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Ulaş Cıkla, Gregory C. Kujoth and Mustafa K. Başkaya

The retrosigmoid approach is a work-horse approach to the cerebellopontine angle (CPA), providing access from the foremen magnum to the tentorium. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of vertebrobasilar system, vascular decompression of cranial nerves (V, VII, IX, X), cranial nerve neurectomies, and intrinsic lesions of the cerebellum and brainstem. In this video, we demonstrate the use of retrosigmoid craniotomy for resection of a large CPA meningioma, delineating all steps including positioning, mapping.

The video can be found here: http://youtu.be/kISkYS16Brk.

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Ulas Cikla, Kutluay Uluc and Mustafa K. Baskaya

Thrombosed giant intracranial aneurysms usually present with symptoms and signs from their mass effect. Although multiple treatment options are available, direct clip reconstruction with thromboendarterectomy remains the gold standard. Here we present a 66-year-old man with seizure, aphasia and hemiparesis. Work-up revealed a giant partially thrombosed aneurysm of the internal carotid artery bifurcation with surrounding vasogenic edema. He underwent clip reconstruction of the aneurysm via a cranio-orbital approach. Although we prepared for bypass with the radial artery and/or the superficial temporal artery, we were able to clip-reconstruct the aneurysm without bypass. The patient improved upon his pre-morbid state after surgery and made an excellent recovery.

The video can be found here: http://youtu.be/P_10hRQFuPo.

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Ulas Cıkla, Kutluay Uluç and Mustafa K. Baskaya

Giant posterior circulation aneurysms pose a significant challenge to neurovascular surgeons. Among various treatment methods that have been applied individually or in combination, clipping under hypothermic circulatory arrest (HCA) is rarely used. We present a 62-year-old man who initially underwent coil occlusion of the right vertebral artery (VA) for a 2.5 cm giant vertebrobasilar junction (VBJ) aneurysm. His neurological condition had declined gradually and the aneurysm grew to 4 cm in size. The patient underwent clip reconstruction of giant VBJ aneurysm under HCA. His postoperative course was prolonged due to his preexisting neurological deficits. His preoperative Modified Rankin Score was 5, and improved postoperatively to 3 at three and six months, and to 2 at one year.

The video can be found here: http://youtu.be/L53SiLV8eJY.

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Kyle I. Swanson, Ulas Cikla, Kutluay Uluc and Mustafa K. Baskaya

The supracerebellar transtentorial approach via a suboccipital craniotomy provides a corridor to reach lesions of the tentorial incisura and supratentorial lesions of the posterior medial basal temporal lobe, such as lesions of the posterior parahippocampal and fusiform gyri. The supracerebellar transtentorial approach obviates the need for either retraction of eloquent cortex or a transcortical route to reach lesions in this region. We present three cases that demonstrate the utility of this approach: a left-sided tentorial meningioma with superior projection, a left-sided posterior parahippocampal cavernous malformation, and a left-sided posterior parahippocampal grade 2 oligodendroglioma.

The video can be found here: https://youtu.be/OLnzUGZfUqk.

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Pinar Eser Ocak, Cem Dinc, Ulaş Cikla and Mustafa K. Başkaya

The complexity of arteriovenous malformations (AVMs) does not necessarily preclude surgical resection. In this video the authors present a 72-year-old male who was known to have an occipital AVM with a large draining varix for the previous 10 years. The patient had progressively worsening visual and cognitive deficits over several years. Total surgical resection was achieved following single stage preoperative embolization. Although resection of the AVMs is challenging, even in experienced hands, it offers a cure and may improve patient clinical outcome.

The video can be found here: https://youtu.be/YI1AwGjJdvo.

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Abdulfettah Tumturk, Yiping Li, Yahya Turan, Ulas Cikla, Bermans J. Iskandar and Mustafa K. Baskaya

Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors’ knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neurological deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs.

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Ulas Cikla, Balkan Sahin, Sahin Hanalioglu, Azam S. Ahmed, David Niemann and Mustafa K. Baskaya

OBJECTIVE

Cerebrovascular bypass surgery is a challenging yet important neurosurgical procedure that is performed to restore circulation in the treatment of carotid occlusive diseases, giant/complex aneurysms, and skull base tumors. It requires advanced microsurgical skills and dedicated training in microsurgical techniques. Most available training tools, however, either lack the realism of the actual bypass surgery (e.g., artificial vessel, chicken wing models) or require special facilities and regulations (e.g., cadaver, live animal, placenta models). The aim of the present study was to design a readily accessible, realistic, easy-to-build, reusable, and high-fidelity simulator to train neurosurgeons or trainees on vascular anastomosis techniques even in the operating room.

METHODS

The authors used an anatomical skull and brain model, artificial vessels, and a water pump to simulate both extracranial and intracranial circulations. They demonstrated the step-by-step preparation of the bypass simulator using readily available and affordable equipment and consumables.

RESULTS

All necessary steps of a superficial temporal artery–middle cerebral artery bypass surgery (from skin opening to skin closure) were performed on the simulator under a surgical microscope. The simulator was used by both experienced neurosurgeons and trainees. Feedback survey results from the participants of the microsurgery course suggested that the model is superior to existing microanastomosis training kits in simulating real surgery conditions (e.g., depth, blood flow, anatomical constraints) and holds promise for widespread use in neurosurgical training.

CONCLUSIONS

With no requirement for specialized laboratory facilities and regulations, this novel, low-cost, reusable, high-fidelity simulator can be readily constructed and used for neurosurgical training with various scenarios and modifications.

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Sahin Hanalioglu, Balkan Sahin, Omer Selcuk Sahin, Abdulbaki Kozan, Melih Ucer, Ulas Cikla, Steven L. Goodman and Mustafa K. Baskaya

OBJECTIVE

In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7–10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date.

METHODS

The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications.

RESULTS

A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7–20.5, p = 0.005) and deep-extraaxial-benign (“skull base”) tumors (OR 3.6, 95% CI 1.3–9.7, p = 0.011) were found to be independent predictors of thromboembolic complications.

CONCLUSIONS

In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.