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34 Prophylactic Surgery forNeurosurgical Pathologies
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Fig. 34.2 Vestibular schwannoma of left pontocerebellar
angle in a 23-year-old woman. The patient presented with
numbness in the left face half. Neurological examination
showed hypoesthesia in the left face half. Preoperative CT
scan demonstrated a tumor in the left pontocerebellar
angle (a, b). Preoperative T1- and T2-weighted MRIs (c,
d) and T1-weighted axial and coronal MRIs with contrast
h
(e, f) suggested a vestibular schwannoma in the left pontocerebellar angle. Total tumor excision was performed with
the left rectosigmoid approach. The patient was very good
postoperatively. Postoperative T1-weighted axial and coronal MRIs with contrast (g, h) conrmed total tumor excision. Histopathological examination conrmed the
vestibular schwannoma
compression. In prolactinomas, if there is no chiasm compression, medical treatment should be
considered rst [13–17].
Metastatic brain tumors are mostly of lung
carcinoma origin in men, while breast carcinoma
origin is seen in women. In children, neuroblastoma, lymphoma and rhabdomyosarcoma are the
causes of metastasis. In supratentorial single
metastases and posterior fossa metastases, surgical treatment should be kept in mind to contribute
to primary treatment [18, 19] (Fig.34.4).
34.4 Cerebrovascular Diseases
Spontaneous subarachnoid hemorrhages (SAH)
can lead to coma or even death. The incidence of
SAH is between 4 and 20 per 100,000 per year.
The rate of SAH from unruptured aneurysms is
1% per year. Aneurysms are the commonest
cause of SAH, which may also result from a ruptured arteriovenous malformation (AVM), from a
tumor or from a blood dyscrasia. Preventive surgical treatments are carried out especially for
cerebral aneurysms, AVMs, cavernous angiomas,
especially due to possible risk of bleeding
(Figs. 34.5 and 34.6). Early diagnosis and prophylactic treatment play a very important role in
reducing morbidity and mortality of patients due
to aneurysm rupture. The main purpose of early
diagnosis and prophylactic treatment is to prevent complications caused by aneurysm rupture
and ischemia. Combining endovascular treatment and surgical treatment increases the success
rate while reducing the complications, in the prophylactic treatment of AVMs. Since cavernoma
can show both bleeding and growth, prophylactic
surgical treatment can be performed especially to
prevent the development of bleeding and neurological decits [20–29].
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Fig. 34.3 Right anterior skull base meningioma in a
60-year-old woman. The patient presented with a headache. Neurological examination was normal. Preoperative
CT scan (a) and T1- and T2-weighted MRIs (b, c) and
T1-weighted axial and coronal MRIs with contrast (d, e)
34.5 Stroke
Over 80% of all rst strokes are due to cerebral
infarction. Only 10% of rst strokes are due to
hemorrhage primarily into parenchyma. The rst
hallmark of a stroke is its sudden onset. The second is the presence of focal symptoms and signs.
When the focal sign happens to be a hemiparesis,
the diagnosis of stroke may come to mind quite
easily. For diagnosis of stroke, CT, MRI and
DSA are the most important investigations. Both
medical (antiplatelet agents, anticoagulants) and
surgical treatments (carotid endarterectomy,
bypass) should be considered to prevent the
development of symptoms and signs due to
show a tumor at the right anterior skull base. Total tumor
excision was performed. Postoperative period was
uneventful. Postoperative control CT scan (f). There is no
residue of the tumor. Histopathological examination
revealed a meningothelial meningioma
stroke. Decompressive therapy may be necessary
if intracranial pressure increase continues despite
medical treatment [1, 30–32]. Prophylactic surgeries are important to prevent the development
of ischemia in diseases that cause recurrent ischemia, such as moyamoya disease. For this purpose, direct revascularization operations should
be considered (Fig.34.7) [33].
