectively. CONCLUSIONS: These SP shunt complications, some of which are avoidable, should be kept in mind.
 

Transorbital stab wound from a speargun: A case report. 

Erşahin Y, Sadat M, Yurtseven T, Mutluer S. Turk Neurosurg 9:133-136, 1999. [No abstract available]

Intraosseous neurinoma of the parietal bone. 

Erşahin Y, Mutluer S, Demirtaş E. Child's Nerv Syst 16: 181-183, 2000.  

Intraosseous neurinoma is very uncommon tumor. Its location in the skull is extremely rare. A 4-year-old boy presented with a lump in the right occipital region. Computed tomography revealed a soft tissue mass with bony erosion in the right occipital bone. The solid, nontender, and immobile mass was totally removed. The pathological examination showed that it was an intraosseous neurinoma. Total resection of intraosseous neurinomas is sufficient treatment and is not followed by recurrence.
 

Intracranial meningeal tumours in childhood: a clinicopathologic study including MIB-1 immunochemistry.

Demirtaş E, Erşahin Y, Yılmaz F, Mutluer S, Veral A. Pathol Res Pract 196:151-158, 2000.  

Primary tumours of the meninges with a relatively high tendency for malignant behaviour are uncommon in childhood. This study concerns 18 cases of meningeal tumours in children under the age of 16, of which 13 were meningiomas and five were other tumours arising in the meninges. Meningiomas showed a preponderance in females as in adult series, and the majority were supratentorial in localisation. The percentage of meningeal tumours and meningiomas among all brain tumours in our centre were 3.72% and 2.69%, respectively. Four out of 13 meningiomas were fibroblastic, four were transitional, one was meningothelial, two were psammomatous and two were papillary meningiomas. Seven (38.8%) out of 18 tumours showed anaplastic features, including two papillary meningiomas, two hemangiopericytomas, one mesenchymal chondrosarcoma, one pleomorphic sarcoma and one anaplastic meningeal tumour. Papillary meningiomas with hemangiopericytoma-like solid areas were seen frequently in our cases (15.3%). Meningoangiomatosis was associated with two meningeal tumours. MIB1 (Ki-67) labelling indices (LIs) ranged between 0% and 13.6% (mean 1.83%) in benign, and between 1% and 20% (mean 7.2%) in malignant tumour, including papillary meningiomas. Mean MIB-1 LIs were 5.61% and 1.14% in non-recurrent and recurrent cases, respectively. MIB-1 LIs showed significant differences between benign and malignant meningeal tumours but no significant correlation either with prognosis or recurrence. Despite the fact that brain tumours are among the most common neoplasms of childhood, meningeal tumours are rare lesions, accounting for less than 2% of published series of intracranial neoplasms in childhood [5, 8, 18, 24, 30, 32]. It has been suggested that the clinical and pathological characteristics of meningiomas in this age group differ from those of adults [14, 18, 24, 45]. Besides meningiomas, there are a few reports of other meningeal tumours in childhood and difficulties in differential diagnosis may arise within this group, especially in anaplastic tumours [11, 13, 32, 44, 46]. One of the major problems in meningiomas and some tumours arising in the meninges is the discordance that arises between the histologic appearance of the tumour and behaviour [4]. Several studies have attempted to determine the proliferation potential of meningiomas, including immunohistochemical labelling with monoclonal antibodies to Ki-67, proliferating cell nuclear antigen (PCNA), and bromodeoxyuridine (BUdR); flow cytometric DNA analysis; or argyrophilic nucleolar organizer regions (AgNORs) counting [9, 10, 15, 19, 22, 26, 31, 35, 53]. The studies concerning proliferation markers have contradictory results [9, 10, 15, 26, 31, 42, 53]. MIB-1 detects the same or a similar epitope as the original antibody Ki-67 and reacts with a proliferation associated antigen expressed in all active parts of the cell cycle, G1, S, G2 and M (mitosis), but not in the G0 or quiescent phases [7]. In this study we examined the clinicopathological characteristics and MIB1 values of 18 meningeal tumours in children under the age of 16 years within the last 25 years (from 1970 to 1995).
 

Intramedullary schwannoma of the spinal cord. A case report and review of the literature. 

Binatlı Ö, Erşahin Y, Korkmaz O, Bayol Ü. J Neurosurg Sci 43: 163-168, 1999.  

A 9-year-old boy presented with the numbness in both arms and hands, and neck stiffness. On examination, he had a slight quadriparesis and restricted neck movements. There were no signs of von Recklinghausen's disease. Magnetic resonance imaging (MRI) scan disclosed a gadolinium enhanced intramedullary tumor located at C6-T1 associated with syringomyelia. C6-T1 laminectomies were performed and the intramedullary tumor was totally removed by a microsurgical technique. Postoperative course was uneventful. The pathological examination revealed an intramedullary schwannoma. The occurrence of intramedullary schwannoma in a patient without signs of von Recklinghausen's disease is extremely rare. We have been able to find 57 cases of intramedullary schwannoma reported in the literature. Intramedullary schwannomas are usually seen in males. The ages of the patients ranged from 9 to 75 years (mean 40.44 years). Only 4 cases in the pediatric age group have been reported. The duration of symptoms ranged from 3 months to 20 years (mean 31.03 months). Symptoms and signs varied with the location of tumor. The vertebral levels of intramedullary schwannomas were usually cervical (61%). MRI has been the choice of diagnostic tool in the cases reported since 1986. The majority of the cases showed either a partial or complete recovery in the postoperative period.

