Sait Kayhan

Objective: To compare the clinical outcomes of endoscopic third ventriculostomy (ETV) alone versus single-stage ETV combined with ventriculoperitoneal (VP) shunt placement in pediatric obstructive hydrocephalus, and to determine whether the combined approach reduces early failure in high-risk etiologies without increasing complication rates. Methods: A retrospective cohort of 59 children treated for obstructive hydrocephalus between 2010 and 2024 was analyzed. Patients underwent either ETV alone (n=26) or single-stage ETV with VP shunt placement (n=33). Etiology, demographic characteristics, intraoperative findings, postoperative complications, revision surgeries, and radiological outcomes were systematically recorded. Treatment success was defined as the absence of additional cerebrospinal fluid diversion procedures and sustained clinical-radiological stability during follow-up. Early and late complications, infection rates, and mortality were also evaluated. Statistical analyses included the Student t-test or Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables, with significance set at p<0.05. Results: Aqueductal stenosis was the most common etiology (64.4%), followed by posthemorrhagic obstruction (16.9%), fourth ventricular outlet obstruction (11.9%), and tumor-related obstruction (6.8%). Treatment success was significantly higher in the combined ETV+VP shunt group compared with the ETV-alone group (87.9% vs. 65.4%, p=0.038). Revision surgery was required in 9 ETV patients (34.6%) and 4 combined-procedure patients (12.1%, p=0.038). Early infection rates were identical between groups (2 cases each, p=1.000), and late infection rates did not differ significantly. Overall infection rates (p=0.744) and mortality (4 vs. 3 patients, p=0.696) were comparable between the two approaches. Conclusion: In this cohort, single-stage ETV with VP shunt placement was associated with a higher treatment success rate compared with ETV alone, particularly in infants and children with posthemorrhagic ventricular obstruction. These findings suggest that the combined strategy may help address early physiological limitations of ETV and could be considered a safe and promising option in appropriately selected pediatric patients with obstructive hydrocephalus.

The objective of this study is to demonstrate the clinical applicability of 3D Slicer-assisted volume calculations through the analysis of results from single/burr-hole craniostomy (sBHC/dBHC), and mini-craniotomy procedures for the management of chronic subdural hematomas (cSDHs). A total of 163 patients with cSDH between January 1, 2020, and December 31, 2024, were admitted to our department. sBHC, dBHC or mini-craniotomy procedures were performed. Baseline characteristics, radiological features, and surgical and postoperative parameters were evaluated for all three procedures. Volumetric calculations were performed by employing 3D Slicer. Mini-craniotomy was performed in 67 patients (41.1%), sBHC in 54 (33.1%), and dBHC in 42 (25.8%). The overall recurrence rate was 20.9%, being lowest after mini-craniotomy (10.4%), followed by dBHC (19%) and sBHC (35.2%) (p = 0.004). Although mini-craniotomy achieved superior evacuation efficiency, surgical technique was not independently associated with recurrence after accounting for volumetric factors. In the primary model, each 10 mL increase in residual hematoma volume (RHV) increased the odds of recurrence ≈ 35-fold (p < 0.001). Both RHV and hematoma evacuation rate (HER) independently predicted recurrence, showing excellent discrimination (Area under the curve [AUC] = 0.965 and 0.961). Optimal cutoffs were ≈ 19 mL for RHV and 68% for HER, confirmed by cross-validation and sensitivity analyses. RHV and HER independently predicted recurrence, whereas surgical technique lost significance after accounting for these volumetric factors. Thresholds of ≈ 19 mL (RHV) and 68% (HER) may guide postoperative monitoring. 3D Slicer provides a simple, accessible tool for recurrence prediction in cSDH.

