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Context. The aim of this study was to explore the prognostic significance correlation between the endocrinopathy and the size of the pituitary adenoma with the sellar floor bone mineral density values using microfocus computerized tomography (μCT) analysis. Subjects and Methods. 16 consecutive patients with pituitary adenomas had full endocrinological and radiological work up prior to endoscopic transnasal transsphenoidal surgery. Multiple bony samples were collected from the sellar floor during surgery, and labeled and analyzed in a double blind fashion. Each bone sample was analyzed for bone mineral density (BMD) and Hounsfield units (HU) with microfocus CT. Results. There was no correlation between adenoma size and BMD values of sella floor but grade IV macroadenomas were found to have lower BMD levels. Statistical analysis showed that the level of correlation between grouped BMD (<1.0 and >1.0) data with ACTH (<46 and >46), IGF (<303 and >303), and PRL (<29.93 and >29.93) levels were insignificant (P=.569, P=.315, and P=1.00, respectively) Conclusion. We have found no clinical relationship between sellar floor BMD values and endocrinopathy and the size of the adenoma. However, it was found out that preoperative conventional CT evaluation seemed insufficient in predicting the sellar floor bone integrity and may mislead the surgeon. [ABSTRACT FROM AUTHOR]

A series of 16 children (nine males, seven females) with traumatic epidural haematoma of the posterior fossa (TEHPF) is presented. All patients had a history of mild to moderate trauma to the occiput. The causes were falls in 15 and traffic accident in one case. Four of the 16 cases had depressed fractures of the occipital bone. Surgical intervention was performed in all cases. In 14 patients the outcome was good, one patient had moderate disability and one died. Our study revealed that early diagnosis and urgent surgical intervention may give the patient a chance of total recovery and craniotomy with haematoma evacuation is an appropriate surgical technique as in the case of supratentorial extradural hematoma. [ABSTRACT FROM AUTHOR]

STUDY DESIGN:: A case report of intraradicular disc herniation. Intraradicular disc herniation is a special type of intradural disc hernations. In this report, we present the tenth case of intraradicular lumbar disc herniation and suggest a new classification for intradural disc herniations. CASE REPORT:: A 32-year-old male was admitted to hospital having experienced pain in the lower back and right leg for 1 month prior to admission. Neurological examination revealed weakness of the extensor hallucis longus, positive Laségue's sign, decreased ankle reflex in his right lower extremity, and bilateral paravertebral muscle spasm. Magnetic resonance imaging (MRI) revealed a disc herniation with a posterolateral extruded fragment on the right at the level of the L5-S1 space. He underwent L5 laminectomy. During the operation, the right S1 root was found to be swollen and immobile. A longitudinal incision was made in the dura of the right S1 root and an intradural free disc fragment was removed, and the S1 root was relieved. The patient was free of pain postoperatively. CONCLUSION:: We suggest a new classification for intradural disc herniations with this unusual case presentation and review the literature for pathogenesis, clinical picture, diagnosis and treatment.Spinal Cord (2001) 39, 545–548. [ABSTRACT FROM AUTHOR]

STUDY DESIGN:: A case report of cervical tuberculous spondylitis associated with systemic lupus erythematosus (SLE). Infection is a frequent problem in SLE, especially in patients hospitalised with the complications of the disease. Tuberculous spondylitis very rarely occurs in SLE patients, and cervical involvement has not been previously reported. CASE REPORT:: A 54-year-old female patient was admitted to our hospital with a complaint of neck pain radiating to her shoulder of 2 months' duration. The neurological examination was completely normal and radiological investigations revealed narrowing, angulation and destruction of the end plates of the 5th and 6th cervical vertebrae. She has received corticosteroid and colchicine treatment for the diagnosis of SLE during the last 10 years. The anterior cervical approach was used and pyogenic material was debrided from the C5-6 intervertebral space, and an otogenous bone graft with a Smith Robinson type fusion was performed. CONCLUSION:: High doses of corticosteroids are implicated as a risk factor for infection in SLE patients. Early diagnosis and appropriate medical and surgical treatment, as well as increased awareness of higher susceptibility to opportunistic infections, such as tuberculous spondylitis, are keystones for decreasing morbidity and mortality in patients with SLE.Spinal Cord (2001) 39, 549–553. [ABSTRACT FROM AUTHOR]

