Topographical Anatomy of the Superficial Temporal Artery.

AIM: To describe in detail the gross anatomy of the superficial temporal artery (STA), its course and branches, its relationships with the branches of the facial nerve, and certain anatomical and surgical landmarks to preserve these structures in daily neurosurgical practice, and to use the STA during revascularization surgery. MATERIAL AND METHODS: This cadaveric study was conducted on 16 cadaver heads bilaterally, in which 32 silicon/latex-injected STAs were dissected using a microdissection technique in a neuroanatomy laboratory. The distances between the facial nerve, tragus, STA, superficial temporal vein (STV), and imaginary lines created between important anatomical landmarks were measured. The curvilinear lengths of STA and STV were also measured. RESULTS: The average distances of the most posteriorly located branch of the facial nerve to the frontal region and the tragus at the midpoint of zygoma in the horizontal plane, at the superior border of the zygoma and at the level of the superior border of the parotid gland, were measured as 25.39, 29.84, and 15.56 mm, respectively. The average distance directly measured between the tragus and STA was 39.29 mm, and that between the tragus and STV was 20.26 mm. The average curvilinear lengths of the frontal and parietal branches of STA were 97.63 and 96.45 mm, respectively. CONCLUSION: Understanding the clinical anatomy of the STA and its branches and its relationships with other structures is of critical importance for a successful and noncomplicated surgery. Our findings will be useful not only for surgical approaches such as pterional craniotomy and orbitozygomatic approaches but also for cerebral revascularization.

Effectiveness of multiple endoscopic fenestrations for the treatment of Sylvian fissure arachnoid cysts: a multicenter study.

PURPOSE: Arachnoid cysts are usually asymptomatic lesions. However, they can sometimes cause intracranial hypertension, headache, seizures, focal neurological deficits, and bleeding. The most commonly used surgical techniques are microsurgical cyst fenestration/excision/drainage, cyst shunting, and endoscopic procedures. We aimed to investigate the success of different surgical techniques. METHODS: Between 2000 and 2021, patients with Sylvan fissure arachnoid cysts who received treatment via an endoscopic approach chosen as the first-line treatment in three centers were enrolled. All case notes and radiological studies were evaluated retrospectively. RESULTS: The study included 131 (female, n = 28; male, n = 103) patients with a mean age of 87.04 ± 66.76 (range, 0-216) months. Of the patients, 25 had Galassi type II left-sided arachnoid cysts, 33 had Galassi type II right-sided arachnoid cysts, 40 had Galassi type III left-sided arachnoid cysts, and 32 had Galassi type III right-sided arachnoid cysts. No difference was found between patients who underwent single and multiple fenestrations in terms of Galassi type, side, clinical outcome, and cyst size (p > 0.05). On the contrary, the rate of additional surgical intervention was lower in patients with multiple fenestrations than in those with single fenestration (36.10% vs. 5.30%; p < 0.001). CONCLUSION: Endoscopic fenestration of Sylvian fissure arachnoid cysts is a good alternative to open surgery or cystoperitoneal shunting, and the number of fenestrations made during this surgery decreases the need for a second surgical procedure.

The association between pain, balance, fall, and disability in patients with lumbar spinal stenosis with vascular claudication.

