Endoscopy-Assisted Suturectomy: Can It be the Priority Choice in the Treatment of Metopic Synostosis?

AIM: To mathematically present the results of endoscopic assisted surgery in the treatment of metopic synostosis. MATERIAL AND METHODS: We present a follow-up of the stages of treatment of 43 patients with metopic synostosis who underwent surgery in a multicenter retrospective study between 2018 and 2021. We developed the formula D3/((D1+D2)/2) based on the theory of "The Angle of a Triangle Opposite The Longest Side is the Largest Angle". And we called this method "Metopic Angle Proportion (MAP)". Paired samples T-test was performed for statistical results. A p-value of < 0.05 was considered statistically significant. RESULTS: According to the MAP method; measurements for frontal enlargement, mean pretreatment length D1: 34,57 mm, D2: 34,81 mm, D3: 60,46 mm, and the end of treatment as D1: 37,88 mm, D2: 38,19 mm, D3: 71,09 mm. We perfomed the formula D3/ [(D1+D2)/2]. While this rate was 1.74 before treatment, it increased to 1.87 after treatment. As a result of statistical analysis, it was also found to be significant (p≤0.05). CONCLUSION: Endoscopy-assisted suturectomy can be applied in health centres where available, because it is safe, easy and cheaper.

A Novel Perspective to Gamma-Knife Radiosurgery for Solitary Meningiomas: Adaptability of Fast Imaging Employing Steady-State Acquisition/Constructive Interference in Steady-State Magnetic Resonance Imaging.

AIM: To compare T1-weighted contrast-enhanced (T1+C) with fast imaging employing steady-state acquisition (FIESTA) magnetic resonance imaging (MRI) sequences to protect healthy brain tissue during meningioma treatment with Gamma-Knife radiosurgery (GKRS). MATERIAL AND METHODS: After reviewing the data of 54 patients with solitary meningioma who underwent GKRS between January 2020 and June 2022, demographic characteristics were noted, tumor volumes on T1+C and FIESTA MRI sequences were measured, and sequences were compared. The patients were then divided into two groups according to the presence of invasion to intracranial venous sinuses (groups 1 and 2, respectively). SPSS 11.5 software was used for data analysis, with the level of significance set at 0.05. RESULTS: While no significant age and tumor size differences were observed between groups 1 and 2, sinus invasion was significantly higher among males. Tumor volumes measured in both groups were significantly smaller on FIESTA sequences than on T1+C sequences. CONCLUSION: The T1+C sequence has been the primary imaging method because of meningiomas' high contrast enhancement feature. However, the T1+C sequence during GKRS planning is an effective imaging method in treating meningiomas; FIESTA sequences can more precisely delineate the tumor border. In this study, we consider that using the FIESTA/CISS sequence MRI for planning meningioma therapy with Gamma-Knife can reduce target volume and prevent irradiation of healthy brain tissue.

Endoscopy-Assisted Craniosynostosis Surgery Versus Cranial Vault Remodeling for Non-Syndromic Craniosynostosis: Experience of a Single Center.

AIM: To evaluate and compare open cranial vault remodeling (OCVR) and endoscopy-assisted craniosynostosis surgery (EACS) in patients with non-syndromic craniosynostosis and to develop an algorithm to determine the most appropriate surgery for each patient. MATERIAL AND METHODS: Eighty-five children with craniosynostosis who underwent surgery between 2010 and 2022 were retrospectively analyzed. Demographic data, comorbidities, and peri-operative findings of the patients were recorded. Pre- and post-operative comparisons were made between predetermined measurement techniques for each deformation. In addition, measurements were obtained by computed tomography (CT) or 3D stereophotogrammetric (3DSPG) methods from eligible patients and compared with one another. RESULTS: In our study, 61 patients underwent EACS, whereas 24 underwent OCVR. The operating time of OCVR was approximately 54.4 minutes longer than that of EACS (p < 0.001). The intra-operative blood loss was around 139 ml higher in OCVR (p < 0.001). The length of hospital stay for patients who underwent EACS was shorter at 8.4 days on average (p < 0.001). Surprisingly, 5 complications were observed in OCVR compared with 7 in EACS. While the cosmetic outcome of EACS was superior in most of the pathologyspecific measurement techniques, the metopic index increased only in patients with metopic synostosis after both surgical operations. Still, this increase was lower in EACS than in OCVR. CONCLUSION: This study suggests that endoscopic craniosynostosis surgery has lower estimated blood loss and operation and hospitalization times, as well as comparable cosmetic results compared with open vault surgeries on long-term follow-up. CT and 3DSPG methods can help distinguish between different types of measurement techniques for synostoses. However, no significant differences were found in the comparisons since 3DSPG can also provide reliable measurements comparable to those on CT during follow-up.