Nowadays, Endoscopic transsphenoidal approach is accepted as the standard method for pituitary adenomas. Endoscope presents two-dimensional panoramic view of surgical field. The orientation of the surgical field becomes easier by the effective use of endoscope in short time and finding anatomic landmarks. Anatomic landmarks are the most important anatomic formations that surgeon has to find to form safe surgical field. Endoscopic Transsphenoidal Pituitary Surgery is carried out in four stages including preoperative preparation, nasal stage, sphenoidal stage and sellar stage. Superior-middle-inferior nasal conchas and sphenoid ostium are landmarks of nasal stage. By going forward through the inferior line of Concha Nasalis, concha nasalis media is leaned to lateral and by doing this concha nasalis superior becomes visible. Concha nasalis superior is approximately 1,5 cm above choanae and ostium sphenoidale with 1-2 mm diameter is just at the bottom of concha nasalis superior. Sphenovomerine suture is used for passing from nasal stage to sphenoidal stage. When sphenovomerine suture is removed, sellae base becomes clearly visible. Then, the sellae base becomes a surgical field with carotid prominence at the laterals and field from planum sphenoidale to clivus. Tumor is removed by preserving neurovascular structures. After the tumor is removed, it is checked whether there is CSF leak or not. If there is no leak, sellar reconstruction is unnecessary. If dura mater is preserved, it is re-placed and surgical field is covered with surgicel-spongostan. Preserved part of sinus mucosa is laid on surgical field and then the operation is finished. [ABSTRACT FROM AUTHOR]

The first transsphenoidal surgical approach to pituitary adenomas has been performed by Herman Schloffer with superiolateral nasoethmoidal approach in Austria Innsburg on March 16,1907. Hirsch has applied endonasal transseptal transsphenoidal approach in 1910. In 1960s, by the usage of microscope in operations, endoscopic endonasal transsphenoidal approach has been being used for pituitary adenomas. The first complete endoscopic approach to sella turcica has been performed in France by Jankowski and his friends to three patients in year 1992. In 1997 at Pittsburg University, neurosurgery expert Jho and otolaryngologist Carrau have performed complete pituitary adenoma excision surgery with their 50 case series. Till now, Enrico de Divitiis and Paolo Cappabianca (Napoli), Giorgio Frank (Bologna) from Italy, Amin Kassam from USA and Mustafa Berker from Turkey have contributed to the usage of complete endoscopic techniques for both glandula pituitary surgery and pathologies related with skull base. In the following years, recognition of endoscope by brain surgeons, approach to sellar and parasellar region gained a new perspective. Nowadays, endoscopic transsphenoidal approach has taken place of microscopic surgery for brain surgeons and has become standard approach at many clinical centers. [ABSTRACT FROM AUTHOR]

A 50-year-old male patient with a history of transcranial surgery and subsequent radiotherapy for a pituitary adenoma presented with repetitive pulsatile nasal bleeding. A right cavernous segment pseudoaneurysm was discovered on the angiogram, and the patient failed the balloon occlusion test. A Papyrus (Biotronik, Berlin, Germany) stent graft, which is approved for coronary interventions, was successfully deployed over a coaxial guiding system during the emergent treatment of the false aneurysm. The patient tolerated the procedure well and nasal bleeding did not recur after the procedure. At one-year angiographic follow-up, the stent graft was patent and there was no evidence of recanalization of the false aneurysm.

Purpose: The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients., Methods: A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission., Results: Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission., Conclusion: Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications., (© 2024. The Author(s).)

Objective: The utilization of digital technologies has experienced a notable surge, particularly in cases where access to cadavers is constrained, within the context of practical neuroanatomy training. This study evaluates augmented reality (AR)- and virtual reality (VR)-based educational models for neuroanatomy education., Methods: Three-dimensional models were created using advanced photogrammetry. VR- and AR-based educational models were developed by arranging these 3D models to align with the learning objectives of neurosurgery residents and second-year medical students whose cadaveric training was disrupted due to an earthquake in Turkey. Participants engaged with and evaluated the VR- and AR-based educational models, followed by the completion of a 20-item graded user experience survey. A 10-question mini-test was given to assess the baseline knowledge level prior to training and to measure the achievement of learning objectives after training., Results: Forty neurosurgery residents were trained with a VR-based educational model using VR headsets. An AR-based educational model was provided online to 200 second-year medical students for their practical neuroanatomy lesson. The average correct answer rates before the training were 7.5/10 for residents and 4.8/10 for students. These rates were significantly improved after the training to 9.7/10 for residents and to 8.7/10 for students (p < 0.001). Feedback from the users concurred that VR- and AR-based training could significantly enhance the learning experience in the field of neuroanatomy., Conclusions: VR/AR-based educational models have the potential to improve education. VR/AR-based training systems can serve as an auxiliary tool in neuroanatomy training, offering a realistic alternative to traditional learning tools.