BACKGROUND: The effect of lumbar spinal stenosis (LSS) and peripheral vascular disease (PVD), which occurs with similar degenerative conditions, when seen together, has not been studied. The aim of this study is to examine and compare the relationship between pain, balance, disability, fear of falling, and kinesiophobia in LSS patients with intermittent vascular claudication (IVC). METHODS: Seventy-two patients diagnosed with LSS using magnetic resonance imaging participated in this study. Thirty-five patients with IVC symptoms and showing vascular lesions by lower extremity venous and arterial Doppler ultrasonography imaging were included in the IVC-LSS group. The pain, static balance, dynamic balance, disability, fear of falling, and kinesiophobia were evaluated using the numeric rating scale, single leg stance test, Time Up and Go (TUG), the Oswestry Disability Index (ODI), Fall Efficacy Scale-International (FES-I), and Tampa Scale for Kinesiophobia (TSK), respectively. RESULTS: Age and female sex were found to be higher in the IVC-LSS group (P = 0.024; P = 0.012). The IVC-LSS group had a shorter single leg stance time and TUG test duration, pain intensity, ODI, FES-I, and TSK scores were higher than patients with LSS (P = 0.001). Pain, fear of falling, and kinesiophobia were moderately correlated with disability in the IVC-LSS group. No relationship was found between pain and dynamic balance. Also, the pain was not related to kinesiophobia. CONCLUSIONS: The findings indicated that IVC causes loss of balance and an increase in pain, disability, fear of falling, and kinesophobia in patients with LSS.

Temporal Artery and Temporal Region Supplied by the Middle Cerebral Artery: An Anatomical Study.

ABSTRACT: This study was conducted to describe in detail the branching patterns of cortical branches from the middle cerebral artery supplying the feeding of the temporal region, to define the arterial structure of temporal artery (TA) and to determine the effect of this arterial supply to the temporal region. The arteries of brains (n = 22; 44 hemispheres) were prepared for dissection after filling them with colored latex. TA was defined, and its classification was described, specifying its relationship with other cortical branches. A new classification was defined related to TA terminology. TA was found in 95% of cadavers, and it originated as an early branch in 75% and from the inferior trunk in 24% of cadavers. TA was classified as Type 0: No TA, Type I: single branch providing two cortical branches, Type II: single branch providing three or more cortical branches and Type III: double TA. Type I-TA (45%) was the most common, and Type II-TA arterial diameter was significantly larger than that of other types. All cadavers showed the cortical branches of temporal region from middle cerebral artery, anterior TA , middle TA, posterior TA and temporooccipital artery, except temporopolar artery (81%). Temporopolar artery, anterior TA, and middle TA primarily originated from TA, an early branch, but posterior TA and temporooccipital artery primarily originated from the inferior trunk. Detailed knowledge about cortical branches together with TA and also this region's blood supply would enable increased prediction of complications, especially in cases with these region-related pathologies, and would make interventions safer.

Endoscopic Anatomy and a Safe Surgical Corridor to the Anterior Skull Base.

OBJECTIVE: We describe the possibility to create precise preoperative planning for endonasal endoscopic approaches to the anterior skull base by overlapping endoscopic and radiologic anatomy. The important anatomic structures were marked. Morphometric measurements between these anatomic landmarks were performed endoscopically and compared with radiologic measurements of the same areas to ensure result compatibility. METHODS: Seven cadaver heads injected intravascularly with colored silicone were used for this study. Thin-section brain and paranasal sinus computed tomography scans were obtained on all cadavers. Using 0-degree rigid endoscopes and endonasal endoscopic surgical instruments, the anterior skull base was examined binostrally in all cadavers. Bilateral middle turbinates were identified and preserved. Next, an inferior uncinectomy and middle meatal antrostomy were performed. After performing a frontal antrostomy, bilateral anterior and posterior ethmoidal cells were opened and the skull base was identified and followed to the posterior wall of the frontal sinus. A transnasal transethmoidal sphenoidotomy was done with full exposure to the entire anterior skull base. RESULTS: The anatomic landmarks for endonasal endoscopic skull base approaches were distinguished and measurements were made. The anterior skull base was divided into 3 compartments: anterior (area between the posterior inferior border of the frontal sinus and the course of anterior ethmoidal artery), middle (area between the course of the anterior ethmoidal artery and that of the posterior ethmoidal artery [PEA]), and posterior (area between the course of the PEA and the attachment point of the anterior border of the sphenoid sinus to the skull base) compartments. The distances between important anatomic markers and endoscopic depth measurements of this area were measured. CONCLUSION: During endonasal endoscopic anterior skull base surgery, the area between the anterior border of the sphenoid sinus and PEA artery was safe as the first dissection zone. Preoperative radiologic width and depth measurements facilitate orientation to the endoscopic anatomy during surgery and help predict the endonasal surgical corridor anatomy preoperatively.

