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    Comparison of Three Surgical Approaches for Frontobasal Meningiomas: Purely Endoscopic Endonasal, Purely Microscopic Bifrontal Transcranial, and Combined Endoscopic and Microscopic Supraorbital Transciliary Approaches
    (Lippincott Williams & Wilkins, 2021) Kahilogullari, Gokmen; Baykara, Yigit; Eroglu, Umit; Guler, Tugba Morali; Beton, Suha; Comert, Ayhan; Meco, Cem
    Surgical removal of frontobasal meningiomas (FBMs) can be achieved using different techniques, including endoscopic, transcranial, and combined approaches. The advantages and disadvantages of the outcomes of these approaches should be compared to provide the most convenient surgical treatment to the patient. This study aimed to compare 3 surgical approaches for FBMsin terms of outcomes and determine the superiority of each on the basis of anatomical, surgical, and clinical efficacy. Systematic review was performed to identify studies comparing techniques for the surgical removal of FBMs. Each group included 13 patients; 39 patients with FBMshad undergone surgery. These groups were endoscopic endonasal approach (EEA), microscopic bifrontal transcranial approach (MTA), and endoscopic plus microscopic combined supraorbital transciliary approach (STA) groups. Data on the demographics of patient population, pre- and post-operative neurological examination, tumor properties, imaging studies, and surgical complications were extracted. The mean age at the time of surgery for the patient population was 53.2 years. Among the groups, no statistically significant differences were observed with regard to sex (P = 0.582). The mean follow-up time was 56.7 months. A statistically significant difference was observed in the mean tumor volume among the groups; the MTA group showed the highest mean tumor volume. However, no significant difference was found in the mean tumor volume between EEA and STA groups. Regarding operation duration, the STA group had the shortest operation time (mean = 281.5 minutes), whereas the average surgical duration in MTA group was the longest (mean = 443.8 minutes). The average bleeding volume was highest in the MTA group (mean = 746.2 ml) and lowest in the EEA group (mean = 320.8 ml). Tumor removal was incomplete in three patients (two in the EEA group and one in the MTA group). Recurrence was detected in two cases. One patient with recurrence was operated using the endoscopic surgical approach, whereas the other patient underwent the microscopic bifrontal approach. Post-operative hyposmia/anosmia or decreased olfactory function was the most common complication observed in 5 patients, 2 patients each in the EEA and MTA groups and one in the STA group. The second most common complication was wound infection in one patient in the MTA group and two patients in the STA group (7.7%). Both cerebrospinal fluid (CSF) leakage and meningitis were present in two patients (5.1%), one patient each from the EEA and STA groups. Pre-operative visual disturbances were reported in 13 patients (33.3%), all of which resolved post-operatively No statistical differences were found among the groups. Mortality occurred in a patient in the MTA group (2.6%) caused by cardiac arrest on post-operative day 1. This is the first study comparing the surgical outcomes of three surgical approaches for FBMs. Although recent literature suggests that both endoscopic and transcranial approaches have their own advantages and disadvantages, the authors showed that none of the surgical approaches have obvious superiority over the others with regard to outcomes. Thus, the selection of the ideal surgical approach should be based on surgical experience and tumor characteristics.
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    Endoscopic Anatomy and a Safe Surgical Corridor to the Anterior Skull Base
    (Elsevier Science Inc, 2021) Kilinc, Mustafa Cemil; Basak, Hazan; Coruh, Aysegul Gursoy; Mutlu, Merve; Guler, Tugba Morali; Beton, Suha; Comert, Ayhan
    OBJECTIVE: We describe the possibility to create precise preoperative planning for endonasal endoscopic approaches to the anterior skull base by overlapping endoscopic and radiologic anatomy. The important anatomic structures were marked. Morphometric measurements between these anatomic landmarks were performed endoscopically and compared with radiologic measurements of the same areas to ensure result compatibility. METHODS: Seven cadaver heads injected intravascularly with colored silicone were used for this study. Thinsection brain and paranasal sinus computed tomography scans were obtained on all cadavers. Using 0-degree rigid endoscopes and endonasal endoscopic surgical instruments, the anterior skull base was examined binostrally in all cadavers. Bilateral middle turbinates were identified and preserved. Next, an inferior uncinectomy and middle meatal antrostomy were performed. After performing a frontal antrostomy, bilateral anterior and posterior ethmoidal cells were opened and the skull base was identified and followed to the posterior wall of the frontal sinus. A transnasal transethmoidal sphenoidotomy was done with full exposure to the entire anterior skull base. RESULTS: The anatomic landmarks for endonasal endoscopic skull base approaches were distinguished and measurements were made. The anterior skull base was divided into 3 compartments: anterior (area between the posterior inferior border of the frontal sinus and the course of anterior ethmoidal artery), middle (area between the course of the anterior ethmoidal artery and that of the posterior ethmoidal artery [PEAR and posterior (area between the course of the PEA and the attachment point of the anterior border of the sphenoid sinus to the skull base) compartments. The distances between important anatomic markers and endoscopic depth measurements of this area were measured. CONCLUSION: During endonasal endoscopic anterior skull base surgery, the area between the anterior border of the sphenoid sinus and PEA artery was safe as the first dissection zone. Preoperative radiologic width and depth measurements facilitate orientation to the endoscopic anatomy during surgery and help predict the endonasal surgical corridor anatomy preoperatively.
