Onur Ozgural

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 tectal plate can be affected by a broad spectrum of pathological processes, resulting in diverse clinical manifestations. These include primary or metastatic tumors, granulomatous diseases, cerebrovascular malformations, ischemic insults, traumatic injury, lipomas, cysticercosis, and degenerative disorders. However, isolated tectal thickening is typically not regarded as a pathological entity and remains insufficiently investigated. This study retrospectively analyzed the clinical and radiological features of 50 patients presenting to the Ankara University Faculty of Medicine between 2012 and 2023 who exhibited tectal thickening on neuroimaging. The objective was to evaluate the association between tectal thickness and clinical symptoms, as well as related radiological pathologies. Clinical data and imaging findings were assessed to investigate correlations between tectal thickening and conditions such as hydrocephalus, Chiari II malformation, syringomyelia, and cerebral atrophy. Statistical analyses were performed to delineate the clinical significance of increased tectal thickness and to explore its potential role in diagnosis and management. All 50 patients demonstrated tectal thickening, with hydrocephalus identified in 76% of cases. Tectal thickness was significantly greater in patients with Chiari II malformation and syringomyelia. However, tectal thickening did not have a statistically significant effect on the area of the cerebral aqueduct. No association was observed between tectal thickening and visual or auditory symptoms. The risk of malignant transformation was found to be low. This study demonstrates a significant association between increased tectal thickness, hydrocephalus, and specific craniospinal pathologies. These findings suggest that tectal thickening may represent a relevant radiological feature associated with distinct clinical and imaging characteristics, warranting further investigation in larger prospective studies.

OBJECTIVE: The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques. METHODS: All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered. RESULTS: Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient’s fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1–79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10–540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material. CONCLUSIONS: Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.

The Utility of Folding Technique in Duraplasty - Journal of Ankara University Faculty of Medicine

In this case report, we aimed to describe the clinical presentation, surgical approach, and follow-up of a patient with rare anterior meningocele associated with rectothecal fistula. An 17-year-old female patient was admitted to the emergency department with meningitis. On further examinations, an anterior sacral meningocele accompanied by rectothecal fistula was detected. Appropriate antibiotic treatment was arranged and surgical plan was made with the pediatric surgery clinic. The patient underwent meningocele repair via posterior approach and colostomy operation. The patient did not experience any neurological issues after the surgery. The colostomy was reversed 3 months later, and third-month follow-up MRI showed complete regression of the meningocele sac with no neurological complications. Anterior meningocele accompanied by a rectothecal fistula is a rare and complicated case. Only seven cases of coexisting ASM and RTF have been reported in literature. Although both anterior and posterior approaches have been used for the treatment of ASM, the choice of treatment is essentially based on the patient’s clinical and imaging findings.

OBJECTIVE: Virtual simulation and imaging systems have evolved as advanced products of computing technology over the years. With advancements in mobile technology, smartphones, and tablets, the quality of display and processing speed have gradually improved, thanks to faster central processing units with higher capacity. Integrating these two technologies into the fields of healthcare and medical education has had a positive impact on surgical training. However, contemporary neurosurgical planning units are expensive and integrated neuronavigation systems in operating rooms require additional accessories. The aim of this study was to investigate the compatibility of smartphone applications in augmented reality (AR)–based craniotomy planning, which can be available even in disadvantaged workplaces with insufficient facilities. METHODS: Thirty patients diagnosed with supratentorial glial tumor and who underwent operations between January 2022 and March 2023 were included in the study. The entire stages of the surgical procedures and the surgical plans were executed with neuronavigation systems. The patient CT scans were reconstructed using software and exported as a 3D figure to an AR-enhanced smartphone application. The evaluation of the application’s success was based on the spatial relationship of the AR-based artificial craniotomy to the neuronavigation-based craniotomy, with each AR-based craniotomy scaled from 0 to 3. RESULTS: In the comparison between neuronavigation-based and AR fusion-based craniotomies, 8 of 30 (26.6%) patients scored 0 and were considered failed, 6 (20%) scored 1 and were considered ineffective, 7 (23.3%) scored 2 and were considered acceptable, and 9 (30%) scored 3 and were considered favorable. CONCLUSIONS: AR technology has great potential to be a revolutionary milestone of neurosurgical planning, training, and education in the near future. In the authors’ opinion, with the necessary legal permissions, there is no obstacle to the integration of surgical technological systems with mobile technology devices such as smartphones and tablets that benefit from their low-budget requirements, wide-range availability, and built-in operating systems.