Comparison of Three Surgical Approaches for Frontobasal Meningiomas: Purely Endoscopic Endonasal, Purely Microscopic Bifrontal Transcranial, and Combined Endoscopic and Microscopic Supraorbital Transciliary Approaches.

ABSTRACT: Surgical removal of frontobasal meningiomas (FBMs) can be achieved using different techniques, including endoscopic, transcranial, and combined approaches. The advantages and disadvantages of the outcomes of these approaches should be compared to provide the most convenient surgical treatment to the patient. This study aimed to compare 3 surgical approaches for FBMsin terms of outcomes and determine the superiority of each on the basis of anatomical, surgical, and clinical efficacy. Systematic review was performed to identify studies comparing techniques for the surgical removal of FBMs. Each group included 13 patients; 39 patients with FBMshad undergone surgery. These groups were endoscopic endonasal approach (EEA), microscopic bifrontal transcranial approach (MTA), and endoscopic plus microscopic combined supraorbital transciliary approach (STA) groups. Data on the demographics of patient population, pre- and post-operative neurological examination, tumor properties, imaging studies, and surgical complications were extracted. The mean age at the time of surgery for the patient population was 53.2 years. Among the groups, no statistically significant differences were observed with regard to sex (P = 0.582). The mean follow-up time was 56.7 months. A statistically significant difference was observed in the mean tumor volume among the groups; the MTA group showed the highest mean tumor volume. However, no significant difference was found in the mean tumor volume between EEA and STA groups. Regarding operation duration, the STA group had the shortest operation time (mean = 281.5 minutes), whereas the average surgical duration in MTA group was the longest (mean = 443.8 minutes). The average bleeding volume was highest in the MTA group (mean = 746.2 ml) and lowest in the EEA group (mean = 320.8 ml). Tumor removal was incomplete in three patients (two in the EEA group and one in the MTA group). Recurrence was detected in two cases. One patient with recurrence was operated using the endoscopic surgical approach, whereas the other patient underwent the microscopic bifrontal approach. Post-operative hyposmia/anosmia or decreased olfactory function was the most common complication observed in 5 patients, 2 patients each in the EEA and MTA groups and one in the STA group. The second most common complication was wound infection in one patient in the MTA group and two patients in the STA group (7.7%). Both cerebrospinal fluid (CSF) leakage and meningitis were present in two patients (5.1%), one patient each from the EEA and STA groups. Pre-operative visual disturbances were reported in 13 patients (33.3%), all of which resolved post-operatively No statistical differences were found among the groups. Mortality occurred in a patient in the MTA group (2.6%) caused by cardiac arrest on post-operative day 1. This is the first study comparing the surgical outcomes of three surgical approaches for FBMs. Although recent literature suggests that both endoscopic and transcranial approaches have their own advantages and disadvantages, the authors showed that none of the surgical approaches have obvious superiority over the others with regard to outcomes. Thus, the selection of the ideal surgical approach should be based on surgical experience and tumor characteristics.

Repeat endoscopic third ventriculostomy success rate according to ventriculostoma closure patterns in children.

