Effect of endoscopic endonasal skull base approaches on olfactory function and facial development in children.

INTRODUCTION: Endoscopic approaches for skull base pathologies are increasingly being performed, and the subsequent complications, especially in the long term, have also been partially clarified. However, there is no information on the effects of endoscopic endonasal skull base surgeries (EESBS) in children on odor and facial development in parallel with long-term development. We conducted this study to investigate postoperative olfactory function and facial development in pediatric patients who underwent skull base surgery using the endoscopic endonasal method. METHODS: We evaluated the smell test, sinonasal symptoms, and facial development of pediatric patients who underwent endoscopic endonasal skull base surgery after long-term follow-up. Odor was evaluated using the "Sniffin' Sticks" test kit, which assessed the T (odor threshold), D (odor discrimination), and I (odor identification) parameters. Sinonasal symptoms were evaluated using the SNOT-22 (sinus-nose outcome test) questionnaire. SNA (sella-nasion-A point), SNB (sella-nasion-B point), and ANB (A point-nasion-B point) angles were calculated from maxillofacial tomography and magnetic resonance imaging) to evaluate facial development. Data were compared with those of the healthy control group. RESULTS: We included 30 patients comprising 19 (63.3%) boys and 11 (36.7%) girls, with no age difference between case and control groups. The mean follow-up period was 7 years. Odor test data, cephalometric measurements, and SNOT-22 analysis results showed no statistically significant differences between the two groups. CONCLUSION: To our knowledge, this is a comprehensive study with the longest follow-up period in terms of evaluation of facial development after EESBS in children to analyze odor using the Sniffin' Sticks test kit and the quality of life using SNOT-22. Olfactory function, facial development, and quality of life remained unaffected after long-term follow-up after EESBS  in children. Although this surgical approach is minimally invasive, we recommend considering the possibility of complications, and the procedure should be performed by an experienced surgical team with adequate equipment.

Prediction of Meningioma Grade Using Hematological Parameters.

OBJECTIVE: Predicting the aggressiveness of meningiomas may influence the surgical strategy timing. Because of the paucity of robust markers, the systemic immune-inflammation (SII) index is a novel biomarker to be an independent predictor of poor prognosis in various cancers including gliomas. We aimed to investigate the value of SII as well as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) indices in predicting prognosis. METHODS: Records including demographic, clinical, and laboratory data of patients operated on due to intracranial meningioma in 2017-2023 were retrospectively reviewed. RESULTS: A total of 234 patients were included in this study. All of SII index, NLR, and PLR values at presentation were significantly higher in grade ≥2 meningiomas. A positive correlation was observed between SII index and Ki67 index (r=0.313; P<0.001); between NLR and Ki67 index (r=0.330; P<0.001); and between PLR and Ki67 index (r=0.223; P<0.01). SII index (optimal cutoff level >618), NLR (optimal cutoff level >3.53), and PLR (optimal cutoff level >121.2) showed significant predictive values. CONCLUSIONS: This is the first study to assess the prognostic value of the SII index in patients with intracranial meningiomas. Increased SII index, NLR and PLR were correlated with higher grade and higher Ki-67 index. They also harbor the potential to screen patients that may need more aggressive treatments or more frequent follow-up examinations.

Does the Extent of Rod Bending and Actual Lumbar Lordosis Mismatch Affect Quality of Life?

