A 47-year-old female with diabetic nephropathy presented with acute onset of severe back pain and progressive weakness in both lower extremities. Neuroimaging revealed a spinal epidural hematoma extending from the T-3 vertebra to the sacrum. Removal of all or every other lamina on levels with epidural hematoma and emergent evacuation of the hematoma were planned. T-9 and T-10 laminectomies were performed, but excessive bleeding during the operation prompted us to abandon the procedure. Plasma and desmopressin administration controlled the bleeding from the drain 8 hours after the operation. Follow-up neuroimaging one month later revealed total resolution of the hematoma with improved neurological status. Acute spinal epidural hematomas extending over more than 15 segments are extremely rare and the surgical treatment is still challenging. Coexisting hemorrhagic diathesis creates more problems. Conservative treatment may be the best option.

Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding.

AIM:To examine a series of surgically treated spinal arachnoid cysts in light of the literature. MATERIAL and METHODS:This was a retrospective study of patients treated in the Istanbul Umraniye Training and Research Hospital Neurosurgery Clinic. A total of 18 patients with spinal arachnoid cysts underwent surgical treatment between January 2012 and December 2019. All patients were assessed before and after surgery for muscle strength, pain, sensory changes, and bowelbladder symptoms. All patients underwent magnetic resonance imaging and computed tomography for diagnosis and treatment. RESULTS: Among the 18 patients, 8 were men and 10 were women, with a mean age of 43.7 (25-66) years. Congenital conditions were discovered in 15 of the patients, 2 after lumbar drainage and 1 after spinal anesthesia. Intradural extramedullary and intraextradural cysts were found in 17 patients and 1 patient, respectively. The cyst was smaller than level 3 in 14 patients and greater than level 3 in 4 patients. Cyst excision and cyst fenestration were performed in 11 and 7 patients, respectively. Cyst excision was performed in four of the patients who underwent cyst fenestration because their complaints did not improve.CONCLUSION: Surgery should be considered in patients with symptomatic spinal arachnoid cysts. Fenestration may be a suitable alternative, especially if magnetic resonance imaging reveals no intracystic adhesion or trabeculation. Residual and recurrence rates are high in patients with a history of intradural intervention, adhesions, or trabeculation. When there is trabeculation, the best option is cyst removal.

IntroductionSurgical clipping of superior hypophyseal artery (SHA) aneurysms is a challenging task for neurosurgeons due to their close anatomical relationships. The development of endovascular techniques and the difficulty in surgery have led to a decrease in the number of surgical procedures and thus the experience of neurosurgeons in this region. In this study, we aimed to reveal the microsurgical anatomy of the ipsilateral and contralateral approaches to SHA aneurysms and define their limitations via morphometric analyses of radiological anatomy, three-dimensional (3D) modeling, and surgical illustrations.MethodFive fixed and injected cadaver heads underwent dissections. In order to make morphometric measurements, 75 cranial MRI scans were reviewed. Cranial scans were rendered with a module and used to produce 3D models of different anatomical structures. In addition, a medical illustration was drawn that shows different sizes of aneurysms and surgical clipping approaches.ResultsFor the contralateral approach, pterional craniotomy and sylvian dissection were performed. The contralateral SHA was reached from the prechiasmatic area. The dissected SHA was approached with an aneurysm clip, and maneuverability was evaluated. For the ipsilateral approach, pterional craniotomy and sylvian dissection were performed. The ipsilateral SHA was reached by mobilizing the left optic nerve with left optic nerve unroofing and left anterior clinoidectomy. MRI measurements showed that the area of the prechiasm was 90.4 ± 36.6 mm2 (prefixed: 46.9 ± 10.4 mm2, normofixed: 84.8 ± 15.7 mm2, postfixed: 137.2 ± 19.5 mm2, p < 0.001), the distance between the anterior aspect of the optic chiasm and the limbus sphenoidale was 10.0 ± 3.5 mm (prefixed: 5.7 ± 0.8 mm, normofixed: 9.6 ± 1.6 mm, postfixed:14.4 ± 1.6 mm, p < 0.001), and optic nerves’ interneural angle was 65.2° ± 10.0° (prefixed: 77.1° ± 7.3, normofixed: 63.6° ± 7.7°, postfixed: 57.7° ± 5.7°, p: 0.010).ConclusionAnatomic dissections along with 3D virtual model simulations and illustrations demonstrated that the contralateral approach would potentially allow for proximal control and neck control/clipping in smaller SHA aneurysm with relatively minimal retraction of the contralateral optic nerve in the setting of pre- or normofixed chiasm, and ipsilateral approach requires anterior clinodectomy and optic unroofing with considerable optic nerve mobilization to control proximal ICA and clip the aneurysm neck effectively.

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