Transorbital neuroendoscopic surgery for treatment of sphenoid wing meningiomas extending to the cavernous sinus: clinical implications and a technical illustration.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of transorbital neuroendoscopic surgery (TONES) in the management of sphenoid wing meningiomas (SWMs) with cavernous sinus and orbital invasion. METHODS: The authors conducted a retrospective review of 32 patients with SWMs treated at Gazi University using TONES from October 2019 to May 2023. The study includes clinical applications to elucidate the endoscopic transorbital approach. Surgical techniques focused on safe subtotal resection, aiming to minimize residual tumor volume for subsequent radiosurgery. Data were collected on patient demographics, tumor characteristics, surgical procedures, complications, and postoperative outcomes, including radiological imaging and ophthalmological evaluations. RESULTS: Surgical dissections delineated a three-phase endoscopic transorbital approach: extraorbital, intraorbital, and intracranial. In the clinical application, gross-total resection was not achieved in any patient because of planned postoperative Gamma Knife radiosurgery. The mean follow-up period was 16.3 months. Of 30 patients with preoperative proptosis, 25 experienced postoperative improvement. No new-onset extraocular muscle paresis or visual loss occurred postoperatively. The average hospital stay was 1.15 days, with minimal complications and no significant morbidity or mortality. CONCLUSIONS: Total resection of SWMs invading the cavernous sinus and orbit is associated with substantial risks, particularly cranial nerve deficits. TONES offers a minimally invasive alternative, reducing morbidity compared with transcranial approaches, and represents a significant advancement in the surgical management of SWMs, especially those extending into the cavernous sinus and orbit. The approach provides a safe, effective, and patient-centric approach, prioritizing subtotal resection to minimize neurological deficits while preparing patients for adjunctive radiosurgery. This study positions TONES as a transformative surgical technique, aligning therapeutic efficacy with neurovascular preservation and postoperative recovery.

Evaluation of neurocognitive and social developments after craniosynostosis surgery.

OBJECTIVE: The study focused on assessing the potential neurocognitive and social developmental issues in children with non-syndromic craniosynostosis (NSC) who received optimal surgical treatment. The primary objective was to determine whether NSC, even after optimal surgical treatment, could have negative effects on brain development. METHODS: The study included a total of 73 pediatric patients aged between 2 and 6 years who had previously undergone surgery for NSC at the Gazi University Faculty of Medicine, Department of Neurosurgery. These patients were carefully matched with 107 healthy children who visited the outpatient clinic of the same department in terms of sociodemographic characteristics such as age, gender, and social status. To assess the neurocognitive and social development of the participants, the child psychologist administered a developmental scale to the child and his/her family via video conference. This scale was adapted from the Bayley-III Infant and Child Development Scale by the Gazi University Faculty of Medicine, Division of Pediatric Neurology. RESULTS: The study found no social or gross motor developmental issues in patients who had undergone optimal surgical treatment for NSC. However, the risk of fine motor developmental deficiencies was 4.79 times higher than that of the normal population, and the risk of language developmental deficiencies was 5.75 times higher than that of the normal population. CONCLUSIONS: Despite timely treatment of NSC, long-term neurocognitive and social development issues may arise in affected children. Therefore, it is crucial to monitor these patients after completing surgical treatment and thoroughly examine their development using a multidisciplinary approach.

Beyond human in neurosurgical exams: ChatGPT's success in the Turkish neurosurgical society proficiency board exams.

Chat Generative Pre-Trained Transformer (ChatGPT) is a sophisticated natural language model that employs advanced deep learning techniques and is trained on extensive datasets to produce responses akin to human conversation for user inputs. In this study, ChatGPT's success in the Turkish Neurosurgical Society Proficiency Board Exams (TNSPBE) is compared to the actual candidates who took the exam, along with identifying the types of questions it answered incorrectly, assessing the quality of its responses, and evaluating its performance based on the difficulty level of the questions. Scores of all 260 candidates were recalculated according to the exams they took and included questions in those exams for ranking purposes of this study. The average score of the candidates for a total of 523 questions is 62.02 ± 0.61 compared to ChatGPT, which was 78.77. We have concluded that in addition to ChatGPT's higher response rate, there was also a correlation with the increase in clarity regardless of the difficulty level of the questions with Clarity 1.5, 2.0, 2.5, and 3.0. In the participants, however, there is no such increase in parallel with the increase in clarity.

Retrospective Analysis of Paediatric Glial Tumours that Required Modern Molecular Techniques.

