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Hatice Türe, M. Volkan Harput, Nural Bekiroğlu, Özgül Keskin, Özge Köner and Uğur Türe

OBJECTIVE

The semisitting position of a patient confers numerous advantages in various neurosurgical procedures, but venous air embolism is one of the associated complications of this position. To date, no prospective studies of the relationship between the degree of head elevation and the rate and severity of venous air embolism for patients undergoing a procedure in this position have been performed. In this study, the authors compared changes in the severity of venous air embolism according to the degree of head elevation (30° or 45°) in patients undergoing an elective cranial neurosurgical procedure in the semisitting position.

METHODS

One hundred patients undergoing an elective infratentorial craniotomy in the semisitting position were included, and each patient was assigned to 1 of 2 groups. In Group 1, each patient’s head was elevated 30° during surgery, and in Group 2, each patient’s head elevation was 45°. Patients were assigned to their group according to the location of their lesion. During surgery, the standard anesthetic protocol was used with total intravenous anesthesia, and transesophageal echocardiography was used to detect air in the blood circulation. Any air embolism seen on the echocardiography screen was classified as Grade 0 to 4. If multiple events occurred, the worst graded attack was used for statistical analysis. During hemodynamic changes caused by emboli, fluid and vasopressor requirements were recorded. Surgical and anesthetic complications were recorded also. All results were compared statistically, and a p value of < 0.05 was considered statistically significant.

RESULTS

There was a statistically significant difference between groups for the total rates of venous air emboli detected on transesophageal echocardiography (22.0% [n = 11] in Group 1 and 62.5% [n = 30] in Group 2; p < 0.0001). The rate and severity of air embolism were significantly lower in Group 1 than in Group 2 (p < 0.001). The rates of clinically important venous air embolism (Grade 2, 3, or 4, venous air embolism with decreased end-tidal carbon dioxide levels and/or hemodynamic changes) were 8.0% (n = 4) in Group 1 and 50.0% (n = 24) in Group 2 (p < 0.0001). There was no association between the rate and severity of venous air embolism with patient demographics (p > 0.05). An association was found, however, between the rate of venous air embolism and the type of surgical pathology (p < 0.001); venous embolism occurred more frequently in patients with a meningioma. There were no major surgical or anesthetic complications related to patient position during the postoperative period.

CONCLUSIONS

For patients in the semisitting position, an increase in the degree of head elevation is related directly to a higher rate of venous air embolism. With a 30° head elevation and our standardized technique of positioning, the semisitting position can be used safely in neurosurgical practice.

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Carlo Serra, Hatice Türe, Cumhur Kaan Yaltırık, Mehmet Volkan Harput and Uğur Türe

OBJECTIVE

The object of this study was to present the surgical results of a large, single-surgeon consecutive series of patients who had undergone transcisternal (TCi) or transcallosal-transventricular (TCTV) endoscope-assisted microsurgery for thalamic lesions.

METHODS

This is a retrospective study of a consecutive series of patients harboring thalamic lesions and undergoing surgery at one institution between February 2007 and August 2019. All surgical and patient-related data were prospectively collected. Depending on the relationship between the lesion and the surgically accessible thalamic surfaces (lateral ventricle, velar, cisternal, and third ventricle), one of the following surgical TCi or TCTV approaches was chosen: anterior interhemispheric transcallosal (AIT), posterior interhemispheric transtentorial subsplenial (PITS), perimedian supracerebellar transtentorial (PeST), or perimedian contralateral supracerebellar suprapineal (PeCSS). Since January 2018, intraoperative MRI has also been part of the protocol. The main study outcome was extent of resection. Complete neurological examination took place preoperatively, at discharge, and 3 months postoperatively. Descriptive statistics were calculated for the whole cohort.

RESULTS

In the study period, 92 patients underwent surgery for a thalamic lesion: 81 gliomas, 6 cavernous malformations, 2 germinomas, 1 metastasis, 1 arteriovenous malformation, and 1 ependymal cyst. In none of the cases was a transcortical approach adopted. Thirty-five patients underwent an AIT approach, 35 a PITS, 19 a PeST, and 3 a PeCSS. The mean follow-up was 38 months (median 20 months, range 1–137 months). No patient was lost to follow-up. The mean extent of resection was 95% (median 100%, range 21%–100%), and there was no surgical mortality. Most patients (59.8%) experienced improvement in their Karnofsky Performance Status. New permanent neurological deficits occurred in 8 patients (8.7%). Early postoperative (< 3 months after surgery) problems in CSF circulation requiring diversion occurred in 7 patients (7.6%; 6/7 cases in patients with high-grade glioma).

CONCLUSIONS

Endoscope-assisted microsurgery allows for the removal of thalamic lesions with acceptable morbidity. Surgeons must strive to access any given thalamic lesion through one of the four accessible thalamic surfaces, as they can be reached through either a TCTV or TCi approach with no or minimal damage to normal brain parenchyma. Patients harboring a high-grade glioma are likely to develop a postoperative disturbance of CSF circulation. For this reason, the AIT approach should be favored, as it facilitates a microsurgical third ventriculocisternostomy and allows intraoperative MRI to be done.

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Uğur Türe, Mehmet Volkan Harput, Ahmet Hilmi Kaya, Praveen Baimedi, Zeynep Firat, Hatice Türe and Canan Aykut Bingöl

Object

The exploration of lesions in the mediobasal temporal region (MTR) has challenged generations of neurosurgeons to achieve an appropriate approach. To address this challenge, the extensive use of the paramedian supracerebellar-transtentorial (PST) approach to expose the entire length of the MTR, as well as the fusiform gyrus, was investigated.

Methods

The authors studied the microsurgical aspects of the PST approach in 20 cadaver brains and 5 cadaver heads under the operating microscope. They evaluated the features, advantages, difficulties, and limitations of the PST approach and refined the surgical technique. They then used the PST approach in 15 patients with large intrinsic MTR tumors (6 patients), tumor in the posterior fusiform gyrus with mediobasal temporal epilepsy (MTE) (1 patient), cavernous malformations in the posterior MTR including the fusiform gyrus (2 patients), or intractable MTE with hippocampal sclerosis (6 patients) from December 2007 to May 2010. Patients ranged in age from 11 to 63 years (mean 35.2 years), and in 9 patients (60%) the lesion was located on the left side.

Results

In all patients with neuroepithelial tumors or cavernous malformations, the lesions were completely and safely resected. In all patients with intractable MTE with hippocampal sclerosis, the anterior two-thirds of the parahippocampal gyrus and hippocampus, as well as the amygdala, were removed selectively through the PST approach. There was no surgical morbidity or mortality in this series. Three patients (20%) with high-grade neuroepithelial tumors underwent postoperative radiotherapy and chemotherapy but needed a second surgery for recurrence during the follow-up period. In all patients with MTE, antiepileptic medication could be decreased to a single drug at lower doses, and no seizure activity has occurred until this point.

Conclusions

The PST approach provides the surgeon precise anatomical orientation when exposing the entire length of the MTR, as well as the fusiform gyrus, for removing any lesion. This is a novel technique especially for removing tumors involving the entire MTR in a single session without damaging neighboring neural or vascular structures. This approach can also be a viable alternative for selective removal of the parahippocampal gyrus, hippocampus, and amygdala in patients with MTE due to hippocampal sclerosis.