Applications of enhanced recovery after surgery protocols for unruptured anterior circulation aneurysms in tertiary-level healthcare institutions: a national study.

OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols are standardized perioperative care that reduce patients' stress response during hospitalization and improve hospitalization time, complication rates, costs, and readmission rates. This study aimed to investigate the application rate of protocols for elective craniotomy in the surgery of unruptured anterior circulation aneurysms (AnCAs) at tertiary-level healthcare (TLH) institutions in Türkiye and its effect on the outcomes of the patients. METHODS: An electronic survey was sent to all Turkish TLH institutions (n = 127) between May and June 2023. The number of institutions participating in the survey was 38 (30%). The institutions were subdivided according to three main factors: institution type (university hospital [UH] vs training and research hospital [TRH]), annual case volume (low [≤ 20 aneurysms] vs high [> 20 aneurysms]), and institution accreditation status (accredited vs nonaccredited). RESULTS: Overall, 55.3% (n = 21) of the institutions participating in the study were UHs. The rates of those that were accredited and had a high case volume were 55.3% (n = 21) and 31.6% (n = 12), respectively. It was determined that the accredited clinics applied preoperative protocols at a higher rate (p = 0.050), and the length of stay in the postoperative period was shorter in the clinics that used the intraoperative protocols (p = 0.014). CONCLUSIONS: The length of stay in the postoperative period is lower in TLH institutions in Türkiye that highly implement intraoperative protocols. Furthermore, this is the first study in the literature evaluating protocols for elective craniotomy in unruptured AnCAs.

The connectivity-based parcellation of the angular gyrus: fiber dissection and MR tractography study.

The angular gyrus (AG) wraps the posterior end of the superior temporal sulcus (STS), so it is considered a continuation of the superior temporal gyrus (STG)/ middle temporal gyrus (MTG) and forms the inferior parietal lobule (IPL) with the supramarginal gyrus (SMG). The AG was functionally divided in the literature, but there is no fiber dissection study in this context. This study divided AG into superior (sAG) and inferior (iAG) parts by focusing on STS. Red, blue silicone-injected eight and four non-silicone-injected human cadaveric cerebrums were dissected via the Klingler method focusing on the AG. White matter (WM) tracts identified during dissection were then reconstructed on the Human Connectome Project 1065 individual template for validation. According to this study, superior longitudinal fasciculus (SLF) II and middle longitudinal fasciculus (MdLF) are associated with sAG; the anterior commissure (AC), optic radiation (OR) with iAG; the arcuate fasciculus (AF), inferior frontooccipital fasciculus (IFOF), and tapetum (Tp) with both parts. In cortical parcellation of AG based on STS, sAG and iAG were associated with different fiber tracts. Although it has been shown in previous studies that there are functionally different subunits with AG parcellation, here, for the first time, other functions of the subunits have been revealed with cadaveric dissection and tractography images.

Is It Possible to Get Better Results in Bone Fusion in Laminoplasty Surgery for Lumbar Stenosis? A Novel Autologous Bone Graft Insertion Technique.