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    The microanatomy of the Sylvian fissure
    (Springer, 2023) Guner, Yahya Efe; Salman, Necati; Gungor, Yigit; Guler, Tugba Morali; Comert, Ayhan
    Purpose Microsurgical anatomy of the Sylvian fissure is still a popular research topic for neurosurgeons. It is important for surgeons who perform skull base and Sylvian fissure surgical procedures to master the anatomy of the region. In our study, we aimed to review the current literature on the subject. Methods We reviewed the literature concerning the Sylvian fissure. In addition, we made a microdissection of four human cadaveric brains in order to take images of relevant anatomic structures. Results The Sylvian fissure includes both superficial and deep compartments. From the beginning of the surface structures and variable thickened subarachnoid membrane to the vascular structures located at the operculo-insular compartment, the surgical technique requires meticulous dissection in all stages of the surgery. Conclusions From the view of neurosurgery, novel anatomical knowledge should enhance the success of the surgery. From the view of neuroscience, the Sylvian fissure and the Sylvian cistern have unique anatomical, vascular, and genotypical properties to the other areas of the cerebrum, making them complex and special.
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    Microsurgical anatomy of the anterior cerebral artery and the arterial supply of the cingulate gyrus
    (Springer France, 2023) Guner, Yahya Efe; Comert, Ayhan; Sayaci, Emre Yagiz; Korkmaz, Ali Can; Gungor, Yigit; Guler, Tugba Morali; Kahilogullari, Gokmen
    PurposeThe cingulate gyrus is a potential surgical area to treat tumours, psychiatric diseases, intractable pain and vascular malformations. The aim of the study was to define the topographic anatomy and arterial supply of the cingulate gyrus located on the medial surface of the cerebral hemisphere.MethodsWe studied thirty-six hemispheres, each hemisected in the midsagittal plane. The vertical thickness of the cingulate gyrus was measured at the anterior commissure (AC), posterior commissure (PC), and genu levels of the corpus callosum. The branches of the anterior and posterior cerebral arteries supplying each zone were noted separately. The arterial pathways were transformed to digital data in AutoCAD to identify the condensation and reduction areas.ResultsThe mean AC-PC distance was 27.17 +/- 1.63 mm. The thinnest region was the genu level of the corpus callosum (10.29 mm). The superior internal parietal artery (SIPA), inferior internal parietal artery (IIPA) and pericallosal artery (PrCA) supplied all zones of the cingulate gyrus. The anterior zone received the greatest supply. The arterial condensation and reduction areas on both sides of cingulate gyrus and its x, y, and z coordinates specified.ConclusionsThe target cingulotomy (TC) area was determined for anterior cingulotomy. The properties of the TC area are that the thinnest region of the cingulate gyrus is supplied relatively less than other areas and is close to the anterior cingulotomy areas in the literature. The arterial reduction area (ARA) was found to be suitable for corpus callosotomy in terms of avoiding haemorrhage.
