Tufan Agah Kartum

The superior orbital fissure (SOF), orbital apex (OA), clinoidal space (ClnS) and suprasellar parachiasmatic cisterns (SSPC) represent frequent surgical targets in skull base neurosurgery. Surgical access to these regions remains challenging due to the high density of critical neurovascular structures within multiple cisternal compartments. This study aimed to evaluate a transorbital surgical route to the SOF, OA, ClnS, and SSPC and compare the limits of exposure with those of the conventional trans-sylvian route through a cranio-orbitozygomatic approach (COZA). Methods: Cadaveric dissections were performed to expose the orbital apex, cavernous sinus, sphenoid wing, and suprasellar parachiasmatic cisterns. Trans-sylvian route via COZA was carried out initially, and this was subsequently followed by a transorbital approach directed at the same anatomical areas. Surgical corridors were systematically analyzed, and exposure boundaries were documented and compared. Results: The transorbital route consistently provided access to the SOF, OA, ClnS in addition to the anteromedial cavernous sinus. The extent of exposure achieved via the transorbital route was comparable to that obtained with the COZA for SSPC; however, the transorbital approach appeared to provide a shorter and more direct working corridor. Intradural access to the carotid and proximal sylvian cisterns was achievable; however, chiasmatic and lamina terminalis cisterns were more effectively accessed through the trans-sylvian route via COZA. Conclusion: The transorbital approach offers a direct surgical corridor to selected anterior skull base and parasellar structures without sylvian fissure dissection. While not a substitute for conventional trans-sylvian exposure for all chiasmatic cisterns, the transorbital approach may serve as a complementary or alternative approach for appropriately selected lesions.

Objective: Supratentorial cisterns are specialized compartments of the subarachnoid space that contain critical neurovascular structures and provide natural corridors to deep intracranial regions. These cisternal spaces play an essential role in the surgical management of various intracranial pathologies, including aneurysms and skull base tumors. Therefore, a precise understanding of their microsurgical anatomy is fundamental for safe neurosurgical practice. Methods: This study evaluated the microsurgical anatomy and surgical relevance of supratentorial cisterns through the analysis of neurosurgical procedures involving pathologies located within these regions. Intraoperative findings were documented with high-definition imaging, focusing on arachnoid dissection, cerebrospinal fluid (CSF) release, and identification of neurovascular structures. Postoperative imaging was also reviewed to correlate operative exposure with anatomical landmarks. Results: Several supratentorial cisterns were identified and analyzed, including the sylvian, carotid, chiasmatic, lamina terminalis, pericallosal, olfactory, and oculomotor cisterns. Each cistern demonstrated specific anatomical boundaries and characteristic neurovascular contents. The sylvian cistern provided a principal corridor to the middle cerebral artery complex, whereas the carotid and chiasmatic cisterns were closely associated with the internal carotid artery and optic apparatus. The lamina terminalis and pericallosal cisterns served as key pathways for accessing the anterior cerebral artery and interhemispheric structures. Conclusion: Supratentorial cisterns represent fundamental anatomical corridors in cranial surgery. Detailed knowledge of their microsurgical anatomy facilitates safe surgical dissection, enhances neurovascular orientation, and allows effective CSF drainage, thereby reducing the need for brain retraction and improving operative safety. Cite this article as: Aydın L, Kartum TA, Çerçi HM, Tanrıverdi T. Microsurgical and radiological consideration of the supratentorial brain cisterns. Cerrahpaşa Med J 2026, 50, 0048, doi: 10.5152/cjm.2026.26048.

Objective: To evaluate the correlation between preoperative systemic inflammatory markers and postoperative pathological indices in a group of patients who underwent surgery for supratentorial convexity meningiomas. Methods: Eighty-eight cases served as subjects for this retrospective study. Preoperative systemic inflammatory markers namely neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and lymphocyte to monocyte ratio (LMR), and postoperative pathological indices namely Ki-67 labeling index, progesterone receptor (PR), and mitotic activity were obtained from the electronic database. Results: Significantly higher mean Ki-67 and mean PR were seen in males and females, respectively. No difference was noted related to mean mitotic activity and preoperative systemic inflammatory markers between the 2 genders. Significantly higher mean Ki-67 and PR were detected in malignant and non-malignant meningioma groups, respectively. Additionally, significantly higher mean levels of mitotic activity were seen in the malignant meningioma group. A significant positive and negative correlation was seen between mean Ki-67 and mean mitotic activity and PR, respectively. A significant positive correlation was noted between NLR and PLR but PLR was negatively correlated with LMR in the whole group. Conclusion: In general, preoperative systemic inflammatory markers are not correlated with postoperative pathological indices in convexity meningiomas. Some of the results were not consistent with the current literature; therefore, prospective studies are needed. Cite this article as: Kartum TA, .etintaş SC, Tahmazoğlu B, Paksoy K, Kemerdere R, Tanrıverdi T. Relationship between preoperative systemic inflammatory markers and postoperative pathological indices in supra-tentorial meningiomas: analyzing of 88 patients. Cerrahpaşa Med J 2026, 50, 0051, doi: 10.5152/cjm.2026.26051.