AIM: To define a novel autologous bone graft insertion technique, and to evaluate its effects on bone fusion in patients with lumbar stenosis who underwent laminoplasty. MATERIAL AND METHODS: Fifty-six patients and 142 vertebrae that underwent autologous bone graft insertion technique between 2009 and 2018 were analysed retrospectively. Demographic data, comorbidities, and perioperative findings of patients were recorded. The midline anteroposterior (AP) diameter was measured at the bone graft insertion levels, and fusion formation was evaluated with computed tomography (CT) and dynamic X-Ray images. Pain scores were assessed preoperatively with the visual analogue scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. Scores were re-evaluated on 1 < sup > st < /sup > day, at 3 < sup > rd < /sup > , and 12 < sup > th < /sup > months, postoperatively. RESULTS: Degenerative spinal stenosis was present in 56 patients who underwent autologous bone graft insertion technique. It was found that the diameter of the spinal canal increased by 37% in CT measurements. In postoperative radiological followups, fusion developed in 49 (87.5%) patients. There was a statistically significant decrease in both VAS and ODI scores in the postoperative period when compared to the preoperative evaluations. CONCLUSION: Bone graft insertion technique supports posterior fusion and protects against dural injuries during revision surgery by creating a barrier over the dura. The prevention of epidural fibrosis formation reduces the symptoms of the postlaminectomy syndrome. The fact that this technique does not require fixation material. Therefore, it reduces expenditure and eliminates the risk of complications related to synthetic materials.

The effectiveness of gamma knife radiosurgery for the management of residual high-grade gliomas: A single institutional study.

High-grade gliomas (HGGs) are presently managed via surgical resection, external beam radiation therapy (EBRT), and chemotherapy. Although Gamma Knife radiosurgery (GKRS) is currently used to manage HGGs, it has not been considered standard care. This paper aims to compare the contribution of GKRS to clinical outcomes in patients in which gross total resection (GTR) cannot be achieved. We retrospectively reviewed the data of 99 patients with HGG (World Health Organization (WHO) grade III and IV) from two groups: group 1 consisted of 68 patients for which only EBRT was administered, and group 2 consisted of 31 patients for which EBRT and GKRS were administered. Patient demographic data, the extent of resection, IDH mutation, radiation dosage, progression-free survival (PFS), overall survival (OS), and follow-up time were recorded and compared across groups. The grade III/IV tumor ratio was 10/58 and 10/21 in groups 1 and 2, respectively. In group 2, PFS and OS were higher than in group 1 (P = 0.030 and 0.021). The mean follow-up time was 15.02 ± 11.8 (3-52) and 18.9 ± 98.6 (7-43) months in groups 1 and 2, respectively. In addition to the standard management of HGGs in patients without GTR, boost GKRS during the early postoperative period is beneficial for increasing PFS and OS.

Subdural Hematoma Evacuation via Rigid Endoscopy System: A Cadaveric Study.

ABSTRACT: The utilization of endoscope-assisted surgery is becoming a more common modality for the surgical treatment of subdural collections. Considering the inflexible construction of the rigid endoscope, it's not clear where to perform the optimal craniotomy. Twenty four craniotomies (3 cm diameter) were performed in 8 hemicrania. The craniotomies were placed 1 cm front and behind the coronal suture and to the point where the parietal bone was the most convex. The craniotomies in the anterior (C1) and posterior (C2) of the coronal suture were in the mid pupillary line, while the posterior craniotomy (C3) was just lateral to the midpupillary line. At first, subdural distances measured, and then the distances from the craniotomy to the anterior, posterior, medial, and lateral directions in which endoscope could reach the farthest without the damage to the parenchyma were measured. The subdural distance was significantly deeper in C3 than C1 (P = 0.001); however, there was no difference between C3 and C2 (P = 0.312). The distance that could be reached with C3 was higher than C1 in anterior, posterior, lateral, and medial directions (P ≤0.001, 0.037, <0.001, and <0.001, respectively). The distance that could be reached with C3 was higher than C2 in anterior, posterior, lateral, and medial directions (P < 0.001, 0.02, 0.01 and <0.001, respectively). In subdural hematomas, especially that covers all surface of the hemisphere, the most suitable craniotomy is the posteriorly placed craniotomy to reach the most extended projection in anteroposterior line of the hematoma.