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    Morphology of the trigeminal ganglion: anatomical structures related to trigeminal radiofrequency rhizotomy
    (Springer Wien, 2022) Sayaci, Emre Yagiz; Kahilogullari, Gokmen; Comert, Ayhan; Guler, Tugba Morali; Guner, Yahya Efe; Korkmaz, Ali Can; Gungor, Yigit
    Background Trigeminal neuralgia is the most common example of craniofacial neuralgia. Its etiology is unknown and is characterized by severe episodes of paroxysmal pain. The trigeminal ganglion and its adjacent anatomical structures have a complex anatomy. The foramen ovale is of great importance during surgical procedures such as percutaneous trigeminal rhizotomy for trigeminal neuralgia. Objective We aimed to identify the anatomical structures associated with the trigeminal ganglion and radiofrequency rhizotomy on cadavers and investigate their relationship with the electrodes used during rhizotomy to determine the contribution of the electrode diameter and length to the effectiveness of the lesion formation on the ganglion. Methods Five fresh-frozen cadaver heads injected with red silicone/latex were used. A percutaneous puncture was made by inserting of a cannula through the foramen ovale to create a pathway for electrodes. The relationships between the electrodes, Meckel's cave, trigeminal ganglion, and neurovascular structures were observed and morphometric measurements were obtained using a digital caliper. Results Trigeminal ganglion, therefore the electrode in its final position, shows proximity with important anatomical structures. The electrode was inserted posteriorly into the foramen ovale in all of the specimens and was located on the retrogasserian fibers. This study revealed that the electrodes targeting the ganglion and passing through the foramen ovale may cause a radiofrequency lesion due to the contact effect of the dura itself pressing on the electrode. Pushing the cannula beyond the petroclival angle may result in puncturing of the dura propria and moving further away from the target area. Conclusion The success of radiofrequency rhizotomy is directly related to the area affected by the lesion. Understanding the mechanism of action underlying this procedure will ensure the effectiveness, success, and sustainability of the treatment.
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    Temporal Artery and Temporal Region Supplied by the Middle Cerebral Artery: An Anatomical Study
    (Lippincott Williams & Wilkins, 2021) Guler, Tugba Morali; Guner, Yahya Efe; Korkmaz, Ali Can; Gungor, Yigit; Sayaci, Yagiz Emre; Kose, Serdal Kenan; Comert, Ayhan
    This study was conducted to describe in detail the branching patterns of cortical branches from the middle cerebral artery supplying the feeding of the temporal region, to define the arterial structure of temporal artery (TA) and to determine the effect of this arterial supply to the temporal region. The arteries of brains (n = 22; 44 hemispheres) were prepared for dissection after filling them with colored latex. TA was defined, and its classification was described, specifying its relationship with other cortical branches. A new classification was defined related to TA terminology. TA was found in 95% of cadavers, and it originated as an early branch in 75% and from the inferior trunk in 24% of cadavers. TA was classified as Type 0: No TA, Type I: single branch providing two cortical branches, Type II: single branch providing three or more cortical branches and Type III: double TA. Type I-TA (45%) was the most common, and Type II-TA arterial diameter was significantly larger than that of other types. All cadavers showed the cortical branches of temporal region from middle cerebral artery, anterior TA , middle TA, posterior TA and temporooccipital artery, except temporopolar artery (81%). Temporopolar artery, anterior TA, and middle TA primarily originated from TA, an early branch, but posterior TA and temporooccipital artery primarily originated from the inferior trunk. Detailed knowledge about cortical branches together with TA and also this region's blood supply would enable increased prediction of complications, especially in cases with these region-related pathologies, and would make interventions safer.
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    Topographical Anatomy of the Superficial Temporal Artery
    (Turkish Neurosurgical Soc, 2023) Guler, Tugba Morali; Comert, Ayhan; Gungor, Yigit; Guner, Yahya Efe; Sayaci, Yagiz Emre; Korkmaz, Ali Can; Comert, Ela
    AIM: To describe in detail the gross anatomy of the superficial temporal artery (STA), its course and branches, its relationships with the branches of the facial nerve, and certain anatomical and surgical landmarks to preserve these structures in daily neurosurgical practice, and to use the STA during revascularization surgery.MATERIAL and METHODS: This cadaveric study was conducted on 16 cadaver heads bilaterally, in which 32 silicon/latex-injected STAs were dissected using a microdissection technique in a neuroanatomy laboratory. The distances between the facial nerve, tragus, STA, superficial temporal vein (STV), and imaginary lines created between important anatomical landmarks were measured. The curvilinear lengths of STA and STV were also measured.RESULTS: The average distances of the most posteriorly located branch of the facial nerve to the frontal region and the tragus at the midpoint of zygoma in the horizontal plane, at the superior border of the zygoma and at the level of the superior border of the parotid gland, were measured as 25.39, 29.84, and 15.56 mm, respectively. The average distance directly measured between the tragus and STA was 39.29 mm, and that between the tragus and STV was 20.26 mm. The average curvilinear lengths of the frontal and parietal branches of STA were 97.63 and 96.45 mm, respectively.CONCLUSION: Understanding the clinical anatomy of the STA and its branches and its relationships with other structures is of critical importance for a successful and noncomplicated surgery. Our findings will be useful not only for surgical approaches such as pterional craniotomy and orbitozygomatic approaches but also for cerebral revascularization.