The middle cerebral artery is the largest branch of the internal carotid artery and supplies extensive cortical and deep cerebral territories. Variations in its branching pattern are of considerable importance in microsurgical planning and may influence aneurysm development. This study aimed to evaluate the prevalence of middle cerebral artery variations, their microsurgical anatomy, and their relationship with anterior circulation aneurysms. Computed tomography angiography images of 500 patients were retrospectively reviewed to identify middle cerebral artery variations and anterior circulation aneurysms. Additionally, the microsurgical anatomy of the middle cerebral artery was demonstrated through dissections of two cadaveric heads. Descriptive statistical analyses were performed. Middle cerebral artery variations were identified in 62 patients (12.4%), with a total of 73 variations. The most frequent variants were trifurcation (n=35) and early cortical branch (n=24), followed by accessory middle cerebral artery (n=6), fenestration (n=6), and duplication (n=2). Eleven patients exhibited two concurrent variations. Anterior circulation aneurysms were detected in 118 patients, comprising 132 aneurysms in total. The most common locations were middle cerebral artery (n=53), posterior communicating artery (n=28), and anterior communicating artery (n=27). Fourteen patients harbored multiple anterior aneurysms. Aneurysms were present in 30.6% of patients with middle cerebral artery variations compared to 22.6% of those without variations. Among variation subtypes, trifurcation demonstrated the highest aneurysm rate (45.7%). Cadaveric dissections emphasized the surgical relevance of preserving early cortical branches and perforating arteries. Recognition of middle cerebral artery variations and their association with aneurysm distribution is essential for optimizing microsurgical strategy and improving neurovascular management.

BACKGROUND:This study aimed to evaluate and compare the clinical, laboratory and radiologic characteristics, as well as treatment approaches, in pediatric patients diagnosed with preseptal and orbital cellulitis. METHODS:This descriptive, retrospective, cross-sectional study included pediatric patients treated at a tertiary care center between January 2019 and December 2023. Demographic, clinical, etiologic, laboratory and radiologic data were analyzed. RESULTS:Among 244 patients, 233 (95.5%) had preseptal cellulitis and 11 (4.5%) had orbital cellulitis. There were no significant differences in age and gender between the groups ( P = 0.465 and P = 0.274, respectively). Fever (81.8%), proptosis (54.5%), pain with eye movements (54.5%) and diplopia (18.2%) were significantly more frequent in orbital cellulitis ( P < 0.05). Sinusitis was detected in all patients with orbital cellulitis ( P = 0.001), while conjunctivitis was the leading etiologic factor in preseptal cases (28.3%). Leukocyte and C-reactive protein levels were significantly higher in orbital cellulitis patients ( P = 0.001). All patients underwent computed tomography; subperiosteal abscess was identified in 5 (2%), orbital abscess in 1 (0.4%) and epidural abscess in 1 (0.4%) patient. Surgery was required in 54.5% of orbital cellulitis cases. No permanent complications were observed in either group. CONCLUSIONS:Preseptal cellulitis is more common and typically follows a milder clinical course. In contrast, orbital cellulitis, although rare, presents with more severe symptoms and elevated inflammatory markers. Radiologic imaging plays a key role in the diagnostic process, complementing clinical assessment. The consistent association of sinusitis with orbital cellulitis highlights the importance of early recognition and treatment of sinus infections to prevent serious complications.

OBJECTIVES:The aims of the study were to determine the predictive imaging findings of extranodal extension (ENE) in metastatic cervical lymph nodes of head and neck squamous cell carcinoma and to investigate the interobserver agreement among radiologists with different experience levels.MATERIALS AND METHODS:Patients with cervical lymph node dissection and who had metastatic lymph nodes and preoperative imaging were included. Three radiologists evaluated nodal necrosis, irregular contour, gross invasion, and perinodal fat stranding. They also noted their overall impression regarding the presence of the ENE. Sensitivity, specificity, odds ratios based on logistic regression, and interobserver agreement of ENE status were calculated.RESULTS:Of 106 lymph nodes (that met inclusion criteria), 31 had radiologically determined ENE. On pathologic examination, 22 of 31 nodes were positive for ENE. The increasing number of metastatic lymph nodes was associated with the presence of the ENE ( P = 0.010). Irregular contour had the highest sensitivity (78.6%) and gross invasion had the highest specificity (96%) for the determination of the ENE. The radiologists' impression regarding the presence of the pathlogical ENE had 39.3% sensitivity and 82% specificity. Metastatic lymph nodes with a perinodal fat stranding and with the longest diameter of greater than 2 cm were found to be strong predictors of the ENE. The gross invasion demonstrated the highest κ value (0.731) among the evaluated imaging criteria.CONCLUSIONS:In the assessment of ENE, the gross invasion had the highest specificity among imaging features and showed the highest interobserver agreement. Perinodal fat stranding and the longest diameter of greater than 2 cm in a metastatic lymph node were the best predictors of the ENE.

