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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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    External Auditory Canal Transillumination-Guided Middle Fossa Approaches: An Anatomical Feasibility Study
    (Lippincott Williams and Wilkins, 2025) Şahin, Mustafa; Güngör, Abuzer; Doǧruel, Yücel; Luzzi, Sabino; Yılmaz, Adem; Türe, Uğur
    BACKGROUND AND OBJECTIVES: The middle fossa approaches are tremendously versatile for treating small vestibular schwannomas, selected petroclival meningiomas, midbasilar trunk aneurysms, and lesions of the petrous bone. Our aim was to localize the internal acoustic canal and safely drill the petrous apex with these approaches. This study demonstrates a new method to locate the internal acoustic canal during surgery in the middle fossa. METHODS: The microsurgical anatomy of the middle fossa floor was studied in 11 formalin-fixed and silicone-injected cadaveric heads. Extradural dissection of the skull base was completed from the posterior to the anterior side. A zero-degree rigid endoscope was inserted perpendicularly into the external auditory canal. The light beam was first directed through the tympanic membrane, avoiding injury to the tympanic membrane. The room lights were dimmed to provide a clearer view of the transilluminated bony area. Drilling was performed with transillumination guidance. RESULTS: The transilluminated area included the tympanic and mastoid tegmen up to the arcuate eminence. The nonilluminated area was bounded posteriorly by the arcuate eminence, laterally by the greater superficial petrosal nerve, and posteromedially by the petrous ridge. In all specimens, drilling the transition line between the Kawase triangle and the transilluminated area unroofed the internal auditory canal (IAC). No transillumination of the carotid canal was seen after anterior petrosectomy in any of the specimens. The entire contents of the IAC were preserved in both anterior petrosectomy and unroofing of the IAC. CONCLUSION: In this anatomical study, transillumination of the external auditory canal proved to be feasible, accurate, and safe in guiding the middle fossa approaches. The ease of implementation and cost-effectiveness of the technique may suggest a possible application in operative scenarios. © Congress of Neurological Surgeons 2025. All rights reserved.
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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.