 Bilateral optic nerve glioma.

 Erşahin Y, Yünten NPediatr Neurosurg 31:168,1999 [No abstract available]

Cerebral hydatid cysts in children. 

Kocaman S, Erşahin Y, Mutluer S. J Neurosci Nurs 31: 270-277, 1999.  

A parasitic tapeworm, called Taneia Echinococcus, causes hydatid disease. Hydatid disease is endemic in sheep and cattle-raising areas of the world. Hydatid disease of the central nervous system constitutes 2%-3% of all reported cases of hydatid cysts. In our institution, 23 children underwent surgery for intracranial hydatid cysts between 1979 and 1995. There were 14 boys and 9 girls, aged between 3 to 16 years (mean 8.8 years). Signs and symptoms were related to the site and size of the cyst. Headache and vomiting due to increased intracranial pressure were the most common presenting symptoms. A round cystic lesion without perifocal edema and rim enhancement is the characteristic appearance on a computed tomography (CT) scan. A magnetic resonance image visualizes cyst location better than CT. Associated systemic hydatidosis in four of our patients involved kidney, liver, lung, and liver and lung, respectively. Intact cyst removal was achieved in 14 patients. In three patients with infected or inflamed hydatid disease, the ruptured cyst capsule was totally resected. Aspiration and extirpation were performed in only one patient. Eleven patients were treated with chemotherapeutic agents such as albendazole or mebendazole due to cyst rupture during surgery or associated systemic hydatid disease. Hydatid disease can also be seen in Western countries because of travel and migration. Cerebral hydatid cyst should be kept in mind for the differential diagnosis of cystic lesions.
 

Orbital pseudotumor. 

Erşahin Y. Pediatr Neurosurg 31:53, 1999.

Meningioma of the cavernous sinus in a child.

 Erşahin Y, Özdamar N, Demirtaş E, Karabıyıkoğlu. Child's Nerv Syst  15:8-10, 1999.  

Intracranial meningiomas in children are rare, representing 1-4.2% of central nervous system tumors and 1.5-1.8% of all intracranial meningiomas. Meningiomas arising from the lateral wall of the cavernous sinus account for less than 1% of all intracranial meningiomas. To our knowledge, only one case of a meningioma arising from the cavernous sinus has been reported in childhood. A 6-year-old boy presented with left ophthalmoplegia. A slight drooping of the left eyelid was noted at the age of 1 year. Magnetic resonance imaging (MRI) with contrast administration revealed an enhancing mass lesion located in the left cavernous sinus. The tumor, arising from the lateral wall of the cavernous sinus, was totally removed and the oculomotor nerve was reconstructed with a sural nerve graft. MRI displayed total tumor removal 1 month after the surgery. The pathological diagnosis was of a psammomatous meningioma.
 

A multicenter child maltreatment study: twenty-eight cases followed-up on a multidisciplinary basis.

 Oral R, Can D, Hanci H, Miral S, Ersahin Y, Tepeli N, Bulguc AG, Tiras B. Turk J Pediatr 40: 515-523, 1998.   

Twenty-eight maltreated cases were presented in this multicenter study. Hospital distribution was as follows: Dr. Behcet Uz Children's Hospital, 54 percent; Dokuz Eylul University Hospital, 21 percent; Ege University Hospital, 14 percent; Tepecik Social Security Hospital, 7 percent; Ataturk State Hospital, 4 percent. Age and sex distribution was two months to 25 years and 43 percent male, 57 percent female. The offender was the father in 71 percent, the mother in 32 percent and multiple in 25 percent of the cases. More than three child maltreatment risk factors were present in 93 percent. Nineteen patients (68%), nine of which were effectively followed-up were reported to the Social Affairs Bureau. Sixty-four percent gained acceptable health with the support of our team, 14 percent died, and 21 percent failed to comply with follow-up. A multidisciplinary group may interfere both medically and socially with these cases to interrupt the course of maltreatment. Every children's hospital needs such a team to increase diagnosis establishment necessary to initiate social support.
 

Intradural spinal hydatid cysts. 

İşlekel S, Zileli M, Erşahin Y. Eur Spine J  7:162-164,1998.   

Spinal hydatid cysts are very rare and comprise only 1% of all bony involvement. Intradural hydatid cysts are extremely rare compared to other types of spinal hydatid cysts. We report the case of a 19-year-old man with lumbar intradural hydatid cysts. He complained of paraparesis and urinary hesitancy. Myelography revealed a block of the contrast medium at the L4 level and multiple round radiolucent lesions rostrally. At surgery, multiple hydatid intradural cysts were extirpated. The patient's neurologic deficits improved postoperatively, but recurred 6 weeks later. Reoperation led to partial improvement of deficits. Primary intradural hydatid cysts are extremely rare. It is difficult to explain an isolated intradural location of multiple cysts. In our patient, the cysts were multiple and the patient's cerebral CT scan was normal; he had undergone no previous lumbar puncture. So we can hypothesize that intradural spinal cysts may be primarily multiple.
 

Spinal hydatid disease.