34.6 Head Injury
Today, head injuries in, especially, children and
young people are an important cause of morbidity and mortality. On the other hand, some head
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34 Prophylactic Surgery forNeurosurgical Pathologies
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Fig. 34.4 Top row: Pituitary adenoma in a 41-year-old
man. MRIs. The patient presented with the complaints of
growth in his hands and feet, drinking too much water and
urinating too much. Laboratory investigations revealed
hyperglycemia, somatomedin-C (IGF-1) height and
growth hormone height. Preoperative coronal T1- and
T2-weighted without contrast (a, b) and coronal T1- and
sagittal T1-weighted with contrast (c, d) MRI examinations show pituitary macroadenoma. A gross total tumor
excision was performed with transsphenoidal endoscope-
injuries can lead to serious and life-threatening
complications. For example, delays in patients
with traumatic intracranial hematomas will lead
to increased morbidity and mortality. Trafc
accidents attract attention as the most common
cause of head injuries. CT scan is the denitive
radiographic study in the evaluation of head
injury. It greatly improves diagnostic accuracy
and facilitates management. In the early period
following head traumas, brain damage may be
caused by direct intracranial pressure increase,
especially with hemorrhages, and brain damage
caused by ischemia and hypoxia may also cause
deterioration in patients. The management of
head injuries is aimed at preventing secondary
injury (Fig.34.8). In patients who develop cerebrospinal uid leaks after head trauma, dura
repair and antibiotic treatment should be performed to prevent the development of meningitis
[34–37] (Fig.34.9).
assisted surgery. There was no postoperative problem.
Bottom row: Supratentorial single metastasis in a 36-yearold man with lung carcinoma. The patient was admitted
with headache and left hemiparesis. Preoperative
T1-weighted axial and T1-weighted axial with contrast
MRIs (a, b) show a tumor in the right parietal. Preoperative
thorax CT demonstrates a tumor in the right lung (c).
Tumor was gross total excised. The patients’s hemiparesis
was improved in postoperative stage. Brain edema was
decreased in postoperative CT scan (d)
34.7 Spinal, Spinal Cord
andPeripheral Nerve
Injuries
Spinal and spinal cord injuries are among the most
important problems that can lead to the development of permanent neurological decits. Preventive
surgeries are of great importance for the prevention
of permanent neurological decits. In cases where
neural tissue is preserved and deterioration occurs
in the stabilization of the vertebrae, early diagnosis
and prophylactic surgical stabilization are vital. In
case of deterioration in the stabilization of the vertebrae, prophylactic surgery is also important in
terms of stopping neurological deterioration if neural effects have begun (Fig.34.10) [38–40].
Especially in peripheral nerve injuries that do not
develop neurological decits or are partially developed, good results can be obtained in case of early
diagnosis and prophylactic surgical treatment [41].
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Fig. 34.5 Top row: Cavernous segment aneurysm of
internal carotid artery in a 60-year-old man. The patient
was admitted for 3months with double vision. On neurological examination, there was restriction on the left side
with ptosis and upward and downward gaze. Preoperative
T1-weighted axial MRI with contrast (a) and DSAs (b, c)
demonstrate cavernous segment aneurysm of the left
internal carotid artery. The patient was operated under
general anesthesia. Direct clipping was applied to the
aneurysm. There were no problems after surgery. There is
no aneurysm on postoperative DSA examination (d).
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Bottom row: Cerebellar cavernous angioma in a 16-yearold boy. The patient presented with headache, nausea and
vomiting complaints. He had ataxia. Contrast-free brain
CT examination shows a hematoma in the cerebellar
hemisphere (a). T1- and T2-weighted MRIs demonstrate a
acute hematoma (b, c). The patient was operated under
general anesthesia. Vascular malformation with hematoma was excised in the operation. There was no problem
after the operation. Histopathological examination conrmed a cavernous angioma. Postoperative CT scan was
normal (d)
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Fig. 34.6 Right frontal parasagittal AVM in a 34-yearold man. The patient presented with the complaint of
headache. His neurological examination was normal.