PURPOSE: This study aimed to examine the success rate of repeat endoscopic third ventriculostomy (redo-ETV) according to pattern of ventriculostoma closure based on observations in 97 paediatric redo-ETV patients. METHODS: Clinical data and intraoperative video recordings of 97 paediatric hydrocephalus patients who underwent redo-ETV due to ventriculostoma closure at two institutions were retrospectively analysed. We excluded patients with a history of intraventricular haemorrhage, cerebrospinal fluid (CSF) infection or CSF shunt surgery and those with incompletely penetrated membranes during the initial ETV. RESULTS: Verification of ventriculostoma closure was confirmed with cine phase-contrast magnetic resonance imaging and classified into 3 types: type 1, total closure of the ventriculostoma by gliosis or scar tissue that results in a non-translucent/opaque third ventricle floor; type 2, narrowing/closure of the ventriculostoma by newly formed translucent/semi-transparent membranes; and type 3, presence of a patent ventriculostoma orifice with CSF flow blockage by newly formed reactive membranes or arachnoidal webs in the basal cisterns. The overall success rate of redo-ETV was 37.1%. The success rates of redo-ETV according to closure type were 25% for type 1, 43.6% for type 2 and 38.2% for type 3. The frequency of type 1 ventriculostoma closure was significantly higher in patients with myelomeningocele-related hydrocephalus. CONCLUSION: For patients with ventriculostoma closure after ETV, reopening of the stoma can be performed. Our findings regarding the frequencies of ventriculostoma closure types and the success rate of redo-ETV in paediatric patients according to ventriculostoma closure type are preliminary and should be verified by future studies.

Endonasal endoscopic management of the craniopharyngeal canal meningoencephalocele using a nasoseptal flap in a 6-month-old infant.

Endonasal endoscopic approach (EEA) has become a routine and effective method for the management of large skull base defects in adults and increasingly in older pediatric populations despite their challenging narrow transnasal corridors. To our knowledge, this is the first report in the literature of a large craniopharyngeal canal (CC) meningoencephalocele in a 6-month-old infant managed purely through EEA, also by utilizing a pedicled nasoseptal flap (PNF).

Anatomical aspects of optic nerve decompression in transcranial and transsphenoidal approach.

PURPOSE: The proximal portion of the optic nerve is quite prone to injury at the entrance of the optic foramen by tumoral or traumatic pathologies. As a result, it is important to show which way and which part we can effectively and safely decompress the pathologies affecting the optic nerves. In this study, we compared the decompression of the proximal segment of the optic canal Likewise, we investigated the anatomy and histopathology of the opticocarotid region from below and above. MATERIALS AND METHODS: A total of 30 adult sellar and parasellar samples were extracted from human cadavers. Anatomical dissection and histological examination were performed from transcranial and transsphenoidal ways. The walls of the proximal optic canal were evaluated with an operating microscope and endoscope. The relationship between the optic canal, the internal carotid artery, and the optic nerve were qualitatively and quantitatively examined. RESULTS: Similar rates of circular optic canal decompression were achieved by each approach; however, by means of decompression, the transsphenoidal approach was superior for the inferior and medial portions of the optic nerve and transcranial approach was superior for the superior and lateral portions and also more appropriate for optic nerve mobilization. CONCLUSION: This is one of the first studies to reveal the ways of the decompression of the proximal optic canal by transcranial and transsphenoidal approaches. According to this study, the medial and inferior proximal portions of the optic nerves are histologically more prone to injury caused by traction or compression. Transcranial or transsphenoidal approach should be preferred according to the location of the pathology and anatomical and histological characteristics of this region.

Does Shunt Selection Affect the Rate of Early Shunt Complications in Neonatal Myelomeningocele-Associated Hydrocephalus? A Multi-Center Study.

AIM: To evaluate the effect of shunt selection on the rate of shunt revision due to early shunt complications in neonatal myelomeningocele-associated hydrocephalus. MATERIAL AND METHODS: The data of 157 neonatal myelomeningocele cases in three pediatric neurosurgery centers (Ankara University, Kocaeli University, Selcuk University) who underwent shunt surgery at the time of myelomeningocele repair between 2000 and 2014 were retrospectively analyzed. Clinical features of the patients, shunt types, and early shunt complications within the first three months were recorded. The patients were classified according to several features of the shunt systems, such as the valve type, valve size/contour and catheter type. RESULTS: Of all patients, 71 (45.2%) underwent early shunt revision surgery due to various complications. Mechanical complications were the most frequent cause of shunt failure, followed by infection. There was no significant difference among the valve types. Also, no significant difference was observed among the catheter types. Only valve contour/size (contoured regular/ultra-small/burr-hole/ cylindrical/neonatal) seemed to significantly affect the rate of early complications. The patients with neonatal-design valves or ultrasmall valves had significantly less complications, such as poor wound-healing, wound-dehiscence, cerebrospinal fluid leak or shunt exposure. The infection rate secondary to these complications was found to be lower. CONCLUSION: Myelomeningocele patients with prominent hydrocephalus frequently have a friable skin, due to reduced macrocrania-related subcutaneous tissues. Small-sized (neonatal-design or ultra-small) valves may significantly reduce the early shunt complication rate among this population.