 İşlekel S,  Erşahin Y, Zileli M, Oktar N, Öner K, Övül İ, Özdamar N, Tunçbay E. Spinal Cord 36: 166-170, 1998.         

Vertebral hydatid cysts are rare and found in less than 1% of all the cases of hydatidosis. Neural compression is common in vertebral hydatidosis. The prognosis is generally regarded as very poor. This paper examines the natural history and complications which may arise during the treatment of vertebral hydatid cyst, and discusses their treatment. Thirteen cases of hydatid disease affecting the vertebrae are presented. The patients were admitted with symptoms of spinal cord compression. Twelve were treated by laminectomy and one by costotransversectomy. Low back pain radiating to the legs and lower extremity weakness were the predominant symptoms. Different degrees of pareses were present in 12 patients. Nine patients had impaired sensation in lower extremities. In 13 patients, 27 operations were performed. The major complication of surgery was the death of one patient due to the formaline irrigation. The surgical goal should be an extensive removal of the cysts and affected bone. The surgical area needs to be irrigated with hypertonic saline. Mebendazole or albendazole therapy seems to retard the recurrences and control the disease.
 

Outcome of patients with myelomeningocele: Ege University experience.

Mirzai H,      Erşahin Y, Mutluer S. Child's Nerv Syst  14:120-123, 1998.

Split spinal cord malformations in children. Ersahin Y; Mutluer S; Kocaman S; Demirtas E .J Neurosurg, 88(1):57-65 1998 Jan

The authors reviewed and analyzed information on 74 patients with split spinal cord malformations (SSCMs) treated between January 1, 1980 and December 31, 1996 at their institution with the aim of defining and classifying the malformations according to the method of Pang, et al. METHODS: Computerized tomography myelography was superior to other radiological tools in defining the type of SSCM. There were 46 girls (62%) and 28 boys (38%) ranging in age from less than 1 day to 12 years (mean 33.08 months). The mean age (43.2 months) of the patients who exhibited neurological deficits and orthopedic deformities was significantly older than those (8.2 months) without deficits (p = 0.003). Fifty-two patients had a single Type I and 18 patients a single Type II SSCM; four patients had composite SSCMs. Sixty-two patients had at least one associated spinal lesion that could lead to spinal cord tethering. After surgery, the majority of the patients remained stable and clinical improvement was observed in 18 patients. CONCLUSIONS: The classification of SSCMs proposed by Pang, et al., will eliminate the current chaos in terminology. In all SSCMs, either a rigid or a fibrous septum was found to transfix the spinal cord. There was at least one unrelated lesion that caused tethering of the spinal cord in 85% of the patients. The risk of neurological deficits resulting from SSCMs increases with the age of the patient; therefore, all patients should be surgically treated when diagnosed, especially before the development of orthopedic and neurological manifestations.

Cerebrospinal fluid shunt complications.

Guzelbag E; Ersahin Y; Mutluer S

Turk J Pediatr, 39(3):363-71 1997 Jul-Sep

 

We report our experience with cerebrospinal fluid shunt procedures performed on 306 patients between 1983 and 1993. Patients were between the ages of one day and 15 years (average 14.9 months) on admission. Three hundred and thirty-six shunt placements and 274 revisions were done. The first complication occurred in the first postoperative month in 52 patients and within the first six months following surgery in 97 patients. Age was determined as a statistically significant factor in only infection and the slit ventricle syndrome (SVS). Shunt types and systems were not significant factors causing complications. The level of consciousness of the patients at the time of surgery influenced the rate of complications; patients with impaired consciousness at the time of surgery had higher complication rates than those operated on in a normal state of consciousness (41% and 8.5%, respectively).

Cerebellar mutism: report of two unusual cases and review of the literature.

Ersahin Y; Mutluer S; Saydam S; Barcin E Clin Neurol Neurosurg,99(2):130-4 1997 May

 

Mutism is not a common condition following cerebellar damage. Mutism following posterior cranial fossa surgery was first reported by Rekate et al. and Yonemasu in 1985. Since then, many case reports of mutism have appeared in the English literature. Very few cases developed mutism following brain stem surgery. Although mutism has been described in patients with head injury, only one case of mutism caused by a cerebellar injury has been reported, to our knowledge. We report on two patients in which the cerebellar mutism following a radical excision of an exophytic brain stem glioma and cerebellar injury developed. We reviewed the relevant literature and discussed the mechanism of cerebellar

Immunoglobulin prophylaxis in shunt infections: a prospective randomized study.

Ersahin Y; Mutluer S; Kocaman S

Childs Nerv Syst, 13(10):546-9 1997 Oct

 

Cerebrospinal fluid shunt infection is serious and one of the most frequent complications of shunt implantation. Age has been one of the most significant host factors for the development of shunt infections. A relative deficiency of the immune response against bacteria in infants could partly explain the higher infection rate in the very young patients. This prospective-randomized study was conducted in two groups: group A (immunoglobulin group) and group B (control group). There were 30 patients in each group. The patients in group A received intravenous immunoglobulin (Sandoglobulin) at a dose of 1 g/kg in the night before surgery. Each patient was followed up to 6 months. No infection was seen in group A. In group B, infection rate per procedure were 5.1% (P = 0.494) and 6.6% (P = 0.492), respectively. Intravenous immunoglobulin prophylaxis in infants seems to reduce the shunt infections.

Continuous external subdural drainage in the management of infantile subdural collections: a prospective study.

