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    CMV encephalitis with intracranial hemorrhages in newborn/infant
    (Wiley, 2023) Yeldir, Neşe; Çakır, Aslı; Doğan, Mehmet Sait; Akalan, Nejat
    [Abstract Not Available]
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    Does gross total resection improve progression-free and overall survival in pediatric intracranial ependymomas? Single-center clinical experience of 61 cases
    (Elsevier Inc., 2022) Narin, Fırat; Bahadır, Sinan; Hanalioğlu, Şahin; Karakaya, Dicle; Başar, İbrahim; Işıkay, İlkay; Söylemezoğlu, Figen; Akalan, Nejat; Bilginer, Burçak
    OBJECTIVE: To share our clinical experience of 25 years and identify prognostic factors for progression-free and overall survival in pediatric intracranial ependymomas. METHODS: In total, 61 children who were treated be-tween 1995 and 2020 in a single institution were included in the study. Medical records of the patients were retro-spectively reviewed to obtain and analyze the following data: patient age at first surgery, sex, presenting symptoms, hydrocephalus and any invasive treatment, anatomic site, extent of resection, pathologic grade, time to progression, and time to death. Progression-free and overall survival rates and affecting factors were analyzed by Kaplan-Meier method. RESULTS: Dysphagia, number of surgeries, and spinal seeding were associated with progression free and overall survival in univariate analysis. The extent of resection, World Health Organization grade, and visual problems were also associated with progression whereas sex was associated with overall survival. Cox regression identified the extent of resection and single surgery as an indepen-dent prognostic factor for progression-free survival. No independent factor was found for overall survival. CONCLUSIONS: This single center experience of 25 years confirms the beneficial effect of gross total resection on disease progression. Although spinal seeding seems to affect survival rates, greater number of cases are needed to reveal its full effect.
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    International consensus classification of hippocampal sclerosis and etiologic diversity in children with temporal lobectomy
    (Academic Press Inc., 2020) Günbey, Ceren; Söylemezoğlu, Figen; Bilginer, Burçak; Karlı Oğuz, Kader; Akalan, Nejat; Topçu, Meral; Turanlı, Güzide; Yalnızoğlu, Dilek
    Introduction: The distribution of hippocampal sclerosis (HS) subtypes, according to the classification of the International League Against Epilepsy (ILAE), has been reported mainly in adult patients. We aimed to review the pathological findings in children who had anterior temporal lobectomy accompanied with amygdalohippocampectomy, in view of the current classification, and evaluate postsurgical outcome with respect to HS subtypes in childhood.Methods: Seventy children who underwent temporal resections for treatment of medically refractory epilepsy, with a minimum follow-up of 2 years, were included: the surgical hippocampus specimens were re-evaluated under the HS ILAE classification.Results: Neuropathological evaluations revealed HS type 1 in 38 patients (54.3%), HS type 2 in 2 (2,8%), HS type 3 in 21 patients (30%), and no HS in 9 patients (12.9%). 0170 patients, 23 (32.9%) had dual pathology, and the most common pattern was HS type 3 with low-grade epilepsy-associated brain tumors (LEAT). The distribution of HS types with respect to age revealed that HS type 3 and no HS subgroups had significantly more patients younger than 12 years, compared with those of HS type 1 (90.5%, 77.8% vs 47.4%, respectively). History of febrile seizures was higher in HS type 1. Prolonged/recurrent febrile seizures were most common in patients 12 years and older, whereas LEAT was the most common etiology in patients under 12 years of age (p < 0.001). Patients with HS type 1 had longer duration of epilepsy and an older age at the time of surgery compared with patients with HS type 3 and no HS (p: 0.031, p: 0.007). At final visit, 74.3% of the patients were seizure-free. Seizure outcome showed no significant difference between pathological subtypes.Conclusions: Our study presents the distribution of HS ILAE subtypes in an exclusively pediatric series along with long-term seizure outcome. The study reveals that the leading pathological HS subgroup in children is HS type 1, similar with adult series. Hippocampal sclerosis type 2 is significantly less in children compared with adults; however, HS type 3 emerges as the second most predominant group because of dual pathology, particularly LEAT. Further studies are required regarding clinicopathological features of isolated HS in pediatric cohort. Seizure-free outcome was favorable and similar in all HS types in children. The proportion of HS types may be better defined in pediatric patients with temporal resections, as the current HS ILAE classification becomes more widely used, and may help reveal the surgical and cognitive outcome with respect to HS types.
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    Intraspinal pathology
    (Springer International Publishing, 2022) Akalan, Nejat; Macyszyn, Luke; Hwang, Steven W.; Samdani, Amer F.
    The term "spinal dysraphism" covers two types of spinal congenital malformations, traditionally grouped as "open" and "closed" forms. These two groups have almost no features in common, including their embryological origin, presentation, natural history, and treatment algorithm. Open spinal dysraphism or myelomeningocele is primarily a neural tube closure defect, resulting with a more or less very stereotypic lesion and clinical presentation. The aim of treatment is to preserve the neurological and clinical status of the newborn. Closed spinal dysraphism is far more complicated and is represented by various forms of different combinations of mesodermal structures. While the neurological impairment in myelomeningocele is straightforward related to the incomplete differentiation of the neural tissue, the mechanisms of neurological impairment in closed dysraphisms are far more complex and controversial. This complexity, in turn, generates an ongoing controversy in establishing universal algorithms for treatment.
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    Is external hydrocephalus a possible differential diagnosis when child abuse is suspected? Editorial
    (Springer Wien, 2022) Akalan, Nejat
    This is a retrospective review of 28 infants collected from two different countries and institutions whom their caregivers had been convicted of “child abuse.” The purpose, descriptions, and the conclusion are well accepted but the article as a whole is rather confusing for the general neurosurgical community. The authors speculate that the terms, “benign enlargement of the subarachnoid spaces (BESS)” and subdural collections are sometimes misdiagnosed leading serious medico-legal problems. Subdural collections represent various conditions which are used interchangeably such as subdural hygroma, chronical subdural hematoma, and external hydrocephaly.
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    Kraniosinostoz cerrahisinde komplikasyonlar
    (Türk Nöroşirürji Derneği, 2017) Çakıcı Başak, Nazlı; Akalan, Nejat
    Kraniosinostoz terimi bir ya da birden fazla sütürün prematür olarak kapanmasını ifade eder. Bazı yazarlar tarafından sütürlerdeki bu erken kapanmanın ve olağandışı büyümenin, gelişmekte olan beyin dokusunu etkileyebildiği öne sürülmektedir. Bu durum sadece kozmetik problem yaratabileceği gibi, sendromik olgularda daha ciddi problemlere de yol açabilmektedir. Kraniosinostozlar nadir görülen bir hastalık grubu olup, sıklıkla tek sütür sinostozu olarak karşımıza çıkar. Tedavisinde açık cerrahi yöntemler ve endoskopik yöntemler kullanılabilir. Açık cerrahi yöntemler tek sütürektomiden ekstensif kalvaryal şekillendirme yöntemlerine kadar geniş bir aralığı kapsamaktadır. İnfantil ve çocuk yaşta olduğu gerek anestezi, gerekse