AIM: To determine if previous histological grading systems were sufficient or unreliable with a limited repository of modern techniques. MATERIAL AND METHODS: The pathology reports of pediatric neurosurgery patients between 2019-2022 were accessed. Data on patients that needed unattainable further molecular investigation were extracted. Data were noted from electronic archives, including their sex, age, histologic grade, location, resection type, survival, and therapy. RESULTS: Out of 61 surgeries, 17 patients needed further investigation for a proper 2022 World Health Organization (WHO) diagnosis. Seven were deceased, and nine were alive. Two of 10 patients with low-grade gliomas and five of six patients with highgrade gliomas were deceased. Data on one foreign patient with high-grade glioma was inaccessible. The average survival was 9 months for the deceased. CONCLUSION: Modern molecular techniques such as next-generation sequencing and methylation profiling are the state-ofthe- art methods, but it is hard for developing and underdeveloped countries to utilize such methods. The classification schemes, diagnostic key figures, and treatment modalities are developed using these techniques, but the less developed world is incapable of achieving these. We are trying to hybridize the modern and classic modalities, and the results of our study show that for overall survival, there is still not much difference. More economic and feasible techniques should be produced and summarized for the rest of the world.

Spontaneous improvement in syringomyelia in a patient with Chiari 1 malformation: illustrative case.

BACKGROUND: "Chiari malformation" refers to a spectrum of hindbrain abnormalities characterized by impaired cerebrospinal fluid circulation through the foramen magnum. Syringomyelia is frequently found in patients with Chiari malformation type 1. Although many theories have suggested how cerebrospinal fluid enters and makes the cystic cavity in the spinal cord, the pathogenesis of syringomyelia remains controversial. This report documents a case with spontaneous resolution of syringomyelia followed up by 3-year serial magnetic resonance imaging (MRI). These kinds of cases support a more conservative approach. OBSERVATIONS: A 59-year-old female presented to the authors' clinic in June 2019 with a history of Chiari malformation type 1. This symptomatic patient has been followed up with serial MRI. When the last MRI was performed in August 2022, compared with previous imaging, resolution of the syringomyelia was recognized. LESSONS: Because the natural evolution of mildly symptomatic/asymptomatic patients with syringes is unclear, these patients pose a treatment dilemma. Although surgical intervention is a widely accepted therapeutic method, a more conservative approach can be considered in cases with spontaneous resolution. Especially for patients without progressive symptoms, the surgical approach should not be considered as the first step. In view of relapses, follow-up with periodic neurological examinations and radiological imaging is preferrable.

The first case of glioma detected by an artificial intelligence algorithm running on real-time data in neurosurgery: illustrative case.

BACKGROUND: The aim of this paper is to report one of the significant applications of artificial intelligence (AI) and how it affects everyday clinical practice in neurosurgery. The authors present a case in which a patient was diagnosed via an AI algorithm during ongoing magnetic resonance imaging (MRI). According to this algorithm, the corresponding physicians were immediately warned, and the patient received prompt appropriate treatment. OBSERVATIONS: A 46-year-old female presenting with nonspecific headache was admitted to undergo MRI. Scanning revealed an intraparenchymal mass that was detected by an AI algorithm running on real-time patient data while the patient was still in the MRI scanner. The day after MRI, a stereotactic biopsy was performed. The pathology report confirmed an isocitrate dehydrogenase wild-type diffuse glioma. The patient was referred to the oncology department for evaluation and immediate treatment. LESSONS: This is the first report of a glioma diagnosed by an AI algorithm and a subsequent prompt operation in the literature-the first of many and an example of how AI will enhance clinical practice.

Suprafloccular transhorizontal fissure approach to the cerebellopontine angle: an anatomical study with case series.

The suprafloccular transhorizontal fissure approach is a modified variant of the classical retrosigmoid approach option to be chosen for cerebellopontine angle lesions. In this study, we aimed to demonstrate a previously described but not widely used method, the suprafloccular transhorizontal fissure approach with anatomical dissection on the cadaver, accompanied by a case presentation with the largest clinical series in the literature. Klingler's protocol was used to prepare 8 silicone injected and 8 non-silicone injected human hemispheres. A total of 210 patients who underwent surgery in the cerebellopontine angle between 2019 and 2022 were evaluated in our clinic. Of these, the suprafloccular transhorizontal fissure approach was applied in 33 patient, and it was successful in 26 patient, but this approach could not be achieved in 7 patients. The transhorizontal fissure is a fissure in the cerebellum located between the superior semilunar lobule and the inferior semilunar lobule. In the 26 patients we operated with the suprafloccular transhorizontal fissure approach, there was no need for retraction and no complications developed. However, in 7 patients, this fissure could not be dissected due to adhesions. Suprafloccular approach is an alternative to the classical retrosigmoid approach in tumours smaller than 2 cm, medially localised with little cerebellar oedema and neurovascular compression syndrome. Because in this approach, no cerebellum retraction is required, vascular structures are better preserved and the surgical time is shortened. This approach can be applied in smaller tumours than 2 cm when the sulcal anatomy is appropriate.