BACKGROUND: To evaluate any mismatch between rod bending and actual lordosis during posterior lumbar instrumentation and its effects on the quality of life (QOL) of patients. METHODS: Patient records for posterior lumbar fusion in 2018-2023 were retrospectively reviewed. The radiologic parameters consisted of pelvic incidence, sacral slope, L1S1 lumbar lordosis, lumbosacral angle, the distance between the posterior wall of the vertebra and the rod, lordosis of the rod. The postoperative QOL of patients was assessed using Oswestry Disability Index. The patients were grouped postoperative into Group-1 (minimal/moderate disability) and Group-2 (severe disability/crippled/bed bound). RESULTS: Total of 133 patients were included; 99 women, 34 men. The difference was significant for patients with diabetes to be presented in the more disabled Group-2. The distance between the posterior vertebral wall and the rod was found to be short in Group-2. Preoperative and postoperative sagittal lumbar Cobb angles were significantly higher in Group-2. The changing degree of pain was found to score high in Group-2. The postoperative visual analog scale was high in Group-2. The difference between the preoperative and postoperative lumbar sagittal Cobb and rod Cobb-angles was found to be high in Group-2. CONCLUSIONS: The results of our study confirm the importance of considering the preoperative actual lumbar lordosis during bending and maintaining it as much as possible. To our knowledge, this is the first study that evaluated the effect of rod bending on quality of life (QOL) and supports that this might be affected in case of any mismatches.

Surgery of Cranial Deformity Following Ventricular Shunting: A Multicenter Study.

AIM: To review the cases of craniosynostosis secondary to ventricular shunting procedure. MATERIAL AND METHODS: We retrospectively evaluated the medical records of all pediatric patients with hydrocephalus who were treated with ventriculoperitoneal shunt procedure between the years 2017 and 2021 at the Selcuk University, Ankara University, and Bursa Uludag University. RESULTS: Twenty-one patients were included in the study. The median age at the time of insertion of ventriculoperitoneal shunt for hydrocephalus was 8.1 (range, 1?22) months. Seven patients were shunted because of congenital hydrocephalus. The mean time to development of secondary synostosis was 8.8 (range, 1?36) months. Plagiocephaly was the most common type of secondary synostosis. While shunt revision was performed in 16 patients, cranial vault expansion surgery was performed in 5 patients. CONCLUSION: Slit ventricle syndrome is a frequent condition at shunted patients, but there is no consensus on identifying patients who require treatment. Using programmable or high-pressure valves, performing cranial vault modeling are possible treatment modalities. Increased awareness of this condition in follow-up may allow early diagnosis and intervention and prevent it from evolving into more serious deformities.

Impact of Post-Master PhD Degree on Publication Productivity in Neurosurgery.

AIM: To evaluate the impact of the post-master PhD degree on publication productivity in neurosurgery. MATERIAL AND METHODS: An online national electronic survey was designed based on the recent literature and factors related to publication productivity. The survey was conducted to simply evaluate main bibliometrics of the participants consisting of neurosurgeons in different stages of their career. The survey was distributed via email to all Turkish Neurosurgical Society members. RESULTS: A total of 220 neurosurgeons participated and answered the survey. Neurosurgeons that had published their Master's dissertation were found to have significantly higher number of published articles, citations and Hirsch (h)-index during their career (p < 0.001). Neurosurgeons with a PhD degree who have been involved in such program were found to have significantly higher number of published articles and h-index (p < 0.01). A majority of neurosurgeons who were involved in a PhD program were found to work in university hospitals (41.5%) and research and training hospitals (26.8%). Clinical anatomy, neuroscience, and molecular/ genetic biology were the most common PhD programs. CONCLUSION: Standardization in measurability of scientific productivity is mandatory to maintain stability and move further in academic activity. PhD programs have a significant contribution to academic performance and scientific productivity. Surgical residents and young neurosurgeons should be encouraged to be involved in such PhD training programs to promote success in both neurosurgery and scientific arenas.

Single-institution comparative analysis for odontoid resection: posterior transaxis versus anterior transnasal approach.