Objective: Neurosurgical patient-specific 3D models have been shown to facilitate learning, enhance planning skills and improve surgical results. However, there is limited data on the objective validation of these models. Here, we aim to investigate their potential for improving the accuracy of surgical planning process of the neurosurgery residents and their usage as a surgical planning skill assessment tool., Methods: A patient-specific 3D digital model of parasagittal meningioma case was constructed. Participants were invited to plan the incision and craniotomy first after the conventional planning session with MRI, and then with 3D model. A feedback survey was performed at the end of the session. Quantitative metrics were used to assess the performance of the participants in a double-blind fashion., Results: A total of 38 neurosurgical residents and interns participated in this study. For estimated tumor projection on scalp, percent tumor coverage increased (66.4 ± 26.2%-77.2 ± 17.4%, p  = 0.026), excess coverage decreased (2,232 ± 1,322 mm 2 -1,662 ± 956 mm 2 , p  = 0.019); and craniotomy margin deviation from acceptable the standard was reduced (57.3 ± 24.0 mm-47.2 ± 19.8 mm, p  = 0.024) after training with 3D model. For linear skin incision, deviation from tumor epicenter significantly reduced from 16.3 ± 9.6 mm-8.3 ± 7.9 mm after training with 3D model only in residents ( p  = 0.02). The participants scored realism, performance, usefulness, and practicality of the digital 3D models very highly., Conclusion: This study provides evidence that patient-specific digital 3D models can be used as educational materials to objectively improve the surgical planning accuracy of neurosurgical residents and to quantitatively assess their surgical planning skills through various surgical scenarios., Competing Interests: The authors declare the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Hanalioglu, Gurses, Baylarov, Tunc, Isikay, Cagiltay, Tatar and Berker.)

Purpose: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions., Methods: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes., Results: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients., Conclusion: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Background: An understanding of the anatomy of white matter tracts and their 3-dimensional (3D) relationship with each other is important for neurosurgical practice. The fiber dissection technique contributes to this understanding because it involves removing the brain's white matter tracts to reveal their anatomic organization. Using this technique, we built freely accessible 3D models and augmented and virtual reality simulations of white matter tracts., Objective: To define the white matter tracts of cadaveric human brains through fiber dissection and to make 2-dimensional and 3D images of the white matter tracts and create 3D models and augmented and virtual reality simulations., Methods: Twenty cadaveric brain specimens were prepared in accordance with the Klingler method. Brain hemispheres were dissected step-by-step from lateral-to-medial and medial-to-lateral directions. Three-dimensional models and augmented reality and virtual reality simulations were built with photogrammetry., Results: High-resolution 3D models and augmented reality and virtual reality simulations of the white matter anatomy of the cerebrum were obtained. These models can be freely shifted and rotated on different planes, projected on any real surface, visualized from both front and back, and viewed from various angles at various magnifications., Conclusion: To our knowledge, this is the first detailed study integrating various technologies (3D modeling, augmented reality, and virtual reality) for high-resolution 3D visualization of dissected white matter fibers of the entire human cerebrum., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: Surgeons must understand the complex anatomy of the cerebellum and brainstem and their 3-dimensional (3D) relationships with each other for surgery to be successful. To the best of our knowledge, there have been no fiber dissection studies combined with 3D models, augmented reality (AR), and virtual reality (VR) of the structure of the cerebellum and brainstem. In this study, we created freely accessible AR and VR simulations and 3D models of the cerebellum and brainstem., Objective: To create 3D models and AR and VR simulations of cadaveric dissections of the human cerebellum and brainstem and to examine the 3D relationships of these structures., Methods: Ten cadaveric cerebellum and brainstem specimens were prepared in accordance with the Klingler's method. The cerebellum and brainstem were dissected under the operating microscope, and 2-dimensional and 3D images were captured at every stage. With a photogrammetry tool (Qlone, EyeCue Vision Technologies, Ltd.), AR and VR simulations and 3D models were created by combining several 2-dimensional pictures., Results: For the first time reported in the literature, high-resolution, easily accessible, free 3D models and AR and VR simulations of cerebellum and brainstem dissections were created., Conclusion: Fiber dissection of the cerebellum-brainstem complex and 3D models with AR and VR simulations are a useful addition to the goal of training neurosurgeons worldwide., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: Visualizing and comprehending 3-dimensional (3D) neuroanatomy is challenging. Cadaver dissection is limited by low availability, high cost, and the need for specialized facilities. New technologies, including 3D rendering of neuroimaging, 3D pictures, and 3D videos, are filling this gap and facilitating learning, but they also have limitations. This proof-of-concept study explored the feasibility of combining the spatial accuracy of 3D reconstructed neuroimaging data with realistic texture and fine anatomical details from 3D photogrammetry to create high-fidelity cadaveric neurosurgical simulations., Methods: Four fixed and injected cadaver heads underwent neuroimaging. To create 3D virtual models, surfaces were rendered using magnetic resonance imaging (MRI) and computed tomography (CT) scans, and segmented anatomical structures were created. A stepwise pterional craniotomy procedure was performed with synchronous neuronavigation and photogrammetry data collection. All points acquired in 3D navigational space were imported and registered in a 3D virtual model space. A novel machine learning-assisted monocular-depth estimation tool was used to create 3D reconstructions of 2-dimensional (2D) photographs. Depth maps were converted into 3D mesh geometry, which was merged with the 3D virtual model's brain surface anatomy to test its accuracy. Quantitative measurements were used to validate the spatial accuracy of 3D reconstructions of different techniques., Results: Successful multilayered 3D virtual models were created using volumetric neuroimaging data. The monocular-depth estimation technique created qualitatively accurate 3D representations of photographs. When 2 models were merged, 63% of surface maps were perfectly matched (mean [SD] deviation 0.7 ± 1.9 mm; range -7 to 7 mm). Maximal distortions were observed at the epicenter and toward the edges of the imaged surfaces. Virtual 3D models provided accurate virtual measurements (margin of error <1.5 mm) as validated by cross-measurements performed in a real-world setting., Conclusion: The novel technique of co-registering neuroimaging and photogrammetry-based 3D models can (1) substantially supplement anatomical knowledge by adding detail and texture to 3D virtual models, (2) meaningfully improve the spatial accuracy of 3D photogrammetry, (3) allow for accurate quantitative measurements without the need for actual dissection, (4) digitalize the complete surface anatomy of a cadaver, and (5) be used in realistic surgical simulations to improve neurosurgical education., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hanalioglu, Romo, Mignucci-Jiménez, Tunc, Gurses, Abramov, Xu, Sahin, Isikay, Tatar, Berker, Lawton and Preul.)