Preoperative T1- and T2-weighted axial MRIs without
contrast (a, b) and T1-weighted axial, coronal MRIs (c, d)
with contrast show AVM in the right frontal parasagittal
location. Anteroposterior and oblique MRAs (e, f) reveal
feeders from the distal anterior cerebral artery. Its drainage is in the superior sagittal sinus. The patient was operated under general anesthesia. Total AVM excision was
performed. There were no problems after surgery.
Postoperative MRA was normal (g)
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34 Prophylactic Surgery forNeurosurgical Pathologies
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Fig. 34.7 Moyamoya disease in a 10-year-old girl. The
patient presented with complaints of loss of strength in
her arms and legs, and generalized seizures that did not
pass with triple antiepileptic drugs. Her neurological
examination revealed quadriparesis. Preoperative CT
scan, T1- and T2-weighted axial and diffüzyon MRIs,
SPECT and MRA views demonstrated total occlusion of
ICA, neovascularization associated with bilateral parietooccipitale infarct (a–f). Pial synangiosis surgeries were
performed using the parietal branch of the external carotid
artery on the right side and then on the left side with an
interval of 9months. There was no new nding in air,
diffusion and MRA examinations performed 1year later
(g–i)
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Fig. 34.8 Secondary ischemia following closed head
trauma in 10-year-old boy. The patient was brought to the
emergency room after a trafc accident. The patient was
unconscious and had no lateralized signs. CT scan shows
right frontal fragment fracture (a). Epidural hematoma
and ischemia developed 2days later (b). The hematoma
was drained. Abscess in left hemisphere in 15-year-old
female. The patient was brought to the emergency room
34.8 Spinal Cord andRoot
Pressures
after the fall. Skin incision and fracture were detected in
the left parietal. The skin was sutured. The patient was
given antibiotics. Intracranial surgical pathology was not
detected in CT scan (a). After 15 days, intracerebral
abscess developed in the left hemisphere (b). Abscess
drainage was performed by surgical intervention. In the
microbiological examination, S. aureus reproduced.
Antibiotic treatment was applied for 8weeks
extramedullary tumors are the second most common and come from the leptomeninges or nerve
roots. These tumors are located inside the dura,
Spinal tumors can be classied into three groups
based on their locations: extradural, intraduralextramedullary and intramedullary. Extradural
tumors are most common, as they occupy the
vertebrae body or structures outside the dura.
They are most commonly metastatic. Intradural-
but external from the spinal cord, as exemplied
by meningiomas or neurobromas [42, 43].
Ependymomas and astrocytomas are the most
commonly encountered intramedullary spinal
cord tumors, followed by hemangioblastomas
[44–47] (Fig. 34.11). Tumors leading to spinal
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Fig. 34.9 Diffuse pneumocephalus in a 74-year-old
patient. The patient was brought to the emergency room
after falling from a height. Neurological examination of
the patient was normal. There were headaches and rinore.
CT scan shows diffuse pneumocephalus and fracture of
cord compression are extradural malignant
tumors in adult ages, while children have lymphoma, neuroblastoma and sarcomas [48]. Glial
tumors, especially intramedullary astrocytoma
and ependymoma and intradural-extramedullary
meningioma and schwannomas, leading to spinal
cord compression, can be without symptoms and
signs. In patients with spinal cord compression,
even if there are no symptoms or signs, prophylactic surgery should be performed to prevent
permanent neurological decits. Surgical interventions should be kept in mind in order to prevent permanent neurological decits even in
patients with spondylotic radiculopathy and
myelopathies [49–52], together with intervertebral disc hernias that cause advanced compression [53–56].
the frontal sinus (a, b). The patient was operated. Both
dura repair and frontal sinus repair were performed.
Postoperative stage was uneventful. Control CT scans was
normal (c, d)
Abscesses caused by bacterial infections or
lesions due to parasitic infections, such as hyda-
tid cysts, can lead to increased intracranial pres-
sure. Surgical treatment is applied in central
nervous system infections due to the risk of neu-
rological deterioration [57, 58].
Taenia Echinococcus causes hydatid disease.
