Gokmen Kahilogullari

Objective: Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible cause of functional and cognitive decline in older adults. Although endoscopic third ventriculostomy (ETV) has emerged as an alternative treatment option in selected patients, its multidimensional impact on geriatric syndromes remains unclear. This study aimed to evaluate changes in comprehensive geriatric assessment (CGA) parameters following ETV in patients with iNPH. Materials and Methods: This prospective observational study included 14 patients aged ≥55 years with iNPH who underwent ETV. Patients were categorized according to clinical improvement based on the iNPH Grading Scale. CGA domains—including Katz Activities of Daily Living (ADL), Lawton–Brody Instrumental (ADL), Clinical Frailty Scale (CFS), SARC-F, Mini Nutritional Assessment–Short Form (MNA-SF), Yesavage Geriatric Depression Scale (GDS), Older People’s Quality of Life Questionnaire (OPQOL), and the Quick Mild Cognitive Impairment Screen-Turkish Version (qMCI-TR) were evaluated preoperatively and at 1 and 3 months after ETV. Results: Eight patients (57.1%) demonstrated clinical improvement after ETV. At baseline, the clinical improvement group had higher Katz ADL, IADL, and qMCI-TR scores than the without improvement group. At 1st month, the clinical improvement group showed significant improvements in Katz ADL (Δ=1.0, p=0.025), CFS (Δ=−1.0, p=0.011), SARC-F (Δ=−2.0, p=0.011), MNA-SF (Δ=1.0, p=0.011), and OPQOL (p=0.017). At 3rd month, further significant improvements were observed in CFS (Δ=−1.0, p=0.011), OPQOL (Δ=6.0, p=0.017), SARC-F (Δ=−2.5, p=0.011), and MNA-SF (Δ=1.0, p=0.016). In contrast, patients without clinical improvement showed no consistent favorable changes across CGA domains. Conclusion: In older adults with iNPH, clinical response to ETV was associated with meaningful improvements across multiple geriatric domains, particularly frailty, sarcopenia risk, nutritional status, functional status, and quality of life. These findings suggest that the benefits of ETV may extend beyond the classical symptom triad and support the integration of CGA into the perioperative evaluation of patients with iNPH.

The supraorbital keyhole approach via transciliary incision represents a minimally invasive surgical corridor that is increasingly applied in pediatric neurosurgery; however, large childhood-specific series remain scarce. This study reports our two-center experience with this approach in a heterogeneous pediatric population. A retrospective analysis was performed of all pediatric patients who underwent surgery via the supraorbital keyhole approach through a transciliary incision at Ankara University and Rome Catholic University between 2017 and 2024. Patient demographics, pathological diagnoses, extent of resection, complications, and clinical outcomes were recorded. The extent of resection was classified as gross total resection (GTR), subtotal resection (STR), or near-total resection (NTR) based on the postoperative MRI findings. Twenty-six patients (mean age, 8.7 years; range, 0.7-17 years) were included in the study. The pathologies included craniopharyngioma (n = 5), cavernous malformation (n = 4), optic pathway glioma (n = 3), pilocytic astrocytoma (n = 2), epidural hematoma (n = 2), frontal abscess (n = 2), and other lesions (n = 8). Among the 20 patients with discrete resectable lesions, GTR was achieved in 11 (55%), STR in six (30%), and NTR in three (15%). Complications occurred in eight patients (30.8%), including transient diabetes insipidus in four, permanent panhypopituitarism in one, permanent diabetes insipidus in one, postoperative epidural hematoma in one, and visual deterioration in one patient. Permanent morbidity was observed in three patients (11.5%). There was no mortality. The supraorbital keyhole approach via a transciliary incision is a technically feasible and applicable minimally invasive surgical corridor in the pediatric population, offering access to a wide range of anterior cranial base, sellar, suprasellar, and frontal pathologies. The observed complication profile was consistent with the complexity and heterogeneity of the treated pathologies in this study. Prospective comparative studies are warranted to further define the role of this approach in pediatric neurosurgery.