BACKGROUND AND OBJECTIVES: Access to the orbit, cavernous sinus, Meckel cave (MC), and infratemporal fossa (ITF) remains challenging due to the complex 3-dimensional anatomy and proximity to critical neurovascular structures. An extradural endoscopic orbitozygomatic (OZ) approach has the potential to provide a direct surgical corridor across these compartments while minimizing the limitations of compartment-specific corridors. METHODS: Five formalin-fixed, silicone-injected cadaveric heads (10 sides) were dissected using an extradural OZ approach under operative microscopy supplemented with 0° and 30° rigid endoscopes. After a two-piece OZ craniotomy, extradural dissection was performed toward the superior orbital fissure and foramen rotundum/ovale, combined with anterior petrosectomy and opening of MC. Anatomic exposure, corridor continuity, and visualization of key neurovascular structures were qualitatively assessed. RESULTS: The extradural endoscopic OZ approach created a direct working corridor from the lateral orbit to the ITF and petroclival region. Endoscopic augmentation enhanced visualization of the lateral cavernous sinus wall, trigeminal divisions (V ₁ -V ₃ ), cavernous internal carotid artery, medial orbital apex, deep infratemporal recesses, and the petroclival region. Anterior petrosectomy extended exposure toward the upper clivus and ventrolateral brainstem. Limitations included restricted microscopic visualization of the medial orbit and inferior ITF, which were partially mitigated by angled endoscopy. CONCLUSION: This cadaveric study demonstrates that the extradural OZ–anterior petrosectomy approach establishes a continuous anatomic corridor integrating the orbit, cavernous sinus/MC, ITF, and petroclival region, while defining its boundaries, areas of optimal exposure, and inherent limitations. As a qualitative study, the findings are descriptive in nature and do not include quantitative morphometric analysis.

Objective: To evaluate the diagnostic performance of 2 multimodal large language models (LLMs), ChatGPT-4V and Claude Sonnet 3.7, in preoperative magnetic resonance imaging (MRI)-based diagnosis and histopathological subtyping of WHO Grade I meningiomas and to compare their performance with a radiology resident. Methods: This retrospective study included 113 patients with WHO Grade I meningiomas who underwent preoperative MRI between January 2020 and December 2024. Multisequence MRI (T1WI, T2WI, FLAIR, T1WI+C, DWI, ADC maps) and radiologist-extracted imaging features were provided to both LLMs in a structured "images + human extracted features" format. Each evaluator performed tumor type and subtype prediction using the 2021 WHO CNS classification. Diagnostic accuracies with 95% confidence intervals were calculated, and comparisons between LLMs and the resident were performed using McNemar's test. Results: For type classification, ChatGPT-4V achieved 76.99% accuracy and Claude Sonnet 3.7 achieved 73.45%, while the radiology resident showed significantly higher accuracy at 92.04% (P < .001 for both). Subtype classification was challenging. ChatGPT-4V achieved 20.35% accuracy, Claude Sonnet 3.7 30.09%, and the resident 30.97%, with no statistically significant differences among them. No significant performance differences were observed between the 2 LLMs. Conclusion: Multimodal LLMs demonstrated moderate ability to identify WHO Grade I meningiomas but did not match the diagnostic performance of the radiology resident. Subtype prediction remained limited, reflecting the constraints of conventional MRI for distinguishing subtle histopathological subtypes. Large language models may assist preoperative assessment, but expert interpretation remains essential. Further development using larger datasets and domain-specific model refinement may improve clinical usefulness. Cite this article as: Karaman AK, Demircan NG, Yılmaz B, et al. Preoperative MRI-based diagnosis and subtyping of WHO grade I meningiomas using multimodal large language models: A comparative reader study. Cerrahpaşa Med J. 2026, 50, 0003, doi: 10.5152/cjm.2026.26003.

