Automatic electrode scalar location assessment after cochlear implantation using a novel imaging software.

As of today, image-based assessment of cochlear implant electrode array location is not part of the clinical routine. Low resolution and contrast of computer tomography (CT) imaging, as well as electrode array artefacts, prevent visibility of intracochlear structures and result in low accuracy in determining location of the electrode array. Further, trauma assessment based on clinical-CT images requires a uniform image-based trauma scaling. Goal of this study was to evaluate the accuracy of a novel imaging software to detect electrode scalar location. Six cadaveric temporal bones were implanted with Advanced Bionics SlimJ and Mid-Scala electrode arrays. Clinical-CT scans were taken pre- and postoperatively. In addition, micro-CTs were taken post-operatively for validation. The electrode scalar location rating done by the software was compared to the rating of two experienced otosurgeons and the micro-CT images. A 3-step electrode scalar location grading scale (0 = electrode in scala tympani, 1 = interaction of electrode with basilar membrane/osseous spiral lamina, 2 = translocation of electrode into scala vestibuli) was introduced for the assessment. The software showed a high sensitivity of 100% and a specificity of 98.7% for rating the electrode location. The correlation between rating methods was strong (kappa > 0.890). The software gives a fast and reliable method of evaluating electrode scalar location for cone beam CT scans. The introduced electrode location grading scale was adapted for assessing clinical CT images.

C-reactive protein/albumin ratio greater than 7.1 is a good candidate to be used as an inflammation biomarker to predict perforation in appendicitis.

OBJECTIVE: We aimed at identifying novel biomarkers to predict perforation in patients with acute appendicitis. PATIENTS AND METHODS: Medical records of patients who underwent appendectomy due to acute appendicitis were reviewed. Complete blood count and biochemistry panel results of these patients were analyzed. This study included 58 patients, 42 (72.4%) male and 16 (27.6%) female. The mean age of the patients was 33.8±14.1 years (range: 18-75). 49 (84.5%) patients had non-perforated acute appendicitis. Perforated acute appendicitis was observed in 9 (15.5%) patients. RESULTS: Patients with perforated appendicitis had higher appendiceal diameter, C-reactive protein (CRP) level, CRP/albumin and monocyte/lymphocyte (M/L) compared to patients with non-perforated appendicitis. Moreover, patients with perforated appendicitis had lower lymphocyte count than those with no perforation. Sensitivity rates of appendiceal diameter, CRP level, CRP/Albumin and M/L for perforated appendicitis were similar (89%). However, the most specific biomarker for perforation was CRP/albumin (87.8%), followed by CRP (85.7%), M/L (63.3%) and appendiceal diameter (57.1%). Patients with CRP/albumin>7.1, CRP>32.7 mg/L, M/L>0.44 and appendiceal diameter>9.8 mm were most likely to have appendiceal perforation. CONCLUSIONS: We suggest that CRP/albumin, CRP, M/L, appendiceal diameter and lymphocyte count can be used to predict perforation in patients with acute appendicitis. However, the most specific inflammation biomarker indicating perforated acute appendicitis is CRP/Albumin>7.1.

Impact of model for end-stage liver disease (MELD) score for mortality in patients undergoing coronary bypass surgery.

OBJECTIVES: The aim of the study is to evaluate the predictive value of the model for end-stage liver disease (MELD) score for mortality in stable angina pectoris patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: We retrospectively analyzed 261 consecutive patients with stable angina pectoris who underwent CABG while not being on anticoagulant therapy. The patients were divided into two groups: survivors and non-survivors. The MELD score was calculated for all patients. The all-cause mortality within postoperative 12 months was the primary end point of the study. RESULTS: The follow-up period was 12 months. The non-survivors were older (72.0±6.1 vs 62.4±8.4, p<0.001). The MELD score was significantly higher in the non-survivors group (7.5±1.2 vs 6.7±0.7, p<0.001). The MELD score (p=0.001) was an independent predictor of postoperative one-year mortality. The addition of MELD score to EuroSCORE II significantly improved the prognostic performance of the EuroSCORE II (EuroSCORE II vs EuroSCORE II plus MELD score: AUCs: 0.792 vs 0.842). CONCLUSION: Our research showed that the MELD score could be useful to predict mortality in patients who have stable coronary artery disease, and are undergoing CABG surgery (Tab. 3, Fig. 2, Ref. 25).

Assessment of serum levels of copeptin and corticotropin-releasing factor in children with monosymptomatic and non-monosymptomatic nocturnal enuresis.