OBJECTIVE: The resection of an upwardly migrated odontoid is most widely performed via an anterior endoscopic endonasal approach after the addition of posterior occipitocervical instrumentation. In patients with craniovertebral junction (CVJ) anomalies like basilar invagination (BI), surgery is usually achieved in two separate stages. However, the authors have recently introduced a novel posterior transaxis approach in which all the therapeutic goals of the surgery can be safely and effectively accomplished in a single-stage procedure. The aim of the current study was to compare the widely used anterior and the recently introduced posterior approaches on the basis of objective clinical results in patients who underwent odontoid resection for BI. METHODS: Patients with BI who had undergone odontoid resection were retrospectively reviewed in two groups. The first group (n = 7) consisted of patients who underwent anterior odontoidectomy via the standard anterior transnasal route, and the second group (n = 6) included patients in whom the novel transaxis approach was performed. Patient characteristics, neurological conditions, and modified Rankin Scale (mRS) scores at admission were evaluated. Operative time, changes in intraoperative neurophysiological monitoring, blood loss during surgery, odontoid resection rate, postoperative complications, and mortality were compared between the patient groups. RESULTS: Data were retrospectively reviewed for 13 patients who underwent odontoid resection, posterior CVJ decompression, and occipitocervical instrumentation at the Ankara University School of Medicine Department of Neurosurgery between 2009 and 2022. In the first group (n = 7), patients who underwent anterior odontoidectomy via the standard endonasal route, two serious complications were observed, pneumocephaly and basilar artery injury. In the second group (n = 6), patients in whom the novel transaxis approach was performed, only one complication was observed, occipital plate malposition. CONCLUSIONS: This study represents the results of what is to the authors' knowledge the first comparison of a novel approach with a widely used surgical approach to odontoid resection in patients with BI. The preliminary data support the successful utility of the transaxis approach for odontoid resection that meets all the operative therapeutic demands in a single-stage operation. Considering the diminished surgical risks and operative time, the transaxis approach may be regarded as a primary approach for the treatment of BI.

Alternative Path for Optic Nerve Decompression in Pseudotumor Cerebri With Full Endoscopic Lateral Transorbital Approach.

Endonasal endoscopic approaches are the most preferred surgical methods in patients with pseudotumor cerebri because of easy access to the optic nerve, but the choice of this technique may not apply to all endoscopic endonasal cases. Moreover, there may be difficulties in practice in some cases, including the coronavirus disease 2019 pandemic. This study aimed to suggest an alternative endoscopic approach by lateral orbitotomy for optic nerve decompression in patients with pseudotumor cerebri. The study was performed using 5 fresh-frozen cadaver heads (bilaterally, total of 10 sides) injected intravenously with colored silicone preserved in the cold chain. An average of 2.5 cm skin incision was made to fit the lateral orbitotomy. The lengths of the recurrent meningeal artery (mm), the meningo-orbital band (mm), and the optic nerve (mm) to the orbital margin were measured. After these morphometric measurements, optic nerve decompression was performed endoscopically, and the length of the decompression was measured (mm). The average length (mm) between the orbital rim and meningeal recurrent artery (or meningolacrimal branch) was 16.2 mm, between the orbital rim and the meningo-orbital band was 18.5 mm, and between the orbital rim and optic nerve was 44.1 mm. The average optic nerve decompression length was 4.4 mm. The endoscopic lateral orbitotomy approach provides easy access to the optic nerve by anatomically following the recurrent meningeal artery and the meningo-orbital band. It can be a safe second-line approach after endonasal approaches for optic nerve decompression in pseudotumor cerebri.

Microsurgical anatomy of the anterior cerebral artery and the arterial supply of the cingulate gyrus.