Cerebral hydatid cysts are mostly seen in children and young adults. The most common symptom is headache and vomiting due to increased
intracranial pressure. Diagnosis can be made
with CT scan and MRI (Fig.34.12). It is important to remove the hydatid cysts without rupture
[59, 60].
34.10 Congenital Hydrocephalus
34.9 Brain Abscess andCerebral
Hydatid Cyst
Brain abscess is a focal suppurative infection of
the brain parenchyma. Its incidence is 1.3 per
100,000. They usually occur in the third and
fourth decade. Brain abscess is more common in
patients who have undergone bone marrow and
solid organ transplantation, AIDS and neutropenic. Intracranial abscesses can be seen after a
direct spread of a neighboring infection, such as
the ears and sinuses, or a previous head injury.
Brain abscess usually presents as a focal decit.
Hydrocephalus is a common but complex condition caused by physical or functional obstruction of cerebrospinal uid ow that leads to
progressive ventricular dilatation. The incidence
is 1 in 1000 births. Congenital obstructive or
communicated hydrocephalus can be diagnosed
by ultrasonography and magnetic resonance
imaging in the prenatal period. Early diagnosis
in the prenatal period facilitates prophylactic
surgical interventions in the neonatal period or
in infants without the emergence of neurological decits. The main causes of congenital
hydrocephalus are aqueductal stenosis, spina
bida (myelomeningocele) and Dandy-Walker
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Fig. 34.10 Top row: Odontoid fracture in an 80-year-old
woman. The patient presented with neck pain after falling.
Her neurological examination was normal. Cervical T1and T2-weighted sagittal MRIs and cervical sagittal CT
scan examinations show the odontoid fracture in the second cervical spine (a–c). Odontoid fracture was xed with
screw. Control CT scan was normal (d). The patient was
malformation. The most preferred surgical treat-
very well after the operation. Bottom row: Thoracic vertebral fractures in a 56-year-old man. The patient was
admitted with post-fall back pain. His neurological examination was normal. Preoperative spinal CT scan (a), T1and T2-weighted sagittal MRIs (b, c) show fractures of
fth and seventh thoracic vertebra. Images of kyphoplasty
are seen in postoperative CT (d)
34.11 Craniosynostosis
ment method in congenital hydrocephalus is
ventriculoperitoneal shunts. In addition, if intraventricular bleeding is detected during prenatal
follow-up, ventriculosubgaleal shunts can be
applied in the premature or neonatal period to
prevent the development of hydrocephalus and
neurological decits (Fig.34.13) [3–5, 61, 62].
Craniosynostosis is the clinical condition that
results from premature fusion of one or more
sutures between the bones. Sagittal synostosis is
the most common type of craniosynostosis and is
most often seen in those who are nonsyndromic.
Physical examination is very important in the
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Fig. 34.11 Cervical intramedullary tumor in a 45-yearold man. The patient presented with a loss of strength in
his arms for 15days. Cervical T1- and T2-weighted sagittal MR examinations show the intramedullary tumor (a,
b). Gross total tumor excision was performed.
Histopathological examination conrmed the ependymoma. The patient was very well after the operation.
There was no problem in control MR examinations (c, d)
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Fig. 34.12 Right frontal abscess in a 5-year-old girl. The
patient presented with a headache complaint. She had no
neurological decit. Contrast-free and contrast-enhanced
brain CT examinations show an abscess in the right frontal lobe, the content of which was hypodense and peripheral hyperdense (a, b). The patient was operated under
general anesthesia. Right frontal burr hole was opened.
Abscess was drained. There was no problem after the
operation. Staphylococcus aureus was detected on the
microbiological examination. Antibiotic treatment was
applied for 6 weeks after the operation. There was no
abscess in the control contrast-enhanced CT scan
3months after surgery (c)
diagnosis of craniosynostosis. In new borns and
infants diagnosed with craniosynostosis, prophylactic surgical intervention can be planned in the
early months without any physical and neurological problems. In congenital diseases, such as
tethered spinal malformation and tethered spinal
cord syndrome diagnosed in the neonatal period
or prenatal period, preventive surgical interventions should be performed without any neurological decits (Fig.34.14) [63–66].