BACKGROUND: Nocturnal enuresis is defined as bed-wetting in children from the age of five years that occurs during sleep; if untreated, the condition can result in social and psychological problems both for the children and their parents. Nocturnal enuresis is a complicated disease that includes multiple pathogenetic factors. Nocturnal enuresis is divided into two subgroups: monosymptomatic and non-monosymptomatic. The role of some biomarkers in patients with monosymptomatic enuresis has been reported in a small number of the studies. OBJECTIVE: The aim of this research was to evaluate the serum levels of copeptin and corticotropin-releasing factor (CRF) in monosymptomatic and non-monosymptomatic nocturnal enuresis cases. Although these markers were previously examined in children with monosymptomatic enuresis, there is no study that has evaluated these markers in non-monosymptomatic children. STUDY DESIGN: One hundred nineteen children with nocturnal enuresis (5-16 years) and forty healthy children (5-17 years) were enrolled to the study. Of the nocturnal enuresis group, forty-nine were monosymptomatic and seventy were non-monosymptomatic. Copeptin and CRF were measured by a competitive inhibition method with enzyme-linked immunosorbent assay. RESULTS: The serum copeptin levels were significantly lower in children with monosymptomatic and non-monosymptomatic nocturnal enuresis than in the controls.(median, 34.7 [interquartile range (IQR): 34 pg/ml], 39.8 [IQR: 29 pg/ml] vs 52.1 [IQR: 14 pg/ml], respectively, P < 0.05). The serum CRF levels were significantly lower in children with monosymptomatic and non-monosymptomatic nocturnal enuresis than in the controls (median, 35.1 [IQR: 19 pg/ml], 34.05 [IQR: 24 pg/ml] vs 78.3 [IQR: 39 pg/ml], respectively, P < 0.05). There was no significant difference in copeptin and CRF levels between the children with monosymptomatic and non-monosymptomatic nocturnal enuresis. DISCUSSION: Copeptin is presumed to be a sensitive surrogate biomarker for arginine vasopressin release. To date, there are only two studies in the literature that assess the relationship between copeptin and monosymptomatic enuresis. The only study in the literature demonstrated significantly decreased levels of CRF in monosymptomatic enuretic children. It was demonstrated that the levels of copeptin and CRF differ in both children with monosymptomatic and non-monosymptomatic nocturnal enuresis from the control groups. It was also demonstrated that copeptin and CRF levels were not different between the children in monosymptomatic and non-monosymptomatic groups. CONCLUSION: Those changes in both copeptin and CRF which were shown in this study in monosymptomatic and non-monosymptomatic enuretic children may contribute to the pathogenesis of nocturnal enuresis. Further case-control studies can evaluate the copeptin and CRF levels before treatments in monosymptomatic and non-monosymptomatic patients to decide potential effectiveness of treatment.

PROTECTIVE EFFECT OF NIGELLA SATIVA OIL ON MYOCARDIUM IN STREPTOZOTOCIN-INDUCED DIABETIC RATS.

BACKGROUND: To evaluate the protective effect of Nigella sativa oil (NSO) on the myocardium in streptozotocin-induced diabetic rats. MATERIALS AND METHODS: Thirty-two 7-8-week-old female Wistar albino rats (300-350 g) were equally divided into 4 groups: nondiabetic untreated animals (control), diabetes mellitus (DM), NSO, and DM+NSO groups. For the induction of diabetes, 45 mg/kg streptozotocin was applied to the rats in the DM and DM+NSO groups as a single intraperitoneal dose. NSO (400 mg/kg) was orally administered through an intragastric catheter once a day over 21 days. Formalin-fixed, paraffin-embedded tissue sections of the myocardium were evaluated histopathologically and immunohistochemically. RESULTS: Compared to the control, NSO, and DM+NSO groups, the myocardial tissue samples from the rats in the DM group had significantly higher myositis, hyaline degeneration, and Zenker's necrosis. Moreover, the Bcl-2 expressions were significantly higher in the control, NSO, and DM+NSO groups than in the DM group. CONCLUSION: NSO has a protective effect on the myocardium of streptozotocin-induced diabetic rats, most likely via suppressing apoptosis.

Combining clinical predictors to better predict for the no-reflow phenomenon.