Background: One of the most important public health concerns is the ever-growing problem of antibiotic resistance. Importantly, the rate of introduction of new molecules into clinical practice has slowed down considerably. Moreover, the rapid emergence of resistance shortens the effective 'lifespan' of these molecules., Objective: The quality of care before and after active intervention and feedback was evaluated in patients diagnosed with sepsis/septic shock or ventilator-associated pneumonia (VAP) in the ICUs of Hacettepe University Adult and Oncology Hospitals., Results: There was a significant increase in total scores. Significant improvements were achieved in the management of these patients in terms of requests for necessary diagnostic tests, and the prolonged infusion of beta-lactam agents., Conclusion: Implementation of an ASP in centers where antimicrobial management of ICU patients is largely controlled by infectious diseases specialists remains a feasible strategy that leads to better patient care., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Abstract: A 47-year-old woman with atypical pituitary adenoma was referred to the neurosurgery department due to recent back pain. She had multiple transsphenoidal surgery, stereotactic body radiation, and 177Lu-DOTATATE therapy. Her spinal MRI showed multiple spinal masses. The patient underwent 68Ga-DOTATATE PET/CT to confirm the metastatic spread of the disease. PET/CT images showed increased uptake at the local recurrent tumor site and spinal metastases confirmed by biopsy to pituitary carcinoma. Our case presents the role of 68Ga-DOTATATE PET/CT in patients with pituitary carcinoma., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Human cadavers are an essential component of anatomy education. However, access to cadaveric specimens and laboratory facilities is limited in most parts of the world. Hence, new innovative approaches and accessible technologies are much needed to enhance anatomy training., Objective: To provide a practical method for 3-dimensional (3D) visualization of cadaveric specimens to maximize the utility of these precious educational materials., Methods: Embalmed cadaveric specimens (cerebrum, brain stem, and cerebellum) were used. The 3D models of cadaveric specimens were built by merging multiple 2-dimensional photographs. Pictures were taken with standard mobile devices (smartphone and tablet). A photogrammetry program (Qlone®, 2017-2020, EyeCue Vision Technologies Ltd, Yokneam, Israel), an all-in-one 3D scanning and augmented reality technology, was then used to convert the images into an integrated 3D model., Results: High-resolution 360-degree 3D models of the cadaveric specimens were obtained. These models could be rotated and moved freely on different planes, and viewed from different angles with varying magnifications. Advanced editing options and the possibility for export to virtual- or augmented-reality simulation allowed for better visualization., Conclusion: This inexpensive, simple, and accessible method for creating 360-degree 3D cadaveric models can enhance training in neuroanatomy and allow for a highly realistic surgical simulation environment for neurosurgeons worldwide., (© Congress of Neurological Surgeons 2021.)