Optic nerve sheath diameter (ONSD) measurement is a noninvasive method that can be used for intracranial pressure monitoring. Several studies have investigated normal ONSD values in children, but no general consensus has been reached yet. The aim of our study was to reveal normal ONSD, eyeball transverse diameter (ETD), and ONSD/ETD values on brain computed tomography (CT) in healthy children aged 1 month to 18 years. Children admitted to the emergency department with minor head trauma and had normal brain CT were included in the study. The demographic characteristics of the patients (age and sex) were recorded, and the patients were divided into four age groups: 1 month to 2 years, 2 to 4 years, 4 to 10 years, and 10 to 18 years. The images of 332 patients were analyzed. When the median values of all measurement parameters (right and left ONSD, ETD, and ONSD/ETD) were compared between the right and left eyes, no statistically significant differences were found. When the same parameters were compared according to age group, the ONSD and ETD values differed significantly (values of males were found to be higher), but the ONSD proximal/ETD and ONSD middle/ETD values did not differ significantly. In our study, normal ONSD, ETD, and ONSD/ETD values were determined according to age and sex in healthy children. As the ONSD/ETD index did not statistically significantly differ according to age and sex, diagnostic studies for traumatic brain injuries can be performed using the index.

Aims: To investigate the relationship between E-cadherin, beta-catenin, N-cadherin, ZEB1, and αSMA as epithelial-mesenchymal transformation markers with tumor stage, lymph node metastasis (LNM), and overall survival (OS) in laryngeal squamous cell carcinomas (LSCC). Materials and Methods: A total of 100 cases diagnosed with LSCC were included in the study. Data about the lymphovascular invasion (LVI), perineural invasion (PNI), necrosis, and LNM were recorded by evaluating hematoxylin-eosin–stained slides. Markers of E-cadherin, beta-catenin, N-cadherin, ZEB1, and αSMA were applied to the sections prepared from paraffin blocks of tumor samples. Results: Ninety-five male and five female patients were included in the study, and 38 of them exited. A significant relationship was observed between OS with advanced tumor stage, presence of LNM and PNI. A significant relationship was found between increased tumor Zeb1 expression and advanced tumor stage. In univariate and multivariate analyses, a significant negative relationship with OS, and increased Zeb1 expression in tumor and tumor stroma was seen. Any relationship was not observed between E-cadherin, beta-catenin, N-cadherin, and αSMA and OS. Conclusion: Among the EMT markers, we evaluated in our study, it was seen that Zeb1, which is an EMT transcription factor, is associated with tumor stage, LNM, and OS. Remarkably, Zeb1 expression observed in tumor stroma was also significant for OS. Any similar data reported for LSCCs have not been encountered in the literature, and it was thought that it would be appropriate to support our findings with further studies to be performed on this subject.

OBJECTIVE:Since mastoid bone aeration is a pressure buffer for the middle ear, it can be accepted as a prognostic factor for tympanoplasty. Temporal bone computed tomography (TBCT) is a primary method for estimating mastoid aeration. However, due to the risk of radiation and its high cost, there is a need for a more straightforward, faster, and more reliable method in non-complicated chronic otitis media cases (COM). Tympanometric volume measurement might be used for this purpose. This study investigated tympanometric volume measurement's reliability in showing mastoid bone aeration by comparing tympanometric volume measurement with TBCT aeration grading. PATIENTS AND METHODS:Preoperative tympanometric volume measurements were performed in patients who underwent audiological examination and temporal computerized tomography (CT) with the diagnosis of COM and sequela of COM without discharge for the last three months and were indicated for surgery. CT was classified into six grades: grade 0: there is no aeration, sclerotic mastoid; grade 1: pneumatization only in the mastoid antrum; grade 2: <25% pneumatization; grade 3: 25-50% pneumatization; grade 4: >50 pneumatization, grade 5: full pneumatization. Averages of tympanometric volume values were determined according to CT degrees. RESULTS:48 left and 52 right ears (n: 100) of 81 patients, 24 females and 57 males, were included in the study. The mean age was 37.69±13.38. Mastoid pneumatization grades of patients were 32 grade 0, 23 grade 1, 16 grade 2, 14 grade 3, 11 grade 4, and 4 grade 5, respectively. Each grade's mean tympanometric volume (mL) was grade 0: 1.1594, grade 1: 1.6991, grade 2: 2.2250, grade 3: 3.0471, grade 4: 4.0327, and grade 5: 2.9775. CONCLUSIONS:There is a statistically significant relationship between tympanometrically measured ear volume and mastoid degrees of pneumatization on temporal bone tomography. As the degree of mastoid aeration increases, the tympanometric volume also increases. According to the results of this study, tympanometric air volume can be used reliably in the preoperative evaluation of mastoid bone aeration in cases of simple COM without ear drainage.