Contribution of Countries to Main Neurosurgical Journals with Particular Emphasis on Turkey.

AIM: To quantitatively analyze the contribution of different countries to neurosurgical journals, with emphasis on Turkey. Further, we discuss the factors affecting research productivity and strategies for improvement. MATERIAL AND METHODS: Neurosurgical journals were selected from the Journal Citation Reports database using given criteria. Data were collected from the Web of Science database to analyze the contribution rates of countries to neurosurgical journals in terms of publication numbers and average citations per item from September to December 2018. The article types, departmental contributions, and most cited articles were evaluated particularly for Turkey. RESULTS: Fourteen of 52 journals were chosen for analysis. There were 82,626 articles published from 2000 to 2018. The top three contributors included the USA with 28,939 (35%), Japan with 6,382 (7.7%), and Germany with 4,454 articles (5.3%). Turkey contributed 2,087 articles (2.5%) to neurosurgical journals, including 1003 (48%) original articles and 742 (36%) case reports, and ranked 10th in the world. Hacettepe University is the only organization in Turkey that ranked in the top 10 in all categories. Among the top-cited articles from Turkey, the majority were retrospective studies (39%), followed by laboratory studies (18%) and prospective studies (15%). CONCLUSION: This bibliometric assessment of neurosurgical journals allows countries to perceive their neurosurgical research productivity. It can function as a benchmark for academic productivity and the methodology can be a model for particular analysis of other countries.

Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern.

BACKGROUND: Approaching ambient cistern lesions is still a challenge because of deep location and related white matter tracts (WMTs) and neural structures. OBJECTIVE: To investigate the white matter anatomy in the course of 3 types of transtemporal-transchoroidal fissure approaches (TTcFA) to ambient cistern by using fiber dissection technique with translumination and magnetic resonance imaging fiber tractography. METHODS: Eight formalin-fixed cerebral hemispheres were dissected on surgical corridor from the temporal cortex to the ambient cistern by using Klingler's method. The trans-middle temporal gyrus, trans-inferior temporal sulcus (TITS), and trans-inferior temporal gyrus (TITG) approaches were evaluated. WMTs that were identified during dissection were then reconstructed on the Human Connectome Project 1021 individual template for validation. RESULTS: The trans-middle gyrus approach interrupted the U fibers, arcuate fasciculus (AF), the ventral segment of inferior frontoocipital fasciculus (IFOF), the temporal extensions of the anterior commissure (AC) posterior crura, the tapetum (Tp) fibers, and the anterior loop of the optic radiation (OR). The TITS approach interrupted U fibers, inferior longitudinal fasciculus (ILF), IFOF, and OR. The TITG approach interrupted the U fibers, ILF, and OR. The middle longitudinal fasciculus, ILF, and uncinate fasciculus (UF) were not interrupted in the trans-middle gyrus approach and the AF, UF, AC, and Tp fibers were not interrupted in the TITS/gyrus approaches. CONCLUSION: Surgical planning of the ambient cistern lesions requires detailed knowledge about WMTs. Fiber dissection and tractography techniques improve the orientation during surgery and may help decrease surgical complications.

Experience of Fully Awake Craniotomy for Supratentorial Lesions: A Single Institution Study.