Third Ventricle Floor Variations and Abnormalities in Myelomeningocele-Associated Hydrocephalus: Our Experience with 455 Endoscopic Third Ventriculostomy Procedures.

AIM: To evaluate the incidence of anatomical variations and abnormalities of the third ventricle floor encountered during the endoscopic third ventriculostomy (ETV) procedure in myelomeningocele-associated hydrocephalus (MAH) cases. MATERIAL AND METHODS: A retrospective analysis was performed on 455 pediatric MAH cases that had been treated with ETV. This case series consisted of the patients who were initially treated with ETV and also those who were treated with ETV for the management of cerebrospinal fluid shunt dysfunction. Variations and anomalies of the third ventricle floor were determined by reviewing the video records of the ETV procedures. RESULTS: The analysis of the data revealed that the rate of the MAH cases with variations and abnormalities of the third ventricle floor was 41.1%. The most common anatomical features were "thick and prominent massa intermedia" (37.1%) and "narrow tuber cinereum" (33.1%). CONCLUSION: This study documents the most common anatomical variations and abnormalities of the third ventricle floor in cases with MAH. Various anatomical situations and specific ventricular configuration of MAH cases may add an operative factor of difficulty which should be well recognized by the neurosurgeon who plans and executes an ETV procedure in this patient population.

Effect of Pre/Postconditioning at Temporary Clipping.

Intracranial aneurysms and their treatment is one of the leading problems of neurosurgery that create high mortality and morbidity. The technique of safe clipping is as generally used depends on the temporary occlusion of the cerebral vasculature during surgery. However, there is no exact data about temporary clipping or timing of this procedure. Preconditioning by exposure to sublethal hypoxic stress, hours or days before severe hypoxia, decreases cell death, and this resistance of the brain to injury is known as ischemic tolerance. Brief alternating periods of reperfusion-reocclusion at the beginning of reperfusion is defined as postconditioning. Cerebral ischemic pre/postconditioning protects against stroke, but is clinically feasible only when the occurrence of stroke is predictable. Brief, repetitive occlusion and release of the main trunk of a vessel during early aneurysm surgery or before long-lasting temporary artery occlusion may protect the brain against later possible vasospasm/ischemia.

Transnasal Transsphenoidal Surgical Method in Pediatric Pituitary Adenomas.

AIM: To evaluate the clinical outcome in a 13-year consecutive series of children operated for pituitary adenomas with transnasal transsphenoidal surgery. METHODS: All patients <18 years who were operated on at our center by transsphenoidal surgery for pediatric pituitary adenomas were included in the study. Clinical features, hormonal profile, radiology, surgical approach, results and complications were analyzed. RESULTS: Eighteen patients (90%) had functional pituitary adenomas and 2 (10%) patients had nonfunctional pituitary adenoma. The most common type was prolactin-secreting adenoma (n = 12), followed by corticotropinoma (n = 4), growth hormone-secreting adenoma (n = 2), and nonfunctioning adenoma (n = 2). Prolactin-secreting adenomas in children occurred more commonly with suprasellar expansion than did other adenomas. CONCLUSION: Transsphenoidal surgery was effective for decompression of suprasellar extension and relieved the chiasmal compression immediately. Prolactin-secreting tumors required postoperative medical therapy for persistently elevated prolactin levels.