OBJECTIVE: We aimed to determine whether the combination of a CHA2DS2-VASc score (C: Congestive Heart Failure, H: Hypertension, A2: Age ≥ 75 years, D: Diabetes mellitus, S: Stroke history, V: Vascular disease, A: Age ≥ 65 years, Sc: Sex category) and pre-percutaneous coronary intervention (PCI) thrombus load score was more sensitive at detecting the no-reflow phenomenon compared to the CHA2DS2-VASc score alone or to the thrombus load score alone in patients with acute ST-elevation myocardial infarction (STEMI) who had underwent primary PCI (PPCI). PATIENTS AND METHODS: 497 patients with acute STEMIs were divided into two groups: no-reflow group (n: 194) and control group (n: 303). The Thrombolysis In Myocardial Infarction (TIMI) flow grading and Myocardial Blush Grade (MBG) were used together to define angiographic no-reflow as TIMI flow < 3 (with any MBG grade) or TIMI flow 3 with MBG 0 or 1. Successful reperfusion was defined as TIMI flow 3 with MBG 2 or 3. RESULTS: CHA2DS2-VASc score was significantly higher in the no-reflow group than in the control group (2 [1-4] vs. 1 [0-3], p < 0.001]. Compared with the control group, the no-reflow group had a higher pre-PCI thrombus score (5 [4-5] vs. 4 [3-5], p = 0.001). Compared with the CHA2DS2-VASc score alone, the combined use of the pre-PCI thrombus score and the CHA2DS2-VASc score was associated with significant improvements in the ability to predict no-reflow (AUC) (0.65 vs. 0.60, p < 0.05). The addition of the pre-PCI thrombus score to the CHA2DS2-VASc score was related to a significant net reclassification improvement of 6.7% (p = 0.047) and an integrated discrimination improvement of 0.036 (p < 0.05). CONCLUSIONS: We have found that the combination of a CHA2DS2-VASc score and a pre-PCI thrombus load score was more sensitive in detecting the no-reflow phenomenon than only a CHA2DS2-VASc score in patients who underwent PPCIs for STEMIs.

Publisher Correction: Spiral Form of the Human Cochlea Results from Spatial Constraints.

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Spiral Form of the Human Cochlea Results from Spatial Constraints.

The human inner ear has an intricate spiral shape often compared to shells of mollusks, particularly to the nautilus shell. It has inspired many functional hearing theories. The reasons for this complex geometry remain unresolved. We digitized 138 human cochleae at microscopic resolution and observed an astonishing interindividual variability in the shape. A 3D analytical cochlear model was developed that fits the analyzed data with high precision. The cochlear geometry neither matched a proposed function, namely sound focusing similar to a whispering gallery, nor did it have the form of a nautilus. Instead, the innate cochlear blueprint and its actual ontogenetic variants were determined by spatial constraints and resulted from an efficient packing of the cochlear duct within the petrous bone. The analytical model predicts well the individual 3D cochlear geometry from few clinical measures and represents a clinical tool for an individualized approach to neurosensory restoration with cochlear implants.

Transforming growth factor beta-1 An important biomarker for developing cardiovascular diseases in chronic renal failure.

OBJECTIVE: Our study focuses on the determination and evaluation of TGF-ß1 levels of patients receiving hemodialysis treatment because of chronic renal failure. BACKGROUND: Chronic renal failure, characterized by irreversible loss of renal function, is a major public health problem in the world. Transforming growth factor-beta is a multifunctional cytokine involved in the cellular growth, differentiation, migration, apoptosis and immune regulation. Among the three TGF-ß isoforms, TGF-ß1 plays a key role in the pathogenesis of renal diseases. METHODS: We studied 24 patients who were on regular hemodialysis, with non-diabetic nephropathy. 20 healthy people who proved to be in a good state of health and free from any signs of chronic diseases or disorders were enrolled as a control group. Serum samples were collected both before and after hemodialysis treatment from each patient. TGF-ß1 levels were determined by Enzyme Immunoassay method. RESULTS: TGF-ß1 levels were found significantly higher in the hemodialysis patients than those of the control groups. Also, the TGF-ß1 was significantly reduced after hemodialysis treatment but it was still higher than in control groups. CONCLUSION: This result indicates that hemodialysis is an effective treatment method to decrease the serum TGF-B1 levels. Nevertheless, this decrease is not enough to reduce existing risks (Tab. 1, Fig. 2, Ref. 28).

Open, laparoscopic and robot-assisted laparoscopic radical prostatectomy: comparative analysis of operative and pathologic outcomes for three techniques with a single surgeon's experience.