The supraorbital keyhole approach is a minimally invasive technique for treating lesions in the anterior and middle cranial fossa. A major complication of this procedure is injury to the temporal branch of the facial nerve. This study aimed to define safe surgical zones for the lateral borders of the incision to minimize facial nerve injuries. This study examined 15 formalin-fixed adult cadaveric heads (30 sides). The temporal branches of the facial nerve were dissected using a surgical microscope. Three distances were measured using anatomical landmarks: (M1) horizontal distance between the supraorbital notch and facial nerve branches, (M2) vertical distance between the frontozygomatic junction and facial nerve branches, and (M3) horizontal distance between the lateral orbital rim and facial nerve branches. The mean distances were as follows: M1 = 48.96 ± 2.10 mm, M2 = 9.48 ± 0.83 mm, and M3 = 14.80 ± 0.99 mm. All measurements showed significant correlations (p < 0.001). Measurement precision was excellent (TEM 0.14-0.17 mm; rTEM 0.30%-1.74%; R 0.9628-0.9952). Despite intricate and variably interconnected temporal branch patterns, branches consistently lay outside the proposed safe zones. Based on the absolute minimum anatomical measurements, we defined the safe incision limits as 44 mm laterally from the supraorbital notch, 8 mm inferior to the frontozygomatic junction, and 13 mm laterally from the lateral orbital rim. Following these safe zones may reduce the risk of facial nerve injury and improve the outcomes of the procedure.

Tired bullet or falling bullet injuries cause mortality and morbidity, especially in residential areas. Due to their potential velocity, they can penetrate the calvarium and extend to deeper intracranial areas, posing a heightened risk of mortality in pediatric cases due to low bone resistance. We present a pediatric patient with an unusual bullet trajectory caused by a falling bullet, a scenario not documented before. A 5-year-old boy was brought to the emergency department after a sudden loss of consciousness while playing outside. Cranial CT showed a bullet entry wound in the right parietal bone with a comminuted fracture and a hyperdense bullet tract extending through the right lateral ventricle’s temporal horn, right cerebellar peduncle, and right cerebellar hemisphere to the foramen magnum. The bullet’s trajectory extended from the cranium to the spinal canal. A spinal scan showed hyperdensity consistent with an intradural intramedullary bullet core at the T5 level. After stabilization, the bullet was surgically removed and sent for ballistic analysis. Falling bullet injuries have a high mortality rate in children. Given the unpredictable bullet trajectory, the bullet core may not be seen on cranial imaging, highlighting the importance of spinal imaging. To our knowledge, this case represents the first reported instance of a falling bullet injury with such an unusual trajectory.

BACKGROUND AND OBJECTIVES: Robotic surgery systems are commonly used in many surgical fields but currently have limited adoption in neurosurgery. The goal for this work was to share our experience with the da Vinci Xi surgical robot for neurosurgical practice. METHODS: Our senior surgeon (U. E.) underwent robotic surgery training followed by simulation training. Five patients then underwent robotic surgery performed by the surgeon; pathologies included clivus chordoma, odontoid metastatic mass, peroneal neuropathy, and arachnoid cyst. Clinical data, demographic details, and follow-up outcomes were analyzed. RESULTS: Of the 5 patients (2 female, 3 male; mean age, 43 years), 2 had a clivus chordoma, 1 had an odontoid metastatic mass, 1 had peroneal neuropathy, and 1 had an arachnoid cyst. No intraoperative or postoperative neurological deficits or complications were observed. All 5 of the patients had a favorable outcome. CONCLUSION: Robotic systems can offer clear advantages over traditional neurosurgery, particularly for transoral resection and intracranial cyst fenestration. However, practical training is essential for effectively integrating these systems into routine neurosurgical practice. The case series presented here reveals the feasibility of robotic neurosurgery and the need for further evaluation of this technology.