Ersahin Y; Mutluer S; Kocaman S

Childs Nerv Syst, 13(10):526-9 1997 Oct

Abstract

Continuous external subdural drainage (CESD) was suggested as a treatment step to be inserted prior to SP shunting, primarily because it makes it possible to avoid shunt placement in a significant number of patients. Thirty-three patients with symptomatic chronic subdural collection confirmed by computed tomography were included in this study. Unilateral CESD was performed in all cases, using a lumbar drainage set. The drains were left in place for no more than 10 days. A subduroperitoneal (SP) shunt was inserted in those patients in whom re-accumulation of the subdural collection had occurred. Of 33 patients, 17 were definitively treated by CESD and 16 subsequently needed an SP shunt. The cost of treatment with CESD was just less than half the cost of treatment with SP shunting. CESD can be used as a step before SP shunting in the management of chronic infantile subdural collections, since it is effective without further treatment in half the patients and safer than subdural tapping.

 

The effects of fronto-parieto-squamosal suture fusion on cranial growth: an experimental study.

Ulgen O; Gencosmanoglu R; Cankayali R; Tasdemir G; Mutluer S; Songur E

J Craniofac Surg, 7(2):122-9 1996 Mar

Abstract

Craniosynostoses have been known for at least 20 centuries, but their etiopathogeneses are still unclear. There are three main theories to explain the etiology of craniosynostosis, Moss's theory being the most popular. According to Moss, the development of the neurocranial form is viewed as an integration of the growth of the skull base, the calvarial bones, the meninges, and the enclosed brain. Experimental studies, however, are generally focused on cranial vault suture synostosis. This study aims to demonstrate the effects of cranial base synostosis by performing fronto-parieto-squamosal suture fusion. This fusion affected the whole cranial configuration. These effects were more prominent closer to the cranial vault, increasing at the anterior facial height and the lower facial length, reflected by ventral dislocation of the total face, and increasing of the kyphosis at the cranial base. It has also been demonstrated that synostosis of a junction point near the cranial base affects the vault and the base simultaneously. Any approach that tries to treat the cause, and not the symptom, of synostosis must, then, be based on an understanding of how cranial growth occurs and of how sutural growth processes are related to the totality of cranial growth.

 

Pediatric depressed skull fractures: analysis of 530 cases.

Ersahin Y; Mutluer S; Mirzai H; Palali I

Childs Nerv Syst, 1996 Jun, 12:6, 323-31

Abstract

Depressed skull fractures (DSFs) account for 7-10% of children admitted to hospital with a head injury and 15-25% of children with skull fractures. We reviewed the records of 530 patients operated on for DSF from January 1, 1973, to December 31, 1993. This group was made up of 357 boys (67%) and 173 girls (33%) whose ages ranged from 1 day to 16 years (mean age 6.1 years). Fall was the most common cause of injury. Of the 530 patients with DSF, 66% had compound fractures. The incidence of compound fractures increased with age. Compound fractures caused more brain lacerations (29%) than simple fractures (15.5%) did. We also classified DSFs radiologically as true, flat, or ping-pong ball fractures. Associated intracranial lesions were found to be a bad prognostic factor. There were 13 deaths (2.5%) in this series. Satisfactory results were achieved in over 95% of the patients. Compound fractures are associated with a worse outcome and a higher incidence of intracranial lesions and cortical laceration. Unilateral pupillary dilatation and an admission GCS score of 8 or less are ominous signs in regard to mortality. We also found that the deeper the depressed bone, the higher the risk of both dural tear and cortical laceration and the worse the prognosis. A conservative approach should be followed in cases of simple DSF without associated intracranial hematoma and in cases in which the bone depression is not deeper than 1 cm.

Cerebral astroblastoma resembling an      extra-axial neoplasm.

Yunten N; Ersahin Y; Demirtas E; Yalman O; Sener RN,    J Neuroradiol, 23(1):38-40 1996 Jun

Abstract A case of a cerebral astroblastoma is described in which MR imaging findings suggested the diagnosis of an extra-axial neoplasm. The lesion was proven to be intracerebral both surgically and histopathologically. Calvarial erosion, and buckling of the cerebral cortex by a peripherally located well circumscribed, highly enhancing mass, were the main MR findings leading to an errogenous preoperative diagnosis of an extra-axial mass. An astroblastoma should be included to the differential diagnosis of a superficially located tumor presenting with the findings of an extra-axial mass, especially in a young patient

Split cord malformations: report of three unusual cases.

Ersahin Y; Demirtas E; Mutluer S; Tosun AR; Saydam S

Pediatr Neurosurg, 24(3):155-9 1996

Abstract

The unified theory, proposed by Pang et al., explains the embryogenetic mechanisms of all variants of split cord malformations (SCMs). All SCMs originate from one basic error occurring around the time when the primitive neurenteric canal closes. The basic error is the formation of an accessory neurenteric canal between the yolk sac and amnion which is subsequently invested with mesenchyme to form an endomesenchymal tract that splits the notochord and neural plate. Three cases of SCMs which support this unified theory are presented. A 3-month-old girl had a combination of both types of SCMs at the level of T11. The 2nd case, a 2-week-old girl, had type-II SCM associated with a thickened filum terminale, lipomyelomeningocele and ectopic renal tissue within lipoma. A lipomatous tract extending from a subcutaneous lipoma to the intradural fibrous septum contained lymphoid tissues and tubular epithelia in a 3-month-old boy with a type-II SCM. These 3 cases support the unified theory.