Objective  This study was aimed to assess the clinical aggressiveness of pituitary neoplasms that were previously defined as atypical adenomas. Methods  A total of 1,042 pituitary adenomas were included in the study and 101 of them were diagnosed as atypical adenoma. Demographic characteristics, radiological evaluations, and clinical information were obtained from a computer-based patient database. Cases were categorized as atypical or typical using the criteria listed in 2004 Classification of Tumors of Endocrine Organs. Results  The cure and reoperation rates did not show any statistically significant difference between the typical and atypical adenomas. However, a higher K i -67 labeling index was found to be associated with a higher rate of reoperation ( p  = 0.008) in atypical adenomas. Of note, cavernous sinus invasion or parasellar extension was found to be associated with lower cure rates in patients with atypical pituitary adenomas ( p  < 0.001 and p  = 0.001, respectively). Conclusion  Although atypical pituitary adenomas are known to be more invasive, this study demonstrated that the reoperation and cure rates are the same for typical and atypical adenomas. Our findings advocate for omitting the use of atypical adenoma terminology based solely on pathological evaluation. As stated in the 4th edition of the World Health Organization (WHO) classification, accurate tumor subtyping, evaluation of proliferation by means of mitotic count and K i -67 labeling index, and radiological and intraoperative assessments of tumor invasion should be taken into consideration in the management of such neoplasms., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Attention-deficit hyperactivity disorder (ADHD) is one of the most common childhood-onset psychiatric disorders. Although the etiology is complex and has not yet been clarified, dopamine is thought to play a role in the etiology. Methylphenidate (MPH) is a psychostimulant drug used as first-line treatment for ADHD and it inhibits dopamine and norepinephrine reuptake transporters. Dopamine also has an effect on retina and contrast sensitivity. Despite evidence indicating the effects of dopamine on contrast sensitivity, the results of studies examining contrast sensitivity in ADHD patients are inconsistent. Also, no studies have been encountered examining the possible effect of MPH on contrast sensitivity. The hypotheses of this study are that children with ADHD who have not used MPH will have lower contrast sensitivity levels than the members of the control group, that contrast sensitivity levels increase after the use of MPH, and that contrast sensitivity is a potential physiological marker for ADHD. The study was conducted with 30 children with ADHD and 30 children without ADHD. Psychiatric evaluations of the participants were conducted with the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime-Turkish version, Conner's Parent Rating Scale-Revised Short form and the Turgay DSM-IV-based Child and Adolescent Behavioral Disorders Screening and Rating Scale. Photopic contrast sensitivity was measured using the Functional Acuity Contrast Test (FACT). Results showed that FACT mean values of the control group were significantly higher than those of the ADHD group (pre-treatment) in all spatial frequencies. In four spatial frequencies (CPD 1.5, 3, 12 and 18), the FACT mean values of the control group were significantly higher than the ADHD group (during the OROS-MPH treatment). At all spatial frequencies, the mean values of the ADHD group during the OROS-MPH treatment were significantly higher than before the OROS-MPH treatment. In conclusion, the present study showed that contrast sensitivity is low in children with ADHD and increases significantly after OROS-MPH medication, but still did not reach the levels of the children without ADHD. Our findings suggest that contrast sensitivity may be a potential physiological marker in ADHD., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

A pineal parenchymal tumor of intermediate differentiation (PPID) is a rare entity, and optimal treatment is still unclear. Combined multimodality treatment should be considered in PPID due to high recurrence rates. Gross total resection is the first choice of treatment, however, it may not be feasible in every case due to location. Stereotactic radiosurgery (SRS) can be considered for the treatment of primary and recurrent disease, as it enables us to deliver a high radiation dose to the target while minimizing radiation exposure to normal tissue. In this report, we present a case treated with hypofractionated SRS for recurrent/metastatic PPID after the primary tumor was controlled with the combination of surgery and conventionally fractionated radiotherapy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Beduk Esen et al.)

Today, virtual simulation environments create alternative hands-on practice opportunities for surgical training. In order to increase the potential benefits of such environments, it is critical to understand the factors that influence them. This study was conducted to determine the effects of training, used-hand, and experience, as well as the interactions between these variables, on endoscopic surgery skills in an educational computer-based surgical simulation environment. A 2-hour computer-based endoneurosurgery simulation training module was developed for this study. Thirty-one novice- and intermediate-level resident surgeons from the departments of neurosurgery and ear, nose, and throat participated in this experimental study. The results suggest that a 2-hour training during a 2-month period through computer-based simulation environment improves the surgical skills of the residents in both-hand tasks, which is necessary for endoscopic surgical procedures but not in dominant hand tasks. Based on the results of this study, it can be concluded that computer-based simulation environments potentially improve surgical skills; however, the scenarios for such training modules need to consider especially the bimanual coordination of hands and should be regularly adapted to the individual skill levels and progresses.

