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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]

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.