Objective: Coronavirus disease-2019 (COVID-19) has milder clinical fea-tures in children, but information on the association between thoracic imaging and clinical severity of COVID-19 is limited. Material and Methods: Between March 26th and June 30th, 2020, 982 patients with suspected or confirmed COVID-19, 428 of whom had chest X-rays, were included in the study. Demographic and clinical features, chest X-ray and thoracic computed tomography (CT) imaging results, and clinical severity of the disease were analyzed retrospectively. Results: Laboratory-proven COVID-19 was detected in 116 (27.1%) pa-tients; 42 (36.3%) had asymptomatic, 60 (51.7%) had mild, 12 (10.3%) had moderate, and two (1.7%) had severe disease. Chest X-rays were abnormal in 12.1% (14/116) of the patients with confirmed COVID-19. Main pathologic findings on chest X-ray were peribranchial thickening (10/14, 71.4%) and ground-glass opacity (GGO) (4/14, 28.6%) in patients with confirmed COVID-19. Thorax CT imaging was performed in 182 (42.5%) patients, 38 (32.7%) had confirmed COVID-19, 39.5% (15/38) of whom had abnormal imaging. Posterior (n= 7), peripheral (n= 7), and both lobe (n= 5) involvement were more prominent. Consolidated GGO (7/38, 18.4%) and bronchial wall thickening (7/38, 18.4%) were the main pathologic CT imaging patterns. Thorax CT images were abnor-mal in 20% (5/25) of the patients with asymptomatic/mild disease, and in 76.9% (10/13) of the patients with moderate/severe disease (& chi;2= 11.5, Phi= 0.552; p= 0.001). Conclusion: Chest X-ray and thorax CT imaging were mainly normal in patients with asymptomatic/mild COVID-19 disease. In contrast, thorax CT imaging was abnormal in patients with moderate/severe COVID-19, and CT imaging scores correlated with COVID-19 clinical severity. How-ever, since COVID-19 disease is milder in children, applications involving high amounts of radiation such as thoracic CT imaging should only be applied to selected patients.

We aimed to present the management of the patients with necrotizing otitis externa (NOE) and its comorbidities in early and long-term follow-up. Between 2011 and 2022, 30 patients with the diagnose of NEO, who had cortical bone erosion or trabecular demineralization in temporal bone computed tomography and administered at least 6-week antimicrobial therapy were included in the study. Clinical, laboratory and imaging findings of patients, and comorbidities during follow-up were analysed. NOE extending further from the petro-occipital fissure on magnetic resonance imaging was accepted as medial skull base (MSB) involvement. 30 patients, (8 women, 22 men, mean age 66.2 ± 1.7), with NOE were followed 36.4 ± 29.6 months. The mortality rate was 23.33

Objective This study evaluated the effects of the diameter of facial canal segments on the ipsilateral recurrence of idiopathic peripheral facial paralysis. Method This study enrolled 20 patients with ipsilateral recurrent idiopathic peripheral facial paralysis. Measurements were made at the meatal foramen and mid-level of the labyrinthine segment and the narrowest and widest diameters of the mastoid and tympanic segments using the curved planar reformation technique with high-resolution computed tomography. Results The diameters of the labyrinthine segment measured at the meatal foramen and mid-level segments and the narrowest and widest diameters of the tympanic and mastoid segments on the recurrent paralytic side were significantly smaller than the diameters of the segments on the healthy side. Conclusion The narrowness of the facial canal segments may be a risk factor in recurrent idiopathic peripheral facial paralysis.