The education programme of surgery has unique problems. In this study, first, a literature review is conducted to cover the studies found in the literature reporting on the problems of surgical education. Additionally, a survey study is conducted with 31 participants, who are either currently enrolled in endoscopic surgery education programmes in Turkey or are experts in the field. Supportively semistructured individual interviews are also conducted with five participants. These data are collected to better understand the instructional methods being used, their problems and the participants' preferred methods to be used. Additionally, the participants' attitudes are also investigated regarding the use of new technologies to enhance the current education programmes. The results indicate that, in Turkey, surgical education programmes are still mostly offered in traditional ways while other educational methods are used in an extremely limited manner. In general, the authors emphasise that more research needs to be conducted to better understand the characteristics of the medical students and develop standards for surgical education programmes, educational tools specific for related surgical domains and guidelines for the curriculum integration. The results of this study aimed to guide the instructional system designers for the endoscopic surgery education programmes., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In neurosurgery education, there is a paradigm shift from time-based training to criterion-based model for which competency and assessment becomes very critical. Even virtual reality simulators provide alternatives to improve education and assessment in neurosurgery programs and allow for several objective assessment measures, there are not many tools for assessing the overall performance of trainees. This study aims to develop and validate a tool for assessing the overall performance of participants in a simulation-based endoneurosurgery training environment., Methods: A training program was developed in two levels: endoscopy practice and beginning surgical practice based on four scenarios. Then, three experiments were conducted with three corresponding groups of participants (Experiment 1, 45 (32 beginners, 13 experienced), Experiment 2, 53 (40 beginners, 13 experienced), and Experiment 3, 26 (14 novices, 12 intermediate) participants). The results analyzed to understand the common factors among the performance measurements of these experiments. Then, a factor capable of assessing the overall skill levels of surgical residents was extracted. Afterwards, the proposed measure was tested to estimate the experience levels of the participants. Finally, the level of realism of these educational scenarios was assessed., Results: The factor formed by time, distance, and accuracy on simulated tasks provided an overall performance indicator. The prediction correctness was very high for the beginners than the one for experienced surgeons in Experiments 1 and 2. When non-dominant hand is used in a surgical procedure-based scenario, skill levels of surgeons can be better predicted. The results indicate that the scenarios in Experiments 1 and 2 can be used as an assessment tool for the beginners, and scenario-2 in Experiment 3 can be used as an assessment tool for intermediate and novice levels. It can be concluded that forming the balance between perceived action capacities and skills is critical for better designing and developing skill assessment surgical simulation tools.

Allergic diseases have emerged as a major health care burden, especially in the western hemisphere. They are defined by overshooting reactions of an aberrant immune system to harmless exogenous stimuli. The T H 1/T H 2 paradigm assumes that a dominance of T H 2 cell activation and an inadequate T H 1 cell response are responsible for the development of allergies. However, the characterization of additional T helper cell subpopulations such as T H 9, T H 17, T H 22, T H GM-CSF and their interplay with regulatory T cells suggest further layers of complexity. This review summarizes state-of-the-art knowledge on T cell diversity and their induction, while revisiting the T H 1/T H 2 paradigm. With respect to these numerous contributors, it offers a new perspective on the pathogenesis of asthma, allergic rhinitis (AR) and atopic dermatitis (AD) incorporating recent discoveries in the field of T cell plasticity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Craniopharyngioma resection is one of the most challenging surgical procedures. Herein, we describe our extended endoscopic endonasal transsphenoidal surgery (EETS) technique, and the results of 9 years of use on primary and recurrent/residual craniopharyngiomas., Methods: This study reviewed 28 EETSs in 25 patients with craniopharyngiomas between January 2006 and September 2015. The patients were divided into 2 groups, newly diagnosed patients (group A, n = 15), and patients having residual or recurrent tumors (group B, n = 10). There was no significant difference between the groups in terms of the largest tumor diameter (P = 0.495), and all patients underwent EETS. The clinical and ophthalmologic examinations, imaging studies, endocrinologic studies, and operative findings for these cases were reviewed retrospectively., Results: The number of gross total resections in group A was 13/15, and 7/10 in group B. Three of the patients developed postoperative cerebrospinal fluid leakage (all in group A). There were no neurovascular or ophthalmologic complications, and no meningitis or mortality was observed., Conclusions: There has been a notable increase in the use of EETS in the treatment of craniopharyngiomas during the last decade. Despite its increased use in the treatment of primary craniopharyngiomas, its implementation for recurrent or residual craniopharyngiomas has been viewed with suspicion. In this study, the results have been presented separately for primary and recurrent/residual craniopharyngiomas, so that the results can be compared. Overall, EETS is a reliable and successful surgical treatment method for primary and recurrent/residual craniopharyngiomas., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Articulation of rostrum of sphenoid bone with alae of vomer forms a schindylesis type of joint. The circumference of this joint, called sphenovomerine suture (SVS), is very important in establishing a reliable surgical field in the endoscopic transsphenoidal pituitary surgery. Because of its vital role in endoscopic transsphenoidal pituitary surgery, this radio-anatomical study was designed to establish the morphological properties of SVS., Methods: In this study, the authors examined SVS in 235 patients (121 females and 114 males) on the computed tomography images of the paranasal sinus and made 4 measurements to describe SVS., Results: The mean distance between superior margin of the upper labial philtrum and top of SVS was 6.66 ± 0.43 cm for females and 7.44 ± 0.54 cm for males. The distance between the top of SVS and dorsum sellae was 3.08 ± 0.33 cm for females and 3.19 ± 0.32 cm for males, the alae of vomer angle in the upper surface was 74.22 ± 20.06° for females and 74.23 ± 19.68° for males. The distance between the most lateral points of 2 alae of vomer was 0.99 ± 0.17 and 1.01 ± 0.19 cm for females and males, respectively., Conclusions: For an easy and successful operation, removal of the SVS is very important as it will provide a better view of the sellar base and make the management of the surgical instruments easier in the wider safe surgical field thus created.