 

Abdominal cerebrospinal fluid pseudocysts.

Ersahin Y; Mutluer S; Tekeli G

Childs Nerv Syst, 1996 Dec, 12:12, 755-8

Abstract

Abdominal cerebrospinal fluid pseudocyst in an infrequent complication of ventriculoperitoneal (VP) shunts. We reviewed ten patients with abdominal pseudocyst. There were five girls and five boys, aged between 4 months and 14 years. The number of shunt procedures prior to the presentation varied between one and five. Only one patient had had a previous shunt infection. No patients had undergone prior abdominal surgery other than VP shunting. The time from the last shunting procedure to the development of abdominal pseudocyst ranged from 3 weeks to 5 years. Presenting symptoms and signs were mainly related to abdominal complaints in all patients. Three patients also had signs of shunt malfunction. The diagnosis was made by ultrasound in all patients. Shunt infection was determined in six patients. Repositioning if the peritoneal catheter seemed to have a higher rate of recurrence. The diagnosis of abdominal pseudocyst should be considered in VP-shunted patients presenting with abdominal complaints.

Medical abortion: ethics, laws and religious points of view, A study by the 1994-1995 Ethics and Morals Committee of the ISPN.

Hirsch JF; Bhagwati SN; Epstein F; Hoppe-Hirsch E; Mutluer S;Raimondi AJ.  Childs Nerv Syst, 12(9):507-14 1996 Sep

Abstract

Central nervous system malformations are now frequently detected prenatally. Unfortunately, the progress in diagnosis having far outstripped that in therapeutics, the only question to answer is usually whether the pregnancy should be continued or terminated. Pediatric neurosurgeons have to deal with such problems more and more often. They are asked to give an opinion on the prognosis. In many cases the law requires their involvement in the decision about the possibility of a "therapeutic", or more correctly a medical, abortion. The final decision is based on the religious attitutes of the family and the neurosurgeon and on the law of the country in which the medical abortion would be performed. This article reviews the points of view of the main religions and also the laws in different countries. This knowledge may be of some help to neurosurgeons, especially when the religious attitudes of those involved are different or when their final decision is not in accordance with the law of the country.

Cerebellar Mutism: Report of Seven Cases and Review of the Literature.

Yusuf Ersahin; Saffet Mutluer; Sedat Çagli; Yusuf Duman. Neurosurgery 1996; 38 (1):60­66

ABSTRACT:It is well known that degenerative disease, hemorrhage, infection, and neoplastic disease of the cerebellum can lead to speech disorders. Mutism after posterior cranial fossa surgery was first reported by Rekate et al. and Yonemasu in 1985. We review and analyze the cases of cerebellar mutism that are reported in the literature that is available in English. We found 39 reported cases that included details regarding mutism. We review and analyze a total of 46 cases, including those of our seven patients. The ages of the patients ranged from 2 to 61 years (mean, 10.4 yr). Ninety-one percent of the patients were children. The vermis was the site of the mass lesions in >90% of the cases. The pathological findings of the lesions were as follows: 33 medulloblastomas, 7 astrocytomas, 4 ependymomas, 1 metastatic tumor, and 1 arteriovenous malformation. All mass lesions were considered to be large or very large. The latency for the development of mutism ranged from 0 to 6 days (mean, 1.7 d). The mutism lasted from 4 days to 4 months (mean, 6.8 wk). Dysarthric speech ensued after the mutism was resolved in 35 of 46 patients. Mutism was transient in all of the cases. Cerebellar mutism is a transient complication of posterior fossa surgery for midline mass lesions.

A case of thalamic hydatid cyst.

Ersahin-Y; Mutluer-S; Demirtas-E; Yurtseven-T   Clin-Neurol-Neurosurg. 1995 Nov; 97(4): 321-3

ABSTRACT: Cerebral hydatidosis account for approximately 1-2% of patients with hydatid disease. Fifty percent to 75% of intracranial hydatid cysts are seen in children. The cerebral hydatid cysts are usually single and located in the watershed of the middle cerebral artery. To our knowledge, no case of hydatid cyst in the thalamic location has been reported. A 4-year-old boy presented with the left sided weakness. A right thalamic hydatid cyst without rim enhancement and perifocal oedema was detected on the computed tomographic (CT) scan. He was put on albendazole, but headache, nausea and vomiting developed and hemiparesis got worse in the following two weeks. The non-contrast repeat CT showed the pericystic oedema. The rim enhancement and pericystic oedema were also present on magnetic resonance imaging scans. The right thalamic hydatid cyst was removed via the transcallosal approach. The cyst aspiration and intracystic injection of hypertonic saline were performed before the cyst removal. Leakage of the cyst fluid was conceivably the cause of the development of rim enhancement and pericystic oedema. Patients receiving albendazole for the treatment of cerebral hydatid cysts should be closely followed. The surgery is still the choice of treatment in cerebral hybrid cysts, in our opinion.

A case of Rathke's cleft cyst presenting with diabetes insipidus.