OBJECTIVE: To compare outcomes of open (O-), laparoscopic (L-) and robot-assisted laparoscopic (RAL-) radical prostatectomy (RP) performed by the same surgeon. PATIENTS AND METHODS: From May 1999 to April 2012, 484 RPs were performed by a single surgeon. Patients' data including age, body-mass index, serum prostate specific antigen (PSA) level, Gleason score of prostate biopsy and prostatectomy specimen, preoperative prostate and specimen volumes, clinical and pathologic stages, operation time, estimated blood loss (EBL), catheterization time, blood transfusion rate were recorded. Prospectively collected data was evaluated retrospectively by statistical analyses. RESULTS: Of 484 radical prostatectomies, ORP (50), LRP (308) and RALRP (79) done by the same surgeon were included into study. Mean ages were 63.8, 62.7 and 60.3 years for ORP, LRP and RALRP respectively. Operation times for ORP, LRP and RALRP were 255, 208 and 242 minutes. EBL and hospitalization time were 602, 526, 234 mL, and 9.1, 3.2, 3.2 days for ORP, LRP and RALRP, respectively. While a significant advantage was found for EBL and complication rates in RALRP and for operation time in LRP, significant disadvantages were found in terms of catheterization time, hospitalization time, decrease in hemoglobin and blood transfusion in ORP. However, preoperative prostate volume and serum PSA level, oncologic outcomes and positive surgical margins were nearly similar in all operative techniques. CONCLUSIONS: Minimally invasive techniques such as LRP and RALRP are promising techniques with comparable outcomes with ORP. Shorter catheterization time, less blood loss and fewer complication rates can be provided by RALRP.

Oxidative stress and cellular immunity in patients with recurrent aphthous ulcers

Recurrent aphthous ulcer (RAU) is an inflammatory condition of the oral mucosa characterized by painful, well-circumscribed, single or multiple round or ovoid ulcerations. The exact etiologic factor(s) of these ulcerations are not yet understood. The objective of this study was to evaluate inflammatory processes and free radical metabolism of 25 patients with RAUs compared to 25 healthy controls. The levels of malondialdehyde (MDA) and glutathione (GSH) were determined by high-performance liquid chromatography. Tumor necrosis factor-alpha (TNF-α), interleukin-2 (IL-2), IL-10, and IL-12 were determined by ELISA. Nitric oxide (NO), myeloperoxidase (MPO), total antioxidant status (TAS), and total oxidant status (TOS) levels were measured spectroscopically in serum. The levels of MDA, GSH, TNF-α, IL-2, IL-12, MPO, and TOS, and oxidative stress index (OSI) were higher, and the levels of NO, IL-10, and TAS were lower in patients with RAU than in controls. Statistical analysis showed that GSH, TNF-α, IL-2, IL-10, and OSI differed significantly in patients with RAU compared to controls. These parameters have important roles in oxidant/antioxidant defense.

Oxidative stress and cellular immunity in patients with recurrent aphthous ulcers.

Recurrent aphthous ulcer (RAU) is an inflammatory condition of the oral mucosa characterized by painful, well-circumscribed, single or multiple round or ovoid ulcerations. The exact etiologic factor(s) of these ulcerations are not yet understood. The objective of this study was to evaluate inflammatory processes and free radical metabolism of 25 patients with RAUs compared to 25 healthy controls. The levels of malondialdehyde (MDA) and glutathione (GSH) were determined by high-performance liquid chromatography. Tumor necrosis factor-alpha (TNF-α), interleukin-2 (IL-2), IL-10, and IL-12 were determined by ELISA. Nitric oxide (NO), myeloperoxidase (MPO), total antioxidant status (TAS), and total oxidant status (TOS) levels were measured spectroscopically in serum. The levels of MDA, GSH, TNF-α, IL-2, IL-12, MPO, and TOS, and oxidative stress index (OSI) were higher, and the levels of NO, IL-10, and TAS were lower in patients with RAU than in controls. Statistical analysis showed that GSH, TNF-α, IL-2, IL-10, and OSI differed significantly in patients with RAU compared to controls. These parameters have important roles in oxidant/antioxidant defense.

Indications for intraoperative frozen section in robot assisted radical prostatectomy: a pilot study.