Background: Cranio-orbito-zygomatic approach (COZA) requires adequate SCALP, fascia and muscle retraction to access the zygomatic arch, malar eminence (ME) and inferior orbital fissure (IOF), which endanger the facial nerve branches. Performing skull base reconstruction also demands a layer-by-layer understanding of the SCALP and fasciae. We aimed to examine the relationship between the SCALP layers, temporal fascia (TF) and facial nerve branches from a surgical viewpoint and highlight the optimal dissection plane during the COZA. Method: The SCALP and temporal fascia layers were examined using COZA on 10 formalin-fixed cadavers (20 sides). Stepwise dissections analyzed the relationships between SCALP layers, temporoparietal fascia, TF and facial nerve branches. In addition, facial dissections were conducted to examine the relationships between the facial nerve branches and the associated fasciae. Results: The temporoparietal fascia was continuous with the galea superomedial to superior temporal line. Facial nerve branches coursed between the galea and the TF. The TF divided into superficial and deep layers; superficial layer continuous with the pericranium and extending anteriorly toward periorbita. Following the superficial layer of the TF inferiorly provided a natural interfascial surgical plane for exposure of the ME. Deep layer of the TF further divided into medial and lateral laminae with an interfascial fat pad between them. The lateral and medial laminae attached to the lateral and medial surfaces of the zygomatic arch, respectively, and merged at the superior margin. Conclusıons: Recognizing the interfascial plane between the superficial and deep layers of the TF and the deep interfascial fat pad, may improve surgical orientation and facilitate tissue retraction during exposure of the lateral orbital wall and ME in the COZA.

Aim: Vertebral compression fractures are a common cause of pain and disability in the elderly population. Percutaneous vertebroplasty is an established minimally invasive intervention, yet the optimal approach (unilateral or bilateral) remains controversial. This study focused on comparing the clinical and radiological outcomes of unilateral versus bilateral percutaneous vertebroplasty in patients with painful osteoporotic vertebral compression fractures.Material and Methods: A retrospective review was conducted on 203 patients (73 males, 130 females; mean age 65.3 ± 8.9 years) with 309 treated vertebral levels from 2014 to 2024. Patients underwent either unilateral (n = 104) or bilateral (n = 99) PVP. Pain and disability were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), while radiological outcomes included anterior vertebral height restoration and segmental Cobb angle correction. Results: Both approaches provided significant pain relief and functional improvement. Bilateral PVP achieved lower postoperative VAS (1.9 vs 2.1, p = 0.040) and ODI scores (23.1% vs 26.3%, p = 0.020) compared to unilateral PVP. Radiologically, bilateral procedures resulted in superior anterior height restoration (25.8% vs 19.2%, p = 0.001) and greater Cobb angle correction (9.1° vs 6.4°, p = 0.001). Cement leakage rates were similar in both groups (≈4%), with no symptomatic complications.Conclusion: Unilateral and bilateral PVP are both safe and effective for osteoporotic VCFs. Bilateral PVP demonstrated superior radiological correction, whereas unilateral PVP remains advantageous due to reduced operative burden. Treatment decisions should be individualized based on patient anatomy and procedural goals.

Background/aim: To determine whether there is a possible link between selected preoperative systemic inflammatory markers and molecular pathological indices.Material and methods: For this retrospective study, 125 patients served as subjects. Preoperative systemic inflammatory markers, namely neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR), and postoperative pathological indices, namely mitosis, Ki-67 labeling index (LI), isocitrate dehydrogenase-1 (IDH1) mutation, and 1p/19q codeletion, were obtained from the electronic database. Results: Results showed that NLR positively correlated with PLR (p = 0.00001), mitotic activity (p = 0.001), and Ki-67 LI (p = 0.00001). On the other hand, LMR negatively correlated with PLR (p = 0.00001), mitotic activity (p = 0.00001), Ki-67 LI (p = 0.001), and IDH1 mutation (p = 0.04). Conclusion: Our results suggest a link between systemic inflammation and histopathology, and higher NLR and/or lower LMR may be a novel prognostic marker in gliomas. A prospective multicenter study with a larger patient population would be more convincing. Until such a study is published, the results of retrospective studies, including ours, should be evaluated with caution.