AIM: To report and to discuss our experience of awake craniotomy for the treatment of supratentorial lesions. MATERIAL AND METHODS: We included patients who underwent awake craniotomy for supratentorial tumors between 2007 and 2018. A bipolar stimulation probe was used for patients with eloquent area lesions. The demographic features, presenting symptoms, comorbidities, localization, histopathology, pre- and postoperative Karnofsky performance status, mean operation length, mean length of hospital stay, and intraoperative and postoperative complications were recorded. RESULTS: We included 250 patients (age, 53.5 ± 15.3 years; range, 15?90 years; 105 females and 145 males) mostly with metastasis (46%). The tumor resection rate was 90 ± 3.6%. Of 30 patients (12%) who experienced an increase in weakness, 26 experienced improvements within three days, and the remainder had permanent symptoms. Intraoperative and postoperative seizures occurred in three (1.2%) and seven (2.8%) patients, respectively, which were controlled by antiepileptic drugs. Dysphasia occurred intraoperatively in seven patients (2.8%) but improved in a month. The mean follow-up duration was 31.8 ± 11.9 months (range, 7?70 months). No mortality was seen during hospitalization. CONCLUSION: Awake procedures are a good option in supratentorial lesions to avoid the complications of general anesthesia for patients in poor medical condition. To obtain maximal tumor resection and to maintain better quality of life, neurosurgeons should opt for awake craniotomy when necessary.

Academic performance after neurosurgery residency training in Turkey: a national survey.

OBJECTIVE: Neurosurgery training programs aim to train specialists. In addition, they are expected to equip the residents with necessary knowledge and skills for academic development. This study aims to gain insights into academic productivity after neurosurgeons graduated from residency training in Turkey. METHODS: An electronic survey was sent to all Turkish Neurosurgical Society members (n = 1662 neurosurgeons) between September and November 2019. The number of participants was 289 (17.4%). Participants were divided into subgroups based on three main factors: training institution type (university hospital [UH] vs training and research hospital [TRH]), training institution annual case volume (low [< 1000 or inadequate cranial/spinal case numbers] vs high [> 1000 and adequate cranial/spinal case numbers]), and training program accreditation status (accredited vs nonaccredited). RESULTS: The majority of the participants (64.7%) graduated from the UHs. Those trained at UHs (vs TRHs) and high- (vs low-) volume centers had their dissertations more frequently published in Science Citation Index/Science Citation Index-Expanded journals, gave more oral presentations after residency, had higher h-indices, had higher rates of reviewership for academic journals, and had greater participation in projects with grant support. In addition, graduates of accredited programs reported more PhD degrees than those of nonaccredited programs. CONCLUSIONS: Neurosurgeons trained in higher-case-volume, accredited programs, mostly in the UHs, performed better in terms of scientific activities and productivity in Turkey. Strong research emphasis and supportive measures should be instituted to increase academic performance during and after residency training.

Isolated hypoglossal nerve palsy due to a jugular foramen schwannoma.

Introduction - Although the involvement of the hypoglossal nerve together with other cranial nerves is common in several pathological conditions of the brain, particularly the brainstem, isolated hypoglossal nerve palsy is a rare condition and a diagnostic challenge. Case presentation - The presented patient arrived to the hospital with a history of slurred speech and an uncomfortable sensation on his tongue. Neurological examination showed left-sided hemiatrophy of the tongue with fasciculations and deviation towards the left side during protrusion. Based on the clinical and MRI findings, a diagnosis of hypoglossal nerve schwannoma was made. Discussion - Hypoglossal nerve palsy may arise from multiple causes such as trauma, infections, neoplasms, and endocrine, autoimmune and vascular pathologies. In our case, the isolated involvement of the hypoglossal nerve was at the skull base segment, where the damage to the hypoglossal nerve may occur mostly due to metastasis, nasopharyngeal carcinomas, nerve sheath tumors and glomus tumors. Conclusion - Because of the complexity of the region's anatomy, the patient diagnosed with hypoglossal nerve schwannoma was referred for gamma knife radiosurgery.

Bilateral Cerebellopontine Angle Osteomas: Case Report and Review of the Literature.

Osteomas and exostoses of cerebellopontine angle (CPA) are very rare, benign, and usually slow-growing lesions; few case reports have been published about these lesions in literature. The most common localizations of these temporal bone lesions are the mastoid cortex and the external acoustic canal. To our knowledge, only two cases of bilateral osteoma arising from both internal acoustic canals (IACs) have been reported. However, these tumors are usually asymptomatic and diagnose incidentally, and they can cause symptoms related to the 7th and 8th cranial nerve involvement. We report on a 75-year-old woman affected with bilateral osteoma of CPA and review the literature that 27 cases of IAC osteoma and exostoses have been reported.