INTRODUCTION: To evaluate indications for intraoperative frozen section (IFS) during robot assisted laparoscopic radical prostatectomy (RALRP) in our series. PATIENTS AND METHODS: Prospectively documented 80 patients with prostate cancer (PCa) who underwent RALRP were evaluated between June 2010 and July 2012. Patients were divided into 2 groups according to whether systematically IFS was performed or not. Group 1 (n=66) consisted of patients on whom systematic IFS was performed, Group 2 (n=14) consisted of patients on whom IFS was not performed. All recorded data evaluated and statistical analyses were performed for determining indications and predictive factors for IFS during RALRP. All patients were operated by single surgeon and IFS, pathological assessments were performed by experienced uro-pathologist. Statistical significant p value was p < 0.05. RESULTS: Mean follow-up was 15±6 (25-4) months. Pre-operative prostate volume in trans- rectal ultrasonography (TRUS) was statistically higher in Group 1 than Group 2 (p = 0.037). The other parameters were statistically similar in both groups. According to outcomes of our study IFS was a dependent factor for positive surgical margin. Additionally, the cut off value of prostate volume in TRUS for IFS was 55.5 cc for IFS. CONCLUSIONS: Preoperative measured prostate volume in TRUS may be an indicator of IFS. Therefore, more accurate information may be given to patients with prostate cancer (Pca) before RALRP by using preoperative prostate volume in TRUS.

A prospective evaluation of second transurethral resection in non-muscle invasive bladder tumors.

PURPOSE: In this prospective study we evaluated the benefit of a second transurethral bladder resection (TURB) for Ta-T1 bladder carcinomas. METHODS: One hundred consecutive patients with superficial bladder tumor (Ta-T1) undergoing TURB and routine repeat TURB (Re-TURB) 4-6 weeks after the initial resection were included in the study. Re-TURB was applied to the scar of the first resection and other suspicious lesions in the bladder. RESULTS: From January 2003 to December 2008 100 patients were enrolled onto the study (mean age 60 years). At the first TURB, 56 (56%) patients had multiple lesions and 44 (44%) had a solitary tumor. Re-TURB revealed histological residual tumors in 40 (40%) patients. Residual tumor was found in 40% of Ta and 40% of T1 disease and 29% of the tumors were found at initial site of resection. Re-TURB revealed residual tumor in 55% of patients with multiple tumors and only 20% of patients with a solitary bladder tumor. CONCLUSION: These data suggest that tumor stage is not a good indicator to determine the necessity of Re-TURB in superficial bladder carcinomas. Routine Re-TURB is beneficial in Ta-T1 multiple bladder tumors.

Perforated gastric cancer complicating early postpartum period of pregnancy.

BACKGROUND: An unique association of gastric cancer with pregnancy and puerperium is rare. CASE: A 29-year-old woman had complained of epigastric pain, postprandial vomiting and weight loss during the last 3 months of pregnancy. She first applied to our centre for premature rupture of membranes at the 38th week of gestation and underwent an emergency caesarean section because of umblical cord prolapsus. The patient developed generalised abdominal pain, distention and fever on the 2nd postpartum day. She was operated on due to acute abdomen. During surgery, generalised peritonitis with a gastric ulcer perforation at the corpus was found. The perforation area was repaired primarily. Pathological examination revealed gastric adenocarcinoma. Definitive surgery was carried out 2 weeks later. The patient received 6 cycles of adjuvant chemotherapy. After completing chemotherapy the patient was re-explored because of developing intestinal obstruction. In surgical exploration, a disseminated peritonitis carcinomatosa and extensive adhesions were observed and the patient was therefore evaluated as incurable. Postoperatively, the patient developed a high output intestinal fistula which could not be treated with palliative care. The patient died 6 months after initial diagnosis of gastric cancer. CONCLUSION: When peritonitis symptoms exist in a postpartum woman in addition to other peritonitis causes, malignant gastro-intestinal perforations such as gastric cancer perforation should be kept in mind.

Microsurgical landmarks for safe removal of anterior clinoid process.

