Melih Bozkurt

Background: Progesterone signaling has been implicated in diffuse glioma biology, but the factors contributing to variability in progesterone receptor (PGR) activity remain incompletely understood. We investigated whether PROGINS-related PGR variants detected in tumor-derived DNA were associated with PGR expression and selected biological features of diffuse gliomas. Methods: This retrospective translational study included 66 patients with histopathologically confirmed diffuse gliomas. Three PROGINS-associated PGR variants—the Alu insertion, V660L (rs1042838), and H770H (rs1042839)—were analyzed using DNA extracted from fresh-frozen tumor tissue. Relative PGR gene expression, tissue PGR protein concentrations, Ki-67 labeling index, and p53 immunoreactivity were evaluated together with IDH status, ATRX expression, and 1p/19q co-deletion. Separate multivariable regression models assessed variant-specific associations and prespecified variant × sex and variant × tumor grade interactions. Multiple testing within the reported multivariable models was addressed using the Benjamini–Hochberg false discovery rate procedure. Results: Relative PGR gene expression was lower in high-grade than in low-grade gliomas (p = 0.039), whereas tissue PGR protein concentrations did not differ significantly according to grade. In multivariable analyses, V660L L-allele carriage was associated with higher PGR expression and lower Ki-67 labeling indices, H770H G-allele carriage was associated with lower PGR expression and higher p53 immunoreactivity, and Alu insertion carrier status was associated with lower PGR expression. Significant variant × sex interactions were identified for several outcomes, and an H770H × tumor grade interaction was observed for PGR expression. All nominally significant associations reported in the multivariable models remained significant after false discovery rate correction. Conclusions: PROGINS-related PGR variants detected in tumor-derived DNA are associated with selected biological features of diffuse gliomas, with several associations differing according to biological sex and, for selected outcomes, tumor grade. These findings support a context-dependent relationship between PGR variant status and glioma phenotype but do not establish functional causality or clinical biomarker utility. Independent functional and longitudinal studies are required to determine the biological and potential clinical relevance of these associations.

Airway management can be challenging for patients undergoing cervical spinal surgery. This study aimed to evaluate how the duration of the cervical pathology associated with neck pain and numbness affects airway anatomy and airway management, and to correlate radiological measurements. This was a single-center prospective observational study. Eighty-two patients with American Society of Anesthesiologists I to III were selected from those undergoing surgery for cervical pathology. The patients’ symptoms and duration of cervical disease were assessed. Skin-epiglottis, skin-hyoid, epiglottis-vocal cord, and hyomental distance measurements were performed using ultrasonography. The bilateral multifidus and longus colli muscles, presence of prevertebral fluid, thickening of the prevertebral soft tissue, increase in muscle signal intensity, pre-epiglottic depth of field, distance between the vocal cords, and epiglottis were evaluated using magnetic resonance imaging. Patients were intubated using a videolaryngoscope. Intubation times, the percentage of glottic opening, the number of intubation attempts, and complications were recorded during intubation. Intubation quality was evaluated based on intubation time, number of attempts, and the percentage of glottic opening achieved during videolaryngoscopy. The correlation between symptom duration and intubation quality was assessed. Radiological measurements of the airway were compared with the symptom duration. Symptom duration did not affect intubation parameters ( P > .05). Skin-hyoid distance showed a positive correlation with pain duration ( r = 0.410, P = .001) and numbness duration ( r = 0.452, P < .001). The depth of the pre-epiglottic space increased with the duration of numbness ( r = 0.325, P = .034). Epiglottis-vocal cord distance correlated with intubation time ( r = 0.297, P = .026). Our study is significant in that it focuses on analyzing preoperative airway evaluation through radiological data and comparing these findings to the quality of intubation achieved with videolaryngoscopy. Radiological measurements such as skin-hyoid distance and pre-epiglottic space depth demonstrated measurable correlations with symptom duration, suggesting potential value in preoperative airway assessment. However, these anatomical variations did not significantly influence intubation performance when videolaryngoscopy was used.

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.

In this case series, we aimed to report our clinical experience with hybrid positron emission tomography (PET) and magnetic resonance imaging (MRI) navigation in the management of recurrent glial brain tumors. Consecutive recurrent neuroglial brain tumor patients who underwent PET/MRI at preoperative or intraoperative periods were included, whereas patients with non-glial intracranial tumors including metastasis, lymphoma and meningioma were excluded from the study. A total of eight patients (mean age 50.1 ± 11.0 years) with suspicion of recurrent glioma tumor were evaluated. Gross total tumor resection of the PET/MRI-positive area was achieved in seven patients, whereas one patient was diagnosed with radiation necrosis, and surgery was avoided. All patients survived at 1-year follow-up. Five (71.4%) of the recurrent patients remained free of recurrence for the entire follow-up period. Two patients with glioblastoma had tumor recurrence at the postoperative sixth and eighth months. According to our results, hybrid PET/MRI provides reliable and accurate information to distinguish recurrent glial tumor from radiation necrosis. With the help of this differential diagnosis, hybrid imaging may provide the gross total resection of recurrent tumors without harming eloquent brain areas.

AIM: To examine the outcomes of microsurgery only versus combined microsurgery and embolization in treating cerebral arteriovenous malformations (AVM). MATERIAL and METHODS: A total of 62 patients (34 male and 28 female) with Spetzler-Martin grade 3 (n=44) and grade 4 (n=18) AVMs were examined. Thirty-seven patients were treated with a combination of microsurgery + embolization, whereas 25 patients were treated with microsurgery alone. The clinical characteristics of the treatment groups were compared (ruptured/unruptured, eloquent/non-eloquent, modified Rankin scores, duration of surgery, preoperative and postoperative hemoglobin levels, and use of blood products). RESULTS: The number of patients with ruptured or eloquently localized AVMs was more in combination of microsurgery + embolization. On the other hand, the duration, preoperative versus postoperative hemoglobin levels, and usage of blood products did not differ between treatment groups. CONCLUSION: The results of the study showed no superiority of the combined treatment in managing AVMs in parallel to recent meta-analyses. However, a patient-tailored approach is recommended while making the treatment decision for such challenging intracerebral AVM cases.

AIM: To define whether characteristics of fluorescein staining help to distinguish low grade gliomas intraoperatively.MATERIAL and METHODS: We studied 46 patients with supratentorial newly diagnosed noncontrast-enhancing LGGs removed by fluorescence guidance under the YELLOW 560 nm filter. Patients who were treated between July 2019 and 2022 were retrospectively analyzed. Clinical data were collected from patient records. Patients' intraoperative video recordings, pathological examination, and preoperative magnetic resonance imaging (MRI) were analyzed and compared for each patient after the operation. Histopathologically, patients were divided into WHO Grade 2 oligodendrogliomas, diffuse astrocytomas (IDH mutant, 1p19q negative tumors), and pre-glioblastomas (IDH wild type, 1p19q negative tumors). Resection margins were checked using controls contrast -enhanced cranial MRI at the postoperative 24 and72 hours.RESULTS: Our observations indicate that fluorescein primarily stains diffuse astrocytomas (IDH mutant, 1p19q negative tumors) and pre-glioblastomas (IDH wild type, 1p19q negative tumors) rather than WHO Grade 2 oligodendrogliomas.CONCLUSION: Fluorescein staining might be an option to determine tumor borders in WHO Grade 2 glial tumors, particularly for those with a higher malignancy potential.

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.