Ersahin-Y; Ozdamar-N; Demirtas-E; Mutluer-S  Clin-Neurol-Neurosurg. 1995 Nov; 97(4): 317-20

ABSTRACT: Rathke's cleft cysts (RCCs) are considered to arise from the remnants of Rathke's pouch, an invagination of the stomodeum. They are classically described as benign epithelium lined intrasellar cysts containing mucoid material, and also found in 2-33% of routine autopsy series. The most common presenting symptoms are visual impairment, hypothalamic dysfunction, hypopituitarism and headache. Diabetes insipidus has been described in patients with RCC. Very few cases presented with only diabetes insipidus in adults. To our knowledge, our patient is the first case of RCC presenting with only diabetes insipidus in childhood. A 9-year-old girl presented with diabetes insipidus. The physical, neurological and endocrinological examinations were normal, except for diabetes insipidus. Magnetic resonance imaging scan revealed a hyperintense lesion with supra sellar extension in the posterior pituitary both on T1 and T2 weighted images. Subtotal excision of RCC was performed via transsphenoidal surgery. However, diabetes insipidus persisted after the surgery.

Antenatally diagnosed neonatal craniopharyngioma.

Kultursay-N; Gelal-F; Mutluer-S; Senrecper-S; Oziz-E; Oral-R  J-Perinatol. 1995 Sep-Oct; 15(5): 426-8

ABSTRACT: A case of neonatal craniopharyngioma diagnosed by fetal ultrasonography at 29 weeks and by magnetic imaging at 35 weeks of gestation is presented with clinical and neuroradiologic findings. This is a rare tumor and only 10 cases of neonatal craniopharyngioma have been previously reported .

Hydrocephalus in Guillain-Barre syndrome.

Ersahin-Y; Mutluer-S; Yurtseven-T

Clin-Neurol-Neurosurg. 1995 Aug; 97(3): 253-5

ABSTRACT: Hydrocephalus and pseudotumour cerebri are a rare complication of Guillain-Barre syndrome (GBS), occurring in about 4% of the cases. The high concentration of cerebrospinal fluid (CSF) protein may lead to a decreased CSF absorption in arachnoid villi. A 10-year-old boy with GBS and hydrocephalus is presented. A mechanical ventilation was required 7 days after admission and he had been on the mechanical ventilation for 6 weeks. Lumbar puncture performed on admission revealed clear CSF with an opening pressure of 15 cm H2O and no cells, a normal glucose level and a protein of 240 mg/dl. He complained of headache and diplopia 11 weeks after admission. Fundoscopy revealed papilloedema, and bilateral mild abducens pareses were also detected. Magnetic resonance imaging displayed a communicating hydrocephalus and interstitial oedema. A ventriculo-peritoneal shunt relieved the symptoms of intracranial hypertension. In GBS, serial computed tomographic scans should be performed in patients with headache and papilloedema. Hydrocephalus may develop in GBS.

A method for continuous external drainage in the management of infantile subdural collections.

Ersahin-Y; Mutluer-S 

Childs-Nerv-Syst. 1995 Jul; 11(7): 418-20

ABSTRACT: There is no consensus on the management of infantile chronic subdural collections. Subdural tapping, craniotomy and removal of membranes, and shunting from the subdural space have all been used. We performed continuous external subdural drainage (CESD) as a step prior to subdural-peritoneal shunt placement in the management of infantile chronic subdural fluid collections. A lumbar drainage set was used for CESD. The catheter was placed in the subdural space through the anterior fontanel with a Touhy needle. This percutaneous technique seems an easy and safe method for CESD in infants with chronic subdural collections.

Multiple brain abscesses following esophageal dilation.

Ersahin-Y; Mutluer-S; Cakir-Y,

Childs-Nerv-Syst. 1995 Jun; 11(6): 351-3

ABSTRACT: A 6-year-old boy esophageal stricture due to the ingestion of caustic 7 months prior to admission. Eight esophageal dilations and a feeding gastrostomy were performed. He presented with seizure, right-sided weakness, fever, and somnolence. Computed tomographic scans revealed multiple brain abscesses. The abscesses were treated by burr-hole drainage. The patient improved and was discharged from the hospital without neurological deficit. Brain abscesses are not very common following esophageal dilation. It should be kept in mind that brain abscess is a potential complication of esophageal dilation.

Cerebrospinal fluid shunt infections.

Ersahin-Y; Mutluer-S; Guzelbag-E

J-Neurosurg-Sci. 1994 Sep; 38(3): 161-5

ABSTRACT: Cerebrospinal fluid (CSF) shunt infection is one of the most frequent and disabling complications. We reviewed the records of 306 patients who underwent CSF shunt surgery from 1983 through 1992. Six hundred and twelve procedures were performed in these 306 patients. Infection occurred following 46 of the procedures for an infection rate of 7.5% per procedure. The 46 infections involved 39 patients. There were 8 recurrent infections. The infection rate per child was 12.7%. Staphylococcal species were isolated in 50% of all infections. Patients younger than 1 year old and children with multiple revisions have a greater risk of infection than those of older. Myelomeningocele and meningitis had higher infection rate among other etiologies. Patients with multiple revisions had higher infection rate than those with single revision or none. The incidence of infection was higher in cyst-peritoneal shunts than both ventriculo-atrial and ventriculo-peritoneal shunts. Mortality was high in Gram negative infections.

Brain abscess in infants and children.