OBJECTIVE:Chest X-rays are the most commonly performed diagnostic examinations. An artificial intelligence (AI) system that evaluates the images fast and accurately help reducing workflow and management of the patients. An automated assistant may reduce the time of interpretation in daily practice. We aim to investigate whether radiology residents consider the recommendations of an AI system for their final decisions, and to assess the diagnostic performances of the residents and the AI system.METHODS:Posteroanterior (PA) chest X-rays with confirmed diagnosis were evaluated by 10 radiology residents. After interpretation, the residents checked the evaluations of the AI Algorithm and made their final decisions. Diagnostic performances of the residents without AI and after checking the AI results were compared.RESULTS:Residents' diagnostic performance for all radiological findings had a mean sensitivity of 37.9% (vs 39.8% with AI support), a mean specificity of 93.9% (vs 93.9% with AI support). The residents obtained a mean AUC of 0.660 vs 0.669 with AI support. The AI algorithm diagnostic accuracy, measured by the overall mean AUC, was 0.789. No significant difference was detected between decisions taken with and without the support of AI.CONCLUSION:Although, the AI algorithm diagnostic accuracy were higher than the residents, the radiology residents did not change their final decisions after reviewing AI recommendations. In order to benefit from these tools, the recommendations of the AI system must be more precise to the user.ADVANCES IN KNOWLEDGE:This research provides information about the willingness or resistance of radiologists to work with AI technologies via diagnostic performance tests. It also shows the diagnostic performance of an existing AI algorithm, determined by real-life data.

BACKGROUND AND AIM: This study aimed to investigate the association of the chest computed tomography severity score (CT-SS) with mortality in patients who were admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) pneumonia. METHODS: In this single-center retrospective observational study, we reviewed the radiological and medical records of 45 patients with confirmed COVID-19, requiring ICU admission during a 4 month period. The chest CT-SS was used to evaluate the severity of lung involvement. RESULTS: Forty-five patients who admitted to the ICU with COVID-19 and had undergone chest CT scans on admission were enrolled. There wasn't a significant difference in total CT-SS neither between patients who died and those who survived [median (interquartile range) 22 (11-30) vs 16 (9-18), p=0.20] nor between patients who underwent invasive mechanical ventilation and those who did not [median (interquartile range) 22 (12-30) vs 15 (8-17), p=0.17]. The median of CT-SS was 17 (2-39) (n=23 vs n=22). The area under the curve for estimation of mortality according to CT-SS was 0.611 at a 95% CI of 0.434-0.788 (p=0.20). CONCLUSIONS: The total CT-SS, obtained from the chest CT on admission to the ICU, was not associated with an increased risk of mortality in patients admitted to ICU with COVID-19 pneumonia.

Objective: Anatomic variations of the vertebrobasilar junction have been described as uncommon, but may have important neurosurgical implications. The aim of this study is to emphasize the importance of the variations during the surgery and report the frequency of detected uncommon variations through cadaver dissection and computed tomography angiography. Methods: A combined cadaveric and radiologic study was performed to assess for basilar artery fenestration, intervertebral transversal anastomosis, and persistent primitive lateral vertebrobasilar anastomosis. Thirteen formalin-fixed human cadaveric heads were perfused with red- and blue-colored silicone and dissected in a stepwise manner through an endoscopic endonasal transclival approach. Radiologic data from 887 subjects were retrospectively analyzed for the presence of intervertebral transversal anastomosis. Results: Basilar artery fenestration was found in 7 patients (0.8%), intervertebral transversal anastomosis in 1 (0.1%), and persistent primitive lateral vertebrobasilar anastomosis in 1 (0.1%) by CTA analysis. Conclusion: Anatomic variations of the vertebrobasilar junction are a rare, but important, finding in vascular neurosurgery practice. We also report the first case of intervertebral transversal anastomosis discovered through human brain dissection. Cite this article as: Karadağ A, Şenoğlu M, Turkis ÖF, et al. Microsurgical perspective for uncommon variations associated with the vertebrobasilar junction: An anatomical and radiologic investigation. Cerrahpaşa Med J. 2022;46(2):97-100.

Objective. This study evaluated the effects of the diameter of facial canal segments on the ipsilateral recurrence of idiopathic peripheral facial paralysis. Method. This study enrolled 20 patients with ipsilateral recurrent idiopathic peripheral facial paralysis. Measurements were made at the meatal foramen and mid-level of the labyrinthine segment and the narrowest and widest diameters of the mastoid and tympanic segments using the curved planar reformation technique with high-resolution computed tomography. Results. The diameters of the labyrinthine segment measured at the meatal foramen and midlevel segments and the narrowest and widest diameters of the tympanic and mastoid segments on the recurrent paralytic side were significantly smaller than the diameters of the segments on the healthy side. Conclusion. The narrowness of the facial canal segments may be a risk factor in recurrent idiopathic peripheral facial paralysis.