PURPOSE: The cingulate gyrus is a potential surgical area to treat tumours, psychiatric diseases, intractable pain and vascular malformations. The aim of the study was to define the topographic anatomy and arterial supply of the cingulate gyrus located on the medial surface of the cerebral hemisphere. METHODS: We studied thirty-six hemispheres, each hemisected in the midsagittal plane. The vertical thickness of the cingulate gyrus was measured at the anterior commissure (AC), posterior commissure (PC), and genu levels of the corpus callosum. The branches of the anterior and posterior cerebral arteries supplying each zone were noted separately. The arterial pathways were transformed to digital data in AutoCAD to identify the condensation and reduction areas. RESULTS: The mean AC-PC distance was 27.17 ± 1.63 mm. The thinnest region was the genu level of the corpus callosum (10.29 mm). The superior internal parietal artery (SIPA), inferior internal parietal artery (IIPA) and pericallosal artery (PrCA) supplied all zones of the cingulate gyrus. The anterior zone received the greatest supply. The arterial condensation and reduction areas on both sides of cingulate gyrus and its x, y, and z coordinates specified. CONCLUSIONS: The target cingulotomy (TC) area was determined for anterior cingulotomy. The properties of the TC area are that the thinnest region of the cingulate gyrus is supplied relatively less than other areas and is close to the anterior cingulotomy areas in the literature. The arterial reduction area (ARA) was found to be suitable for corpus callosotomy in terms of avoiding haemorrhage.

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.

Transcranial endoscopic treatment of thalamic neuroepithelial cyst: case report and review of the literature.

Thalamic neuroepithelial cysts are rare, benign lesions. Thirteen cases have been published in eight articles. The most frequent symptoms are headache, hemiparesis, tremor and related signs of hydrocephalus such as gait disturbance, confusion, and Paranaud's syndrome. Surgical interventions include endoscopic fenestration, open surgery and stereotaxic biopsy or aspiration. We report a case of a 63-year-old woman who had headache and right hemiparesis for 1 week, but no hydrocephalus. We treated her with transcranial neuronavigation-guided endoscopic complete resection. The patient recovered completely after cyst removal.

Endonasal endoscopic approach for sellar metastatic pathologies: a national observation.

PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Comparison of pre-PICU and per-PICU interventions, clinical features and neurologic outcomes of motor vehicle collision trauma and other mechanisms of trauma in children.

BACKGROUND: Motor vehicle collisions (MVCs) are the number one cause of death in the pediatric age group. The aim of this study was to determine the differences between MVCs and other trauma mechanisms (OTMs) in patients who were followed up at a pediatric intensive care unit (PICU). METHODS: Data were retrospectively collected for pediatric trauma patients hospitalized at a third level PICU between 2014 and 2018. Patients have been divided into two groups as MVC and OTM. Demographic data, pre-PICU interventions (cardiopulmonary resuscitation, intubation, injury severity scores, time period before intensive care), intensive care interventions (invasive mechanical ventilation, non-invasive mechanical ventilation, need for surgery, type of surgery, need for transfusion, and inotrope therapy) were compared between two groups. Outcomes were evaluated by survival, discharge from hospital, Pediatric Cerebral Performance Cate-gory (PCPC) at discharge, tracheotomy presence, and amputation performed. RESULTS: During the 5-year study period, 135 patients were hospitalized for trauma. The injured body regions were the head and neck (61.5%), abdomen and lumbar spine (39.4%), and extremities and pelvis (36.3%). Multiple trauma was mostly seen in the MVC trauma group (p=0.001). The need for invasive mechanical ventilation and inotrope therapy was greater in the MVC group (p=0.002, 0.001 respectively). One hundred and twenty-three patients (91.1%) survived. The mortality rate was higher in the MVC group (p=0.026). The PCPC results were better in the OTM group (p=0.017). CONCLUSION: MVCs lead to more multiple trauma cases than OTMs. Invasive mechanical ventilation, inotropes, and other inten-sive care interventions were necessary much more often in MVC victims than in OTM patients.

Morphology of the trigeminal ganglion: anatomical structures related to trigeminal radiofrequency rhizotomy.