Traumatic brain injury (TBI) is one of the common reasons for decompressive craniectomy (DC). The management of DC must include cranioplasty procedures. Although both procedures may cause several complications, postoperative outcomes are of greater concern for patients. The timing of cranioplasty (CP) and the type of CP material are the main parameters evaluated retrospectively in this report in terms of their impact on postoperative complications and cosmetic results. A total of 47 patients who underwent autologous cranioplasty (n=22) or custom-made titanium cranioplasty (n=25) due to TBI between January 2017 and January 2024 in our department were retrospectively analyzed. The groups were compared in terms of demographic characteristics, complication rates, and operative parameters. Cosmetic results and one-year mortality rates were also reported. The Odom criteria were used for the assessment of cosmetic results. Baseline characteristics and overall complication rates did not differ significantly between the groups. Blood loss was significantly lower in titanium cranioplasty compared to autologous cranioplasty (126.2+-47.9 ml vs. 215.5+-35.6 ml, p<0.001). The highest complication rate was observed in cranioplasties performed 3-6 months after DC. In the early period (<3 months), autologous grafts were associated with significantly more complications than titanium (5/7 vs. 0/7, p=0.021). Cosmetic outcomes were significantly better with titanium, while timing had no effect on cosmetic results. One-year mortality rates were similar between the groups. The timing of cranioplasty and the type of cranioplasty material may influence postoperative outcomes in patients with TBI. Titanium plates could be a preferable option for early cranioplasty if autologous bone cannot be used for reconstruction, whereas late cranioplasty appears to be associated with fewer complications overall. Further studies are needed to support these findings.

BACKGROUND AND OBJECTIVES: The optimal treatment for cranial fibrous dysplasia (CFD) is surgical resection and reconstruction, enhanced by computer-assisted techniques and custom-made implants. This study describes the surgical treatment of CFD using preoperative computer-assisted planning, a custom-made template, and titanium implants for reconstruction. METHODS: Over a 12-year period, 33 patients (19 males, 14 females) with monostotic CFD underwent surgical treatment involving tumor resection and reconstruction with custom titanium implants. The mean age was 38 years (range: 19-63). Preoperative computed tomography (CT) with 0.5-mm slices was used for precise planning. A computer-assisted template was created to determine tumor margins and minimize complications. Based on this, patient-specific titanium implants were designed and manufactured. During surgery, the template guided tumor removal and the implants were secured with miniscrews. Postoperative CT scans were performed for follow-up. RESULTS: Histopathological examination confirmed the diagnosis in all cases. The bone defect that occurred after resection during surgery was reconstructed using a patient-specific, 3-dimensional–printed titanium cranioplasty implant. No complications occurred during or after the surgery. Complete tumor removal and satisfactory cosmetic results were verified on postoperative CT scans. The mean follow-up duration was 108 months (range: 7-149 months). CONCLUSION: Computer-aided design and manufacturing of customized titanium implants provide a safe and effective approach for CFD reconstruction. This method allows precise resection, excellent cosmetic outcomes, and low complication rates, making it a reliable technique for cranioplasty.

POSTERIOR APPROACH IN SPINAL TUBERCULOSIS: WITH OR WITHOUT CORPECTOMY? - The Journal of Turkish Spinal Surgery

Intradural migration of a bullet within the spinal canal represents an exceptionally uncommon clinical scenario and carries the potential for progressive or delayed neurological decline. Although such fragments may initially remain silent, their subsequent movement within the spinal canal can create significant diagnostic and therapeutic challenges. In this report, we present an unusual and instructive case of cauda equina syndrome that developed secondary to the delayed caudal migration of an intradural bullet fragment. We further provide a detailed discussion of the diagnostic evaluation, surgical management, and clinical decision-making considerations associated with this condition. A 32-year-old male patient sustained a gunshot injury in 2022. Initial imaging demonstrated that the bullet had penetrated the spinal canal and become lodged intradurally at the L1-L2 level, although the patient exhibited no neurological deficits at that time. He was, therefore, managed conservatively with routine follow-up. Approximately 2.5 years later, the patient presented with the sudden onset of bilateral lower extremity weakness, progressive gait impairment, and new-onset urinary incontinence. Computed tomography revealed that the intradural bullet fragment had migrated caudally to the S2 vertebral level, resulting in significant compres-sion of the cauda equina nerve roots. Urgent surgical intervention was undertaken, consisting of a partial bilateral laminectomy at the S1-S2 level and microsurgical extraction of the bullet. Postoperative neurological recovery was substantial, with marked improvement in motor function and complete resolution of urinary symptoms. Although intradural bullet fragments may initially appear clinically insignificant in patients who present without neurological deficits, delayed migration poses a serious risk for the development of cauda equina syndrome and other potentially irreversible complications. This case highlights the importance of maintaining a high index of suspicion and considering early prophylactic surgical extraction when intradural localization is identified, even in neurologically intact individuals. Early intervention may prevent severe late complications such as neurological deterioration, infectious sequelae arising from contaminated missile tracts, and possible lead toxicity related to chronic intradural exposure.