Background and purpose – Neurosurgical approaches in Sylvian arachnoid cysts include microsurgery, endoscopy, and shunting. Yet, their relative safety and efficacy is still under debate. This retrospective study evaluated 36 pediatric patients with Sylvian arachnoid cysts and treated with different surgical types to contribute to global data. Methods – The study included 24, 8, and 4 patients receiving endoscopic, microsurgical, and shunt surgeries, respectively. Preoperative and postoperative assessments included the patients’ demographics and symptoms, cyst size and type, psychomotor status, length of hospital stay, and complications with a mean follow-up of 37.3 months. Results – All types of surgeries alleviated headaches and seizures in most of the patients. Shunt operations led to the highest reduction in cyst size in the early postoperative period and relieved cranial palsy in all patients. Microsurgery achieved greater healing regarding hemiparesis and seizures, and reduced cyst size more effectively in the early postoperative period than endoscopy. Complication rates were similar between the endoscopy and microsurgery groups. Conclusion – Arachnoid cyst surgery is efficient and relatively safe. The higher efficacy of microsurgery may be associated with the lesser chronic presence of cysts in this group rather than its technical superiority. Endoscopic surgery is challenging, yet it may be advocated to avoid craniotomy and shunt complications. Surgical-type decisions for arachnoid cysts should be patient-tailored based on careful preoperative clinical and radiological examinations.

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.

Aim of the Study: Clinical consequences of endoscopic endonasal approach (EEA) for Cushing Diseases (CD) were investigated in a single-center series based on definitions and assessments of recurrence and remission. Materials and Methods: 825 patients evaluated, including 64 patients with CD, who underwent EEA at the Ankara University Neurosurgery Department and evaluated retrospectively between the years 2014 and 2021. Postoperative next-morning cortisol and adrenocorticotrophic hormone (ACTH) values were used to assess postoperative endocrinological remission. Results: Twenty-two patients had macroadenoma, and 40 had microadenoma. In 2 patients, no lesions were detected in the sellar region, a diagnosis of magnetic resonance imaging (−) CD was made. Clinical and biochemical follow-ups in Cushing's disease are very important due to risk of recurrence. Regardless of remission, the effect of duration of glucocorticoid use after surgery on recurrence was examined. Glucocorticoid therapy was given in 46 patients (71%) after pituitary surgery. No recurrence was observed in 20 patients whose treatment duration was longer than 1 year. In 12 patients, the glucocorticoid therapy duration was ranged from 6 months to 12 months, and 4 patients showed recurrence. The glucocorticoid therapy duration of >6 months predicted that recurrence would not occur (p 6 months after surgery predicts that recurrence will not occur. Long-term glucocorticoid therapy after surgery suggests surgical success. The mainstay of CD treatment is appropriate postoperative follow-up and administration of the necessary medical and surgical interventions. Keywords: ACTH, Cortisol, Cushing disease, Endonasal endoscopic approach, Recurrence, Remission ÖZET Çalışmanın Amacı: Bu çalışmada, Cushing Hastalığı (CH) için endoskopik endonazal yaklaşımın (EEY) klinik sonuçları, remisyon ve nüks tanımları ve değerlendirmelerine dayalı olarak tek merkezli bir seride araştırıldı. Gereç ve Yöntemler: Ankara Üniversitesi İbni Sina Hastanesi Nöroşirürji Anabilim Dalı'nda 2014-2021 yılları arasında EEY uygulanan 825 hasta arasında CH’ lığı tanısı alan 64 hastanın verileri retrospektif olarak değerlendirildi. Postoperatif ertesi sabah kortizol ve adrenokortikotropik hormon (ACTH) değerleri postoperatif endokrinolojik remisyonu değerlendirmek için kullanıldı. Bulgular: Yirmi iki hastada makroadenom ve 40 hastada mikroadenom saptandı. 2 hastada sellar bölgede lezyon saptanmadı, manyetik rezonans görüntüleme (-) CH tanısı kondu. Kırk hasta kadın, 12 hasta erkekti. CH'de yüksek nüks insidansı nedeniyle, yıllık klinik ve biyokimyasal takipler çok önemlidir. Remisyondan bağımsız olarak ameliyat sonrası glukokortikoid kullanım süresinin nüks üzerine etkisi incelendi. Hipofiz cerrahisi sonrası 46 hastaya (%71) glukokortikoid tedavisi verildi. Tedavi süresi 1 yıldan uzun olan 20 hastada nüks gözlenmedi. 12 hastada glukokortikoid tedavi süresi 6 ay ile 1 yıl arasında değişmekteydi ve 4 hastada nüks görüldü. 6 aydan uzun glukokortikoid tedavi süresinin nüksün olmayacağını saptadığı öngörüldü (p