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    Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia
    (Springer, 2024) Luzzi, Sabino; Bektaşoğlu, Pınar Kuru; Doğruel, Yücel; Güngör, Abuzer
    The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
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    Clival dural reconstruction via transnasal approaches:fat graft fixation technique
    (American Association of Neurological Surgeons, 2025) Luzzi, Sabino; Doğruel, Yücel; Güngör, Abuzer; Gürses, Muhammet Enes; Rahmanov, Serdar; Türe, Hatice; Türe, Uğur
    OBJECTIVE CSF fistulas are the weak spots of transnasal endoscopic and microsurgical skull base approaches. An autologous fat graft is considered the best substrate for clival dural reconstruction via transnasal approaches. However, potential gravitational displacement of the graft may result in CSF leakage. The authors have developed and described herein the fat graft fixation (FGF) technique to secure the fat graft against dislocation after transclival resection of chor- domas invading the dura. METHODS Seventy-five patients with cranial chordomas underwent surgical treatment at the authors’ institution from September 2006 through June 2023. Of these, the authors collected demographic, clinical, radiological, surgical, and outcome data from 34 patients who underwent an endoscope-assisted microsurgical transclival approach via a transna- sal, sublabial, or sublabial transmaxillary extended corridor. The FGF reconstruction technique was progressively imple- mented to improve clival reconstruction, with a focus on the results. With a custom-made 8-mm 3/8 round atraumatic surgical suture needle, a 4/0 Vicryl stitch was placed through the adjacent dural borders. An abdominal autologous fat graft was then placed over the dural defect. One triple knot was tied to secure the graft and prevent its delayed gravita- tional displacement. The primary outcome was to determine if the FGF group had a higher rate of early or late oronasal CSF fistula compared to the unlocked free graft group. Secondary outcomes included tension pneumocephalus, surgical site infection, and meningitis. RESULTS The fat graft was not used in 8 (23.5%) of the 34 patients because the dura was intraoperatively intact. The unlocked free graft and FGF techniques were used in 20 (58.8%) and 6 (17.6%) patients, respectively. Of the 34 patients, no fistulas were observed in the group treated with the FGF technique, while 4 fistulas were found in the unlocked free graft group (p < 0.05), with 2 of these cases involving meningitis. Patients with a CSF fistula underwent a total of 7 surgi- cal procedures: 3 revision surgical procedures, 2 lumboperitoneal shunts, and 2 ventriculoperitoneal shunts. CONCLUSIONS In the authors’ preliminary experience, the FGF technique has shown promise in eliminating the risk of CSF fistula and other related complications after the transclival approach for clival chordomas involving the dura.https://thejns.org/doi/abs/10.3171/2024.11.FOCUS24560 ©AANS 2025, except where prohibited by US copyright law.
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    Graftless Primary Dural Closure Following Retrosigmoid Approach: Doing More With less
    (Elsevier Inc., 2024) Çavuşoğlu, Neslihan; Erol, Gökberk; Sevgi, Umut Tan; Bulgur, Feride; Doğruel, Yücel; Luzzi, Sabino; Gadol, Aaron A.Cohen; Güngor, Abuzer
    Introduction: Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. Methods: Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves 2 critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. Results: Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. Conclusions: In the authors' preliminary experience, the linear dural incision described herein was effective for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary. © 2024 Elsevier Inc.
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    Selective amygdalohippocampectomy via the paramedian supracerebellar-transtentorial approach for mediobasal temporal epilepsy
    (American association of neurological surgeons, 2024) Doğruel, Yücel; Rahmanov, Serdar; Güngör, Abuzer; Türe, Uğur
    Selective amygdalohippocampectomy via the pterional transsylvian approach is a feasible option for many patients with mediobasal temporal epilepsy. However, it may be insufficient for patients when the posterior hippocampal region is involved. The paramedian supracerebellar transtentorial approach offers precise anatomical orientation when expos-ing the entire length of the mediobasal temporal region, including the fusiform gyrus. In addition, this approach allows selective amygdalohippocampectomy without any neocortical damage. This video presents the successful treatment of a patient with posterior hippocampal sclerosis and mediobasal temporal epilepsy through the paramedian supracerebellar transtentorial approach.
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    Thrombosed posterior inferior cerebellar artery aneurysm mimicking a medulla oblongata cavernous malformation: 2-dimensional operative video
    (Lippincott williams & wilkins, 2024) Doğruel, Yücel; Rahmanov, Serdar; Güngör, Abuzer; Türe, Uğur
    The incidence of posterior inferior cerebellar artery (PICA) aneurysms is estimated to be between 0.5% and 3% of total aneurysm cases.(1) Most patients with these aneurysms typically present with subarachnoid hemorrhage, although there are instances in which patients may present with symptoms resulting from mass effect exerted on the brain stem or lower cranial nerves.(1,2) Treatment options for PICA aneurysms include endovascular procedures, surgical clipping, or bypass techniques.(2) Surgical treatment is considered more effective for partially thrombosed aneurysms compared with endovascular approaches.(3) In addition, endovascular coiling of these aneurysms carries the potential risk of coilmigration and subsequent reopening of the aneurysm lumen.(4) In certain instances, thrombosed PICA aneurysms have the potential to simulate the radiological characteristics of alternative pathologies, such as cavernous malformations or brainstem tumors.(5-7) This situation can result in misdiagnosis and inappropriate management. We present the case of a patient who exhibited symptoms of imbalance and dysfunction in the lower cranial nerves. Magnetic resonance imaging findings indicated a possible cavernous malformation in the medulla oblongata. However, further investigation revealed that the underlying cause was a thrombosed PICA aneurysm. The patient was successfully treated through surgical clipping.
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    Virtual anatomical atlas of the deep brain nuclei
    (Springer science and business media deutschland GmbH, 2024) Sevgi, Umut Tan; Güngör, Abuzer; Erol, Gökberk; Canbolat, Çağrı; Middlebrooks, Erik H.; Sönmez, Osman Fikret; Doğruel, Yücel; Türe, Uğur
    This study aims to improve understanding of the anatomy of the deep brain nuclei relevant to deep brain stimulation as well as stereotactic lesioning procedures, including radio frequency, high-focused ultrasound, and radiosurgery. We created interactive, three-dimensional virtual models from cadaveric dissections and radiological segmentation. We used five brain specimens (ten hemispheres) obtained from routine autopsies, prepared according to Klingler's method. Dissections were done from lateral to medial, medial to lateral, and superior to inferior to expose deep brain stimulation targets and adjacent structures. Using photogrammetry, we scanned the specimens to create detailed three-dimensional models. These models were uploaded to an online platform for free global access. Radiological models were also generated from atlas-based regions using the Montreal Neurological Institute template. We produced 16 high-quality cadaveric models at various stages of dissection. These and the radiological models were examined and interacted with through augmented reality and virtual reality headsets. This approach allowed comprehensive visual access to the anatomical structures and delineated their spatial relationships. These three-dimensional models provide detailed anatomical representations that can enhance anatomical orientiation, improve spatial perception, and serve as valuable educational tools for clinicians and students.