Arterial Supply of the Basal Ganglia: A Fiber Dissection Study.

BACKGROUND: The basal ganglia, a group of subcortical nuclei located deep in the insular cortex, are responsible for many functions such as motor learning, emotion, and behavior control. Nowadays, because it has been shown that deep brain stimulation and insular tumor surgery can be performed by endovascular treatment, the importance of the vascular anatomy of the basal ganglia is being increasingly recognized. OBJECTIVE: To explain the arterial blood supply of the basal ganglia using white matter dissection. METHODS: The Klingler protocol was used to prepare 12 silicone-injected human hemispheres. The dissections were performed from lateral to medial with the fiber dissection technique to preserve arteries. RESULTS: The globus pallidus blood supply came from the medial lenticulostriate, lateral lenticulostriate, and anterior choroidal arteries; the substantia nigra and subthalamic nucleus were supplied by the branches of posterior cerebral artery; the putamen was supplied by the lateral and medial lenticulostriate arteries; and the caudate nucleus was supplied by the lateral lenticulostriate and medial lenticulostriate arteries and the recurrent artery of Heubner. CONCLUSION: Knowledge of the detailed anatomy of the basal ganglia and its vascular supply is essential for avoiding postoperative ischemic complications in surgeries related to the insula. In addition, knowledge of this anatomy and vascular relationship opens the doors to endovascular deep brain stimulation treatment. This study provides a 3-dimensional understanding of the blood supply to the basal ganglia by examining it using the fiber dissection technique. Further studies could use advanced imaging modalities to explore the vascular relationships with critical structures in the brain.

Glossopharyngeal neuralgia as initial symptom in combined hyperactive dysfunction syndrome: case report.

OBJECTIVES: Hyperactive dysfunction syndrome (HDS) is defined as symptoms arising from overactivities in cranial nerves, like trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN). A combination of these cranial nerve neuralgias, that might or might not occur in one or both sides, either synchronously, or metachronously is called combined hyperactive dysfunction syndrome (CHDS). CASE PRESENTATION: We presented a 73 years-old male patient with CHDS presenting with GPN as the initial symptom, with total relief from GPN, TN, and HFS after microvascular decompression. Up to date, only nine patients have been reported in the literature with symptomatic. CONCLUSIONS: TN-HFS-GPN. Our case is the first case with GPN as the initial symptom. The combination of arterial and venous origin of the offending vessels makes the case picturesage.

Normal Pressure Hydrocephalus Overshadowed by Traumatic and Degenerative Spinal Diseases: A New Assessment Proposal.

AIM: Normal pressure hydrocephalus (NPH) is a rare disorder among the elderly, characterized by gait disorder, dementia, and urinary incontinence. Considering the rareness of NPH and a lot of other pathologies, such as Parkinson's disease, lumbar spinal stenosis, and even aging cause similar symptoms, NPH is an underdiagnosed entity. However, the percentage of misdiagnosis is not given in the literature. MATERIAL AND METHODS: In this study, patients diagnosed with NPH were retrospectively screened between 2015 and May 2019 in our clinical database and Ste-P formula was applied. Example cases showed that some of the patients receive inaccurate medical and surgical treatments before being diagnosed with NPH. RESULTS: As a result of the study was seen that a few out of 29 patients confused dizziness with trunkal ataxia or imbalance due to gait abnormality. As the time between onset of complaints and diagnosis increased, the value approached "zero", and diagnosis became difficult. CONCLUSION: Every unnecessary operation carries serious risks that may threaten the life of the patient and decrease the quality of life. These surgeries and instrumentation materials used may also result to additional financial cost. Similarly, long-term use of Parkinson's and dementia medications has a serious economical burden on the insurance systems and is detrimental to the patient's health. Considering all these diagnoses and physiological conditions that can be easily confused with each other, we recommend in this article a new formula to reduce the possibility of misdiagnosis and treatment in patients with walking disorder.