Objective: Fenestration is a vascular variation that begins with a common origin, then splits into two parallel luminal channels that rejoins distally. We aim to evalute the frequency of cerebral arterial fenestrations and their association with cerebral aneurysm by computed tomography (CT) angiography. Methods: We retrospectively analyzed cerebral CT angiography of patients obtained between January 2017 and December 2020. Patients older than 18 years-old, without known vascular disease and previous surgery or interventional treatment were included the study. The location of the fenestration and aneurysms were noted. Results: CT angiographies of 887 patients (mean age 54.8 years, range 18-63 years; 405 women and 482 men) were evaluated. 164 fenestrastions found in 152 patients for a detection rate of 17.1%. Anterior communicating artery fenestrations were the most common (51.2%), followed by vertebrobasilar system fenestration (28.7%). In our study, no significant relationship was found between fenestration and aneurysm, regardless of localization (p>0.05). However, in the coexistence of fenestration and aneurysm, these are commonly located at the same localization (p: 0.005). Conclusion: Cerebral artery fenestration is an uncommon and mostly affects the anterior communicating artery and vertebrobasilar system. Cerebral artery fenestrations could be associated with aneurysms at the fenestration site. Further attention should be paid to the coexistence of aneurysm once intracranial artery fenestration has been found.

OBJECTIVE:To evaluate the relationship between the third window abnormalities and congenital inner ear malformations in pediatric patients with different types of hearing loss. If such a relationship should exist, it would be important to take it into account, in order to diagnose and treat pediatric hearing loss cases more accurately.METHODS:Two hundred twenty-one children with hearing loss who had temporal bone computed tomography (CT) examination and were identified from 2013 to 2018 were retrospectively evaluated. The types of hearing loss were grouped as sensorineural hearing loss (SNHL), conductive hearing loss (CHL), and mixed hearing loss (MHL). Third window abnormalities included superior semicircular canal (SC) dehiscence, posterior SC dehiscence, enlarged vestibular aqueduct (EVA), X-linked stapes gusher, perilymph fistula, and bone dyscrasias. Congenital inner ear malformations included cochleovestibular, SC, and internal acoustic canal malformations. The relationships were analyzed with chi-square and Fisher's exact tests.RESULTS:In the study, 40 patients had unilateral hearing loss and 181 had bilateral hearing loss. In 402 ears, the rates of SNHL, CHL, and MHL were 88.5%, 6.9%, and 4.4%, respectively. EVA was the most common third window abnormality (41/402; 9.7%), and SC malformations were the most common inner ear malformations (53/402; 13.2%). In the SNHL group, superior and posterior SC dehiscence were associated with cochleovestibular malformations (P = .035 and.020, respectively). In the CHL group, there was a relationship between EVA and SC malformations (P = .041). No relationships were found in the MHL group.CONCLUSION:Third window abnormalities and congenital inner ear malformations may be encountered simultaneously in children with SNHL and CHL.

Objective:We aimed to investigate the mastoid emissary vein (MEV) canal incidence and to identify its relationship with jugular bulb ( JB) and sigmoid sulcus anatomical variations. Methods:We retrospectively reviewed 1,300 patients with temporal bone computed tomography (CT) scans in January 2016 to March 2020.The presence and the diameter of the MEV canal, and the anatomical variations of the sigmoid sulcus and the JB were reviewed by two radiologists.High riding JB, JB diverticulum, dehiscent JB, and anterior and lateral protrusion of the sigmoid sulcus were evaluated.All variables were summarized using descriptive statistics.The differences between the groups for categorical data were investigated using the chi-square test.Numeric variables were compared with the Mann-Whitney and the Kruskal-Wallis tests.Logistic regression models were constructed. Results:The study included 1,269 patients of whom 694 were female (54.7%) and 575 were male (45.3%).Their mean age was 39.01±18.47.Among them 915 (72.1%) had the right and 871 (68.6%) had the left MEV canal.Men were more likely to have the MEV canal on both sides.The presence of the right and left MEV canals was associated with the ipsilateral dominant JB/ sigmoid sulcus.The left MEV canal was associated with the left high riding JB and right dehiscent JB. Conclusion:This is the largest patient population reported in the literature and allows a more precise estimate of the MEV canal incidence.We also classified the diameter of the MEV canal to identify clinically relevant, prominent MEV incidence.This is also the first study to demonstrate a relationship between the presence of the MEV canal, and the JB and sigmoid canal variations.Since both the prominent MEV and the JB variations may be symptomatic, knowing this association between them may have clinical relevance.