Lumbar Single-Level Dynamic Stabilization with Semi-Rigid and Full Dynamic Systems: A Retrospective Clinical and Radiological Analysis of 71 Patients.

BACKGROUND: This study compares the clinical and radiological results of three most commonly used dynamic stabilization systems in the field of orthopedic surgery. METHODS: A total of 71 patients underwent single-level posterior transpedicular dynamic stabilization between 2011 and 2014 due to lumbar degenerative disc disease. Three different dynamic systems used include: (1) the Dynesys system; (2) a dynamic screw with a PEEK rod; and (3) a full dynamic system (a dynamic screw with a dynamic rod; BalanC). The mean patient age was 45.8 years. The mean follow-up was 29.7 months. Clinical and radiological data were obtained for each patient preoperatively and at 6, 12, and 24 months of follow-up. RESULTS: Clinical outcomes were significantly improved in all patients. There were no significant differences in the radiological outcomes among the groups divided according to the system used. Screw loosening was detected in 2 patients, and 1 patient developed screw breakage. All patients with screw loosening or breakage underwent revision surgery. CONCLUSIONS: Each procedure offered satisfactory outcome regardless of which system was applied.

Early Brain Injury or Vasospasm? An Overview of Common Mechanisms.

BACKGROUND: Subarachnoid hemorrhage (SAH) following rupture of an intracranial is associated with high mortality and morbidity. The late deterioration of the patient's neurological status or late cognitive dysfunctions even after secure clipping or decent endovascular treatment which is defined as delayed ischemic neurological deficits recently has been attributed to vasospasm. Due to the failure of specific anti- vasospastic agents in clinical trials researchers focused to explore new pathological mechanisms to be responsible for the delayed deterioration of the patients suffering from SAH. Early brain injury (EBI), as a new term in the SAH research area has been the focus of scientist for the past couple of years. OBJECTIVE: The goal of this study is to review the common mechanisms of early brain injury and vasospasm. RESULTS: The acute events following SAH, such as increased intracranial pressure and decreased cerebral blood flow, causing global cerebral ischemia initiate a cascade of pathological changes including inflammation, lipid peroxidation, cell death and blood brain barrier disruption. CONCLUSION: The more insight we gain into the EBI we realize that there are a bunch of common mechanisms between EBI and vasospasm. In the SAH management, a therapy targeting these early injuries may also reduce the later developing pathological neurological complications.

Rare case of glioblastoma multiforme located in posterior corpus callosum presenting with depressive symptoms and visual memory deficits.

Most of the primary brain tumours are located in the supratentorial region, and it is uncommon to see tumour growth on deep brain structures such as posterior corpus callosum (PCC). In addition, lesions in PCC are also difficult to recognise, because construction apraxia, visuospatial perception and attentional capacity impairment may be the only presenting symptoms. Here, we represent a rare case of gliobastoma multiforme located in PCC, which solely presents with depressive symptoms and visual memory deficits. Initial manifestations of primary brain tumours with psychiatric symptoms and memory disturbances, in addition to headaches and seizures, should be kept in mind.

Novel Foraminal Expansion Technique.

The technique we describe was developed for cervical foraminal stenosis for cases in which a keyhole foraminotomy would not be effective. Many cervical stenosis cases are so severe that keyhole foraminotomy is not successful. However, the technique outlined in this study provides adequate enlargement of an entire cervical foraminal diameter. This study reports on a novel foraminal expansion technique. Linear drilling was performed in the middle of the facet joint. A small bone graft was placed between the divided lateral masses after distraction. A lateral mass stabilization was performed with screws and rods following the expansion procedure. A cervical foramen was linearly drilled medially to laterally, then expanded with small bone grafts, and a lateral mass instrumentation was added with surgery. The patient was well after the surgery. The novel foraminal expansion is an effective surgical method for severe foraminal stenosis.