Background: Splitting of the optic nerve by a pituitary adenoma is an extremely unusual condition with only 3 cases reported to date., Case Description: A 41-year-old woman presented with visual loss as a result of an aggressive pituitary macroadenoma causing the splitting of the right optic nerve. Possible mechanisms of this condition are discussed, and the literature is reviewed., Conclusions: In aneurysm and tumor cases, awareness of the exact anatomy is particularly important to preserve function. An overlooked duplication or penetration of cranial nerves may result in inadvertent injury to important structures and loss of function., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We report herein a retrospective analysis of the results of 142 consecutive prolactinoma cases operated upon using an endoscopic endonasal trans-sphenoidal approach over a period of 6 years., Methods: Medical records of 142 cases were analysed with respect to indications for surgery, duration of hospital stay, early remission rates, failures and recurrence rates during a median follow-up of 36 months., Results: On the basis of magnetic resonance imaging (MRI) data, 19 patients (13.4 %) had microadenoma, 113 (79.6 %) had macroadenoma, and the remaining 10 (7.0 %) had giant adenomas. Cavernous sinus invasion was identified in 25 patients by MRI and confirmed during surgery. Atypical adenoma was diagnosed in 16 patients. Sparsely granulated prolactin adenoma was identified in 99 patients (69.7 %). Our results demonstrate that male sex and higher preoperative prolactin levels are independent factors predicting persistent disease. The post-surgical complications are as follows: 2.8 % patients had meningitis, 2.1 % patients had postoperative cerebrospinal fluid leak and 2.1 % patients had panhypopituitarism. At the end of follow-up, 74.6 % patients went into remission. During follow-up period, five patients who had initial remission developed recurrence., Conclusions: Our series together with literature data suggest that an endoscopic endonasal trans-sphenoidal approach in the treatment of proloctinomas has a favourable rate of remission. According to the findings of this study, endoscopic endonasal trans-sphenoidal surgery might be an appropriate therapy choice for patients with prolactinoma who could not have been managed with recommended therapeutic modalities.

Object: Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor-I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature., Methods: The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure., Results: In total 214 patients with a mean age of 41.9 ± 12 years (range 17-75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs. 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria., Conclusions: In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4-1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

High levels of endogenous cortisol due to Cushing's disease cause significant mortality and morbidity. Treatment of Cushing's disease is challenging. For many years, transsphenoidal microsurgical resection of the adenoma has been the treatment of choice. However, recently, neuroendoscope has taken its place in the neurosurgeon's armamentarium, and the endoscopic transsphenoidal resection of pituitary tumors has become a familiar approach. Our aim was to present the results of pure endoscopic surgery in the treatment of corticotropinomas for comparison with the results of previous endoscopic and microsurgical series. We present a retrospective analysis of 90 patients with diagnosis of Cushing's disease who were operated between 2006 and 2012. Among 90 patients, a total of 81 (90.0 %) had a remission (28 out of 29 macroadenomas (96.6 %) and 53 out of 61 microadenoma patients (86.9 %)). Of note is that 66 out of 69 (95.7 %) primary patients (i.e., those who were operated in our center) and 15 out of 21 (71.4 %) patients previously operated in other centers reached a hypo/eucortisolemic state. A remission rate comparable with previous endoscopic series was achieved. In nine patients, it was not possible to achieve remission at all. On the other hand, only four of our cases (5.6 %) had a recurrence, and with reoperation, all of these patients entered a re-remission. To our knowledge, our series is the largest series studying endoscopically operated adrenocorticotropic hormone-secreting adenomas. Our results suggest that the endoscopic approach has opened a new avenue in the treatment of Cushing's disease, previously a therapeutic challenge for both the clinician and the neurosurgeon. Endoscopic approach in the treatment of Cushing's disease is clearly better for patients because of its low morbidity rates and short duration of hospital stay. On the other hand, long-term follow-up of our patients will show whether these favorable observations will persist.