Ersahin-Y; Mutluer-S; Guzelbag-E

Childs-Nerv-Syst. 1994 Apr; 10(3): 185-9

ABSTRACT: Forty-four consecutive patients with brain abscesses, aged between 1 month and 16 years, were reviewed. The cause of abscess was meningitis in 36% of the cases, otitis in 27%, head injury in 16%, congenital heart disease in 9%, other in 5%, and undetected in 5%. Thirty patients had a single abscess and 12 had multiple abscesses. Multiloculated abscess was present in 2. Total excision was accomplished in 22 patients. Three patients underwent needle aspiration. Drainage of the abscess was performed in 13. Secondary excision was needed in 5 patients. One patient was treated nonsurgically. Streptococci, staphylococci and Proteus mirabilis were the microorganisms recovered in cultures. Overall mortality was 20% (9 patients). Mortality was significantly higher in patients under 2 years of age than in those older. Of 15 patients who were comatose at the time of admission, 6 died. Etiology, diagnostic method, and treatment modalities were not found to be significant factors in terms of predicting mortality.

Transorbital stab wound: a case report.

Ersahin-Y; Mutluer-S; Guzelbag-E

Turk-J-Pediatr. 1994 Jan-Mar; 36(1): 71-5

ABSTRACT: Stab wounds of the skull are uncommon. They are usually accidental in children. An apparently trivial wound may cause death due to vascular damage or infection. A 5-year-old boy presented with a nail in the left intraorbital region. He fell with a nail in his hand five hours prior to hospital admission. Computed tomographic scans displayed the nail penetrating the cranium through the left orbital roof and extending towards the left anterior clinoid process. The nail was removed under general anesthesia in the operating room. Meningitis developed two days after the removal of the penetrating object and responded well to antibiotics. The pertinent literature was reviewed.

Dumbbell ganglioneuromas in childhood.

Mutluer-S; Ersahin-Y; Binatli-O; Demirtas-E

Childs-Nerv-Syst. 1993 Jun; 9(3): 182-4

ABSTRACT: The incidence of dumbbell tumors among spinal neoplasms is between 10% and 15%. Approximately 1% of neoplasms located at or near the spinal cord are ganglioneuromas. Ganglioneuromas are rare, slow-growing, benign tumors arising from sympathetic ganglia. The cases of two children with spinal dumbbell ganglioneuroma are presented. The tumors were totally resected by combined surgery in both patients. The patients are neurologically intact 5 and 4 years respectively after surgery.

Intracranial hydatid cysts in children.

Ersahin-Y; Mutluer-S; Guzelbag-E

Neurosurgery. 1993 Aug; 33(2): 219-24

ABSTRACT: Brain involvement in hydatid disease occurs in 1 to 2% of all Echinococcus granulosus infections. Fifty to 75% of intracranial hydatid cysts are seen in children. This study included 19 children who underwent surgery for intracranial hydatid cysts between January 1979 and September 1992. There were 12 boys and 7 girls, ages 3 to 16 years (mean, 8.1 yr). Headache and vomiting were the predominant symptoms. Papilledema was present in 16 patients, and 2 patients had secondary optic atrophy. A round, cystic lesion without perifocal edema and rim enhancement was detected on the computed tomographic scans of 13 patients. The cystic lesions with rim enhancement and perifocal edema were noted on the computed tomographic scans of 3 patients. Of these three patients, two subsequently had a recurrence. Total removal of the cyst without rupture was achieved in 12 patients. Only a 3-year-old boy in whom the cyst ruptured at surgery died. Seven patients in whom either the hydatid cyst ruptured at surgery or there was systemic hydatid disease received mebendazole therapy. Mebendazole seems to be effective in hydatid disease. Cerebral hydatid cysts should be removed in toto without rupture. The preoperative diagnosis is very important in planning surgery. When a cystic lesion is detected on computed tomographic scan, hydatid disease should be taken into consideration in countries where hydatid disease is endemic.

Air in acute extradural hematomas: report of six cases

Ersahin-Y; Mutluer-S

Surg-Neurol. 1993 Jul; 40(1): 47-50

ABSTRACT: Presence of air in acute extradural hematomas has been described by several authors. Little attention has been paid to its significance. We report six pediatric patients with air-containing extradural hematomas. A fracture involving air-containing structures in either anterior or middle cranial fossa was detected on computed tomographic scans of all patients. The pertinent literature was reviewed.

Extradural hematoma: analysis of 146 cases.

Ersahin-Y; Mutluer-S; Guzelbag-E

Childs-Nerv-Syst. 1993 Apr; 9(2): 96-9

ABSTRACT: One hundred forty-six consecutive patients operated on for extradural hematoma (EDH) from 1979 through 1991 were analyzed. This series included patients from both before and after the advent of computed tomography (CT). There were 102 boys and 44 girls, aged 1-16 years. All patients underwent plain skull X-radiography. CT scans were obtained in 72 cases and angiography was performed in 10. Thirty patients with EDH did not have skull fractures. Falls were predominant among the modes of injury. Thirty-seven percent of patients had a lucid interval. The overall mortality was 10%. The mortality rates in the CT and plain X-ray groups were 6% and 16% respectively. There was only one death in patients who did not have a lucid interval. The Glasgow Coma Scale scores of all patients who died in this series were less than 8. We concluded that mydriasis, comatose state at the time of operation, and a lucid interval are ominous signs in the prediction of outcome.