OBJECTIVE: The microsurgical and radiological anatomy of the clinoid process were studied to give surgeons more details about the anterior clinoid process and its relations to the vascular and nervous neighbourhood during intradural and extradural clinoidectomy, thus making the operative procedures safer. METHODS: Seven formalin-fixed (14 sides) and two fresh cadavers (four sides) were studied to reveal the surgical anatomy of the anterior clinoid process and related landmarks during intradural and extradural drilling techniques of clinoid process. Furthermore, aeration of the anterior clinoid process was investigated in 100 paranasal tomography (200 sides) scans. RESULTS: Careful drilling of the anterior clinoid process is mandatory to avoid damage to the extremely important adjacent structures. The anterior clinoid process must not be removed in one piece. Clinoid folds and the frontotemporal fold should be exposed adequately. The falciform ligament must be cut to visualize the optic nerve and ophthalmic artery clearly. Preoperative radiological assessment of clinoid process variations should be done. In computerized tomography scans, pneumatization of the right anterior clinoid process was found in 12%, of the left anterior clinoid process in 7% and bilaterally pneumatization was present in 9%. CONCLUSIONS: Removal of the ACP is one of the most critical procedures to the successful and safe management of ophthalmic segment aneurysms and tumors located in the paraclinoid region and cavernous sinus. Special attention should be paid to the anatomic landmarks indicating the relationship between the anterior clinoid process and adjacent structures. Beside that, pneumatization of the anterior clinoid process should be evaluated preoperatively with computed tomography to avoid complications such as rhinorrhea and pneumocephalus.

Posterior communicating artery: from microsurgical, endoscopic and radiological perspective.

OBJECTIVE: The main objective of this study was to display the morphological characteristics of the posterior communicating artery and its perforating branches in various configurations of the circle of Willis and their relationship with neighbouring anatomic structures by microscopic examination of the brain hemispheres and endoscopic examination of cadaver specimens. A secondary aim was to investigate the possibility of detecting the posterior communicating artery and its variations in cerebral MR angiographies performed for various reasons. METHODS: The posterior communicating artery was examined under the microscope in 24 cerebral hemisphere specimens, by endoscopy in 5 cadavers and by 3D TOF MRI in 62 patients. RESULTS: The posterior communicating artery had a hypoplastic configuration in 28 %, whereas it was transitional in 14 %, fetal in 28 % and adult in 30 % of cerebral hemisphere specimens. While no posterior communicating artery and transitional configuration could be detected in 11 % of the MR angiography examinations, 34 % had a hypoplastic configuration, 10 % a fetal configuration and 45 % an adult configuration. The percentage of infundibular dilatation was 22 % and the pre-mamillary artery was the thickest perforating branch. The diameter of the posterior communicating artery varied between 0.5 and 3.03 mm. DISCUSSION: A detailed knowledge on the variations of the posterior communicating artery and the morphological characteristics of the perforators arising from this artery in various configurations of the circle of Willis is an important factor affecting the results of surgical interventions.

The extradural subtemporal keyhole approach to the sphenocavernous region: anatomic considerations.

Fourteen cadaver specimens (28 sides) and twelve dry human skulls (24 sides) were used to study the anatomic relationships between bony, neurovascular and foraminal landmarks in the floor of the middle fossa in preparation for performing the extradural subtemporal keyhole approach to the sphenocavernous region. The interforaminal distance was largest between the foramina rotundum (FR) and ovale (FO) and was smallest between the FO and foramen spinosum (FS). The largest angle between exit foramen was the FR to FO. The greater superficial petrosal nerve (GSPN) was always found to overlie and run parallel to the petrous internal carotid artery, however, its location over the artery and its separation from it by bone was variable. With a subtemporal "keyhole" placed above the posterior zygomatic root (PZR), a 0 degrees endoscope allowed easy visualization of the middle meningeal artery (MMA) and the mandibular nerve (V 3 ) however, a 30 degrees endoscope was more useful for visualizing the maxillary nerve (V 2 ) and the ophthalmic nerve (V 2 ). With a sphenoidotomy performed between V 1 and V 2, the 30 degrees endoscope was found to be the most useful for visualizing the carotid siphon and the contralateral wall of the sphenoid sinus, while the 70 degrees endoscope was the most useful for visualizing of the floor of the sella and the walls of the sphenoid sinus. Two venous concerns with respect to performing endoscopic approaches to the region were identified: a fibrous layer overlies a heavy venous plexus that encircles the petrous carotid artery, and the foramen Vesalius, which transmits a large emissary vein draining the cavernous sinus, was identified medial to the FO in 30 % of our dissected sides.

Perforating branches of the anomalous anterior communicating complex.

The anterior communicating complex was studied in 25 cadaver specimens obtained at routine autopsy. In 15 specimens (60%), an anomalous anterior communicating artery was found. The most common anomaly identified was a multi-channeled anterior communicating artery. The first channel was always the smallest channel, and all of the perforators arose from this smallest channel 45% of the time. All other anomalous anterior communicating arteries presented with concomitant anomalous perforator anatomy.