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Fig. 34.13 Premature posthemorrhagic hydrocephaly in
CT scan of 30th pregnancy month (a). Hydrocephaly was
decreased after ventriculosubgaleal shunt (b, c). CT scan
demonstrates a ventriculoperitoneal shunt 3months after
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Fig. 34.14 Left coronal suture synostosis in a 3-monthold baby. The patient was brought due to a deformity in
her head. 3D CTs and CT scan show left coronal suture
34.12 Meningocele,
Myelomeningocele, Cranial
Dysraphism
Meningocele is located in the midline on the
spine. It is a cystic cavity formed by meningeal
the ventriculosubgaleal shunt (d). There is no hydrocephaly in T1- and T2-weighted axial MRIs 12months after
the ventriculoperitoneal shunt (e, f)
synostosis (a–d).The patient was operated in 9-monthold. Bilateral linear craniectomies were performed parallel to the closed coronal suture
structures out of the spina bida defect. There is
a thin skin or membrane on the cyst.
Embryologically, it is assumed to develop after
the neurulation stage is complete. The majority
of patients do not have neurological decits. The
purpose of prophylactic therapy is to prevent the
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development of infection after rupture. In addition, cosmetic causes are indications for surgical
treatment [67, 68].
Myelomeningocele is one of the most common serious congenital malformations. Myelomeningocele is an open spinal dysraphism, in
which the spinal cord is not open as a result of
neurulation defect. Its incidence is 1in 1000 live
births. The purpose of preventive therapy is to
prevent the development of infection. However,
postnatal surgery does not reverse or prevent the
neurologic injury seen in myelomeningocele,
reverse hindbrain herniation or prevent hydrocephalus. The neurologic defects result from primary incomplete neurulation and secondary
chronic prenatal damage to the exposed neural
elements through mechanical and chemical
trauma [67, 69–71].
Cranial dysraphisms are rare congenital
anomalies. The cranial meningocele contains
meninges and cerebrospinal fluid in the skincovered pouch. Encephalocele is a group of
anomalies in which meninx, cerebrospinal
fluid is protrude out of the calvarial and dural
opening. The presence of gross brain tissue in
the sac of encephalocele and the size of the sac
are unfavorable factors for the prognosis.
Encephaloceles divide into anterior and posterior groups. Posterior location is more common than anterior location. The aim of surgery
is to repair the sac, maintain neural functions
and maintain the cerebrospinal fluid circulation [72, 73] (Fig.34.15).
34.13 Occult Spinal Dysraphism
andTethered Cord
Syndrome
Open spinal dysraphism, such as meningocele
and meningomyelocele, can be diagnosed more
easily in the prenatal and early postnatal period.
However, since closed spinal dysraphisms cause
late clinical ndings, radiological diagnosis can
be made in the late periods. Early prophylactic
surgical treatments without clinical ndings provide very good results [74, 75].
Tethered cord syndrome (TCS) is a diverse
clinical entity characterized by symptoms and
signs, which are caused by excessive tension on
the spinal cord. The majority of cases are related
to spinal dysraphism. TCS can present in any age
group, and presentations differ according to the
underlying pathologic condition and age, with
pain, cutaneous signs, orthopedic deformities and
neurological decits being the most common
(Fig.34.16). Surgical untethering is indicated in
patients with progressive or new onset symptomatology. The surgical strategy aims to release the
tethering structure, and thus the chronic tension
on the cord. Early operative intervention is associated with improved outcomes [76–80].
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Fig. 34.15 Craniocervical meningocele in a 4-monthold baby. The patient was brought due to swelling in her
neck. Neurological examination was normal. There was a
craniocervical meningocele on physical examination.
Preoperative axial CT scan and T1-weighted sagittal MRI
show craniocervical meningocele of the patient (a, b).
The patient was operated on general anesthesia.
Meningocele was excised. Postoperative course was
uneventful. Postoperative T2- and T1-weighted MRIs
were normal (c, d)
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