BACKGROUND: Trigeminal neuralgia is the most common example of craniofacial neuralgia. Its etiology is unknown and is characterized by severe episodes of paroxysmal pain. The trigeminal ganglion and its adjacent anatomical structures have a complex anatomy. The foramen ovale is of great importance during surgical procedures such as percutaneous trigeminal rhizotomy for trigeminal neuralgia. OBJECTIVE: We aimed to identify the anatomical structures associated with the trigeminal ganglion and radiofrequency rhizotomy on cadavers and investigate their relationship with the electrodes used during rhizotomy to determine the contribution of the electrode diameter and length to the effectiveness of the lesion formation on the ganglion. METHODS: Five fresh-frozen cadaver heads injected with red silicone/latex were used. A percutaneous puncture was made by inserting of a cannula through the foramen ovale to create a pathway for electrodes. The relationships between the electrodes, Meckel's cave, trigeminal ganglion, and neurovascular structures were observed and morphometric measurements were obtained using a digital caliper. RESULTS: Trigeminal ganglion, therefore the electrode in its final position, shows proximity with important anatomical structures. The electrode was inserted posteriorly into the foramen ovale in all of the specimens and was located on the retrogasserian fibers. This study revealed that the electrodes targeting the ganglion and passing through the foramen ovale may cause a radiofrequency lesion due to the contact effect of the dura itself pressing on the electrode. Pushing the cannula beyond the petroclival angle may result in puncturing of the dura propria and moving further away from the target area. CONCLUSION: The success of radiofrequency rhizotomy is directly related to the area affected by the lesion. Understanding the mechanism of action underlying this procedure will ensure the effectiveness, success, and sustainability of the treatment.

Changes in Callosal Angle and Evans' Index After Placing a Lumboperitoneal Shunt in Patients with Idiopathic-Normal- Pressure Hydrocephalus.

AIM: To evaluate changes in the Evans? index (EI) and callosal angle (CA) in patients who underwent lumboperitoneal (LP) shunting for idiopathic normal pressure hydrocephalus (INPH) and whose symptoms improved post-operatively. MATERIAL AND METHODS: We retrospectively analysed patients who were clinically and radiologically diagnosed with INPH and treated with an LP shunt between 2010 and 2020. In all patients, we performed radiological imaging with EI and CA measurements and completed clinical assessments, including Mini-Mental State Examination (MMSE) and cognitive, urinary continence, balance and 10-m walking tests, preoperatively and post-operatively (less than 1 year later). Results were compared by statistical analyses. RESULTS: We evaluated 42 patients who received an LP shunt for INPH and had cranial magnetic resonance imaging (MRI) performed within the first 2 months after surgery. When the pre-operative and post-operative MRIs of the patients were compared, a statistically significant decrease was found in EI and CA measurements (p < .001, for each). A statistically significant improvement was found in clinical tests. Post-op early radiological images predicted recovery of the gait-balance function and urinary incontinence (p < .001) but did not predict recovery of dementia (p=.06). CONCLUSION: Radiological and clinical improvements are expected after the placement of ventriculoperitoneal (VP) or LP shunts in patients with INPH. Radiological measurements after an LP shunt in patients with INPH have not been reported in the literature. In the current study, radiological measurements after LP shunt placement were evaluated for the first time in patients with INPH. Significant changes in EI and CA after LP shunt placement may indicate whether patients will benefit clinically from an LP shunt during follow-up. A significant decrease in CA and EI measurements in the early period may be a marker for whether patients with INPH will show signs of clinical improvement and benefit from an LP shunt.

Posterior fossa epidermoid tumors: a single-center study and proposed classification system.

BACKGROUND: Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates. METHODS: The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients' data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical-radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes. RESULTS: The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological-anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup 'a' was correlated with higher resection rates (GTR and NTR), whereas the subgroup 'b' was correlated with STR. CONCLUSIONS: Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.

Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase.

Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. METHODS: After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked by performing the Valsalva maneuver at the end of the surgery. RESULTS: No CSF leakages were observed after surgery. CONCLUSIONS: Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might be effective in cases with untraumatized arachnoid membrane.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

OBJECTIVE: In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. METHODS: Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. RESULTS: Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure. CONCLUSIONS: Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.