Thyroid disorders are frequently encountered. The diagnosis is straightforward unless clinical or laboratory findings are inconclusive and/or perplexing. Hyperthyroidism due to a thyrotropin-secreting pituitary adenoma rarely occurs and symptoms due to thyroid hormone excess are subtle. The presentation of the disease becomes unusual when co-secretion of other hormones with thyrotropin or concomitant thyroid parenchymal pathology exist. We present the case of a 63-year-old female patient with thyrotropinoma co-secreting growth hormone and multinodular goiter. She developed hyperthyroidism first due to thyrotropinoma and later due to a toxic nodule. Herein, we discuss the diagnostic and therapeutic challenges of hyperthyroidism with atypical presentation.

Objective: Dural opening and closures are major steps in endoscopic pituitary surgery. Restoring the normal anatomy at the end of the procedure creates a natural barrier between the intrasellar compartment and the sinonasal cavity., Methods: In this study, we present a relatively simple dural opening and closure technique for endoscopic pituitary surgery. This technique provides a better alternative to the use of a more complex nasoseptal flap or the multilevel closure with artificial materials as it restores the normal anatomy after the tumor removal and provides a better physiological barrier between the sinonasal cavity and the intrasellar compartment. Incision is performed in circular or horseshoe fashion leaving a small peduncle, and then the dura is reflected., Results: Of the 733 endoscopic transsphenoidal procedures in 667 patients conducted between January 2006 and May 2012, we used this described technique in 50 cases (7.4%). In these 50 cases with dural flap, there was no postoperative CSF leakage. Intraoperative CSF leakage was observed in 135 (20.2%) of the 667 patients. In 15 (11.1%) of these 135 patients we used the dural flap technique accompanied with fat and/or fascia lata support. There was no postoperative leakage in these patients. In the remaining 120 (89.9%) patients who had intraoperative CSF leakage, we used fat and/or fascia lata for the reconstruction of the sella floor. But we observed postoperative CSF leakage in 12 (10%) of the 120 patients without the dural flap which were reoperated., Conclusion: The dural flap technique we employ has several advantages. First of all, it allows optimal physiological reconstruction after the surgery. Secondly, the bridge between the flap and the main dura helps maintain the vascular supply, which in turn can radically shorten the healing time. Thirdly, this technique is obviously a better alternative to the time consuming and expensive multilevel closures with tissue sealants and artificial grafts., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Aim: Intracranial hypotension may have variable clinical presentation. The imaging characteristics of intracranial hypotension are especially well depicted on magnetic resonance imaging studies. Although the clinical and radiological manifestations of spontaneous intracranial hypotension are increasingly recognized in many reports, many other abnormalities in this disorder and complicating cases still exist., Material and Methods: A 16-year-old patient suffering from nausea vomiting and blurred consciousness was admitted to the hospital. MRI showed diffuse pachymeningeal thickening resembling intracranial hypotension and ventricular enlargement like compensated hydrocephalus. The patient was investigated and treated using endoscopic third ventriculostomy., Conclusion: The authors presented a case of intracranial hypotension complicated with hydrocephalus. Specific causes for intracranial hypotension as well as additional new treatment options will also be discussed.

Arterial bleeding during transsphenoidal surgery for pituitary adenoma is known complication. This usually happens due to rupture of intracavernous carotid or delayed hemorrhage due to the carotico-cavernous fistula and/or pseudoaneurysm. There is also evidence that cavernous carotid aneurysms may occur with pituitary tumors, yet largest series failed to demonstrate any link between aneurysm formation and pituitary tumors. Usually such an aneurysm rupture results in formation of carotico-cavernous fistula. However, pituitary apoplexy and even epistaxis have been reported. In this paper we present a patient with recurrent pituitary adenoma and cavernous carotid artery aneurysm, which caused significant hemorrhage during the surgery. Although retrospective analysis of MRI disclosed that the patient had the aneurysm before the first surgery, it remained silent until the second operation. Therefore neurosurgeons should be very susceptive to any signal changes on preoperative MR images, especially in recurrent cases, where normal anatomical relations are disturbed by fibrotic tissue. Also, we reviewed the vascular complication of pituitary surgery based on the literature.