Posterior fossa extradural hematomas in children.

Ersahin-Y; Mutluer-S 

Pediatr-Neurosurg. 1993; 19(1): 31-3

ABSTRACT: Posterior fossa extradural hematomas (PFEHs) are less frequent than supratentorial extradural hematomas. 9 children operated on for PFEH are reported. There were 5 boys and 4 girls aged from 1 to 16 years. The mode of injury was fall in 6 and traffic accident in 3 cases. Diagnosis of PFEH was made by computed tomography (CT) scanning in 8 cases. In 1 patient, who deteriorated suddenly, respiratory arrest developed before surgery, and the patient died in spite of evacuation of the hematoma. CT scanning enables early diagnosis and reveals the associated supratentorial lesions. Prompt surgical evacuation of PFEHs is the treatment of choice.

A case of double-compartment hydrocephalus presenting with opisthotonus.

Ersahin-Y; Mutluer-S; Guzelbag-E 

Surg-Neurol. 1992 Oct; 38(4): 291-293

ABSTRACT: Double-compartment hydrocephalus, a rare shunt complication, is caused by occlusion of the aqueduct and the fourth ventricular outlets after shunting of the lateral ventricles. Dilation of the fourth ventricle causes brain-stem dysfunction and cerebellar signs. A case of double-compartment hydrocephalus presenting with opisthotonus is presented, and the relevant literature is reviewed.

Vitamin A-induced suppression/enhancement of protein glycosylation and neurulation.

Ersahin-Y; Higbee-RG; Vanden-Hoek-T; McLone-DG; Knepper-PA

  Pediatr-Neurosci. 1987; 13(6): 293-303

ABSTRACT: Glycoconjugates play major roles in many cellular functions, e.g. cell migration and cell-to-cell adherence, which are involved in neurulation. The maternal administration of vitamin A on gestation day 8.5 and 9.0 resulted in a high percentage of primary and secondary neurulation defects in gestation day 12 mouse embryos. The neuroepithelium of normal and abnormal embryos was analyzed by one- and two-dimensional sodium dodecyl sulfate polyacrylamide gel electrophoresis and one-dimensional Western blots using concanavalin A (Con A) and peroxidase-conjugated wheat germ agglutinin (WGA) lectins. In vitamin A abnormal embryos, WGA binding was decreased to glycoproteins with apparent molecular weights of 15,000 and 30,000 daltons on Western blots, whereas in vitamin A normal embryos, WGA binding was increased to these glycoproteins on Western blots. Computer-aided fluorescence microscopy using fluorescein isothiocyanate (FITC)-conjugated lectins on 1-micron araldite plastic sections indicated a decrease in FITC-WGA binding to the free surface of nonneurulated neuroepithelium. These results suggest: (1) vitamin A administration may have induced a suppression of WGA-binding carbohydrate residues on 15,000- and 30,000-dalton glycoproteins in abnormal embryos, and (2) modification in the type, amount, and distribution of glycoconjugates may provide a basis for the cellular mechanisms of abnormal development of the neural tube.

Ossifying fibroma of the occipital bone.

Binatli-O; Ersahin-Y; Coskun-S; Bayol-U

Clin-Neurol-Neurosurg. 1995 Feb; 97(1): 47-9

ABSTRACT: A case of occipital ossifying fibroma in a 13-year-old girl is presented. Ossifying fibroma is a rare, benign, primary bone tumour that occurs most commonly in the mandible. Cranial vault location is extremely rare. To our knowledge, our patient is the second case of occipital location reported. Total surgical excision is the treatment of choice.

Spinal extradural arachnoid cyst.

Ersahin-Y; Yildizhan-A; Seber-N

  Childs-Nerv-Syst. 1993 Jul; 9(4): 250-2

ABSTRACT: The case of 16-year-old boy with a spinal extradural arachnoid cyst is presented. An extradural arachnoid diverticulum extending from T10 to L1 was excised totally with hemilaminectomy. Surgery caused prompt improvement of the neurological deficit. The pertinent literature is reviewed.

A new understanding of dorsal dysraphism with lipoma (lipomyeloschisis): radiologic evaluation and surgical correction.

Naidich-TP; McLone-DG; Mutluer-S

AJR-Am-J-Roentgenol. 1983 Jun; 140(6): 1065-78

ABSTRACT: The spinal anomaly designated dorsal dysraphism with lipoma (lipomyeloschisis) consists of skin-covered, focal spina bifida; focal partial clefting of the dorsal half of the spinal cord; continuity of the dorsal cleft with the central canal of the cord above (and occasionally below) the cleft; deficiency of the dura underlying the spina bifida; deep extension of subcutaneous lipoma through the spina bifida and the dural deficiency to insert directly into the cleft on the dorsal half of the cord; variable cephalic extension of lipoma into the contiguous central canal of the cord; and variable ballooning of the subarachnoid space to form an associated meningocele. The variable individual expressions of the anomaly are best understood by reference to their archetypal concept. Careful analysis of radiographic and surgical findings in human lipomyeloschisis and correlation with an animal model of lipomyeloschisis indicate that plain spine radiographs and high-resolution metrizamide computed tomographic myelography successfully delineate the precise anatomic derangements associated with lipomyeloschisis and provide the proper basis for planning surgical therapy of this condition.