Growth hormone-releasing pituitary microadenoma overshaded by a macroadenoma: a case of double pituitary adenomas and review of the literature.

OBJECTIVES: Double pituitary adenoma is a rare entity that can pose a significant challenge. The incidence of double or multiple pituitary adenomas is ∼1% in autopsy cases and 0.4-1.3% in surgical series. Its definition varies, including 'double adenomas' in the literature in contrast to 'multiple adenomas', which is more specific and suitable. While some authors require separating topographically unique tumours, others have used a looser definition of separate immunohistochemistry. CASE PRESENTATION: We presented the case of a 26-year-old patient with recurrent carpal tunnel syndrome symptoms, with double pituitary adenomas secreting growth hormone (GH) and thyroid-stimulating hormone (TSH). To date, 89 patients have been reported in the literature with symptomatic carpal tunnel syndrome, but only five had GH-TSH secretion. CONCLUSIONS: Double adenoma resection is of great importance for ensuring successful biochemical treatment. To ensure a successful operation, a careful preoperative 3T MRI examination is of great importance.

Women in neurosurgery: perspectives from a developing country; Turkey.

Although at least half of medical students are women, neurosurgery is not often preferred by women, and the proportion of female neurosurgeons who can participate in the academic platform is very low. In this study, we aimed to show the role of female neurosurgeons in the Turkish Neurosurgical Society and to describe the number and the location of female neurosurgeons in Turkey. We examined the age, academic rank, years of work in the profession, membership rate in society subgroups, h-index parameters, and relationships of certificated female neurosurgeons registered in the Turkish Neurosurgical Society. We examined gender rate differences between society subgroups using chi-square tests. A P value < 0.05 was considered statistically significant. According to the year-end 2020 data of the Turkish Neurosurgery Society, 94 (5.5%) of the 1699 neurosurgery specialists registered in Turkey are women. There are currently 94 board-certified female neurosurgeons between the ages of 31 and 92 years; 10 are full professors (10.6%), 16 are associate professors (17%), 5 are assistant professors (5.3%), and 63 are neurosurgery specialist physicians (67%). Female neurosurgeons are present among six of the subfields categorized by the Turkish Neurosurgical Society: 7 in pediatric neurosurgery (11.47%); 8 in spinal and peripheral nerve surgery (2.4%); 3 in neurovascular surgery (2.02%); 7 in functional neurosurgery (5.8%); 11 in neuroanatomy (9.2%); and 23 in neurooncology (6.9%). The number of female neurosurgeons in Turkey continues to grow each year. To increase the proportion of women in this field, it is important to support female neurosurgeons and enable them to take on more tasks.

The effect of antiepileptic drugs on re-myelinization of axons: Phenytoin, levetiracetam, carbamazepine, and valproic acid, used following traumatic brain injury.

OBJECTIVE: Traumatic brain injury is a major health and socioeconomic problem and the first cause of young death worldwide. For this reason, the prevention of post-traumatic brain injury and the research of new methods for it are important today. In this study, we aimed to determine whether the use of antiepileptic drugs contributed to axonal healing after traumatic brain injury. METHODS: Thirty-six Long-Evans rats, each weighing 300-350 g, were used in this study. A total of 6 groups, including the sham, control, and 4 study groups, were determined. A 1.5 mm-sized trauma was created in the biparietal area with a blunt-tipped dissector. Carbamazepine phenytoin valproic acid and levetiracetam (phenytoin: 30 mg/kg, valproic acid: 60 mg/kg, levetiracetam: 80 mg/kg, and carbamazepine: 36 mg/kg) were intraperitoneally administered to the study groups, and the control group intraperitoneally received a physiological saline solution (15 ml/kg) twice daily for 3 days. After 72 h, hemispheres of the sacrificed subjects were taken for examination in biochemistry and histology. Glutathione, malondialdehyde, and NG2 levels in the samples were determined. RESULTS: No significant difference was found in biochemical measurements. Histopathological examination revealed that the NG2 expression was more intense in the group treated with phenytoin and levetiracetam (phenytoin was partly higher) and the amount of edema decreased. The NG2 expression increased and the edema decreased, though lower in the group treated with carbamazepine and valproic acid, compared with phenytoin and levetiracetam. An increase in the NG2 expression and edema intensity were determined in the control and sham groups. CONCLUSION: Antiepileptic drug selection after traumatic brain injury is an important medical matter. Although the patient-oriented selection is essential, the study suggests that the choice of phenytoin, levetiracetam carbamazepine, and valproic acid will, respectively, have an accelerating effect for axonal healing.

A Comparison of Ramipril and Bevacizumab to Mitigate Radiation-Induced Brain Necrosis: An Experimental Study.

BACKGROUND: Bevacizumab, an anti-vascular endothelial growth factor (VEGF) antibody, is a new treatment approach for radionecrosis. In our study, we compared the prophylactic and therapeutic usage of a promising agent, ramipril (an angiotensin-converting enzyme inhibitor), with that of bevacizumab for reducing radiation-induced brain injury after high-dose stereotactic radiosurgery (SRS). METHODS: A total of 60 Wistar rats were used. The rats were irradiated with a single dose of 50 Gy using a Leksell Gamma Knife device. Bevacizumab and ramipril were administered in the prophylactic protocol (starting the first day of SRS) and in the therapeutic protocol (starting the fourth week of SRS). Their usage was continued until 12 weeks, and the right frontal lobes of the rats were examined histologically (hematoxylin and eosin stain) and immunohistochemically (hypoxia-inducible factor [HIF]-1α, VEGF, and CD31 antibody expression). RESULTS: The expression of VEGF, HIF-1α, and CD31 had significantly increased at 12 weeks after SRS compared with the control group. The addition of bevacizumab or ramipril to SRS significantly mitigated the histological severity of radiation injury and the expression of VEGF, HIF-1α, and CD31. However, the prophylactic use of bevacizumab and ramipril seemed to be more effective than therapeutic administration. Our results also revealed that the greatest benefit was achieved with the use of prophylactic administration of bevacizumab compared with other treatment protocols. CONCLUSIONS: Ramipril might be a promising agent for patients with radionecrosis. Clinical studies are required to investigate the effective and safe doses of ramipril, which is an inexpensive, well-tolerated drug that can cross the blood-brain barrier.

First report of tethered cord syndrome in a patient with Sotos syndrome.

BACKGROUND: Sotos syndrome is caused by a gene deletion with an autosomal dominant pattern of inheritance. The Sotos syndrome was first described by Juan Sotos. Cole and Hughes identified the clinical characteristics of this syndrome. This syndrome is characterized by macrocephaly, frontal bossing, ocular hypertelorism, overgrowth, subdural hygroma, ventricular dilatation, agenesis of the corpus callosum. This syndrome is associated with mutations in NSD 1 (nuclear receptor SET domain-containing protein 1) gene, protein insufficiency, and a 5q35 microdeletion. Sotos syndrome is reported to occur in approximately 1/10,000-15,000 births. CASE PRESENTATION: We present a patient with Sotos syndrome who is harboring a sacral lipoma and tethered cord syndrome and she had growth retardation, frontal bossing and hypertelorism. After a standard approach for tethered cord syndrome, the patient was discharged 3 days after without any additional neurodeficits. CONCLUSION: In the literature, sacral lipoma and tethered cord syndrome with Sotos syndrome have not been published yet.

Women in Neurosurgery: Gender Differences in Authorship in High-Impact Neurosurgery Journals through the Last Two Decades.

OBJECTIVE: Despite common gender disparities in authorship across the vast majority of specialties, the presence of a similar lack of equality in neurosurgery literature is not published yet. Therefore the authors examined the changes in representation of women among the first and senior (last) authors of original articles in high-impact neurosurgical journals between 2003 and 2018. METHODS: Data regarding women proportions among the first and senior authors were collected from the issues of Neurosurgery and Journal of Neurosurgery published in 2003, 2008, 2013, and 2018. RESULTS: According to the analysis of 3247 original articles, compared with male authors, female authors have published fewer articles as the first (518 of women, 2729 of men) and senior authors (352 of women, 2884 of men). Nonetheless, the proportion of women in the first authorship represented a significant increase from 2003 to 2018 (from 12% to 16.5%, respectively; P < 0.01), but not in senior authorship (11.7% in 2003 vs. 10.5% in 2018; P > 0.05). Overall, women wrote more research articles than case reports as both first and senior authors (451 and 301 vs. 67 and 51, respectively). In addition, women demonstrated a higher percentage of first authors on female senior author articles (30.4%) than male senior author articles (14.1%). CONCLUSIONS: Although a rising trend in female authorship of neurosurgical literature has been going on through the last 2 decades, this advancement could not be regarded as satisfactory, as the gender gap in authorship is still excessive. Strikingly, female first authors had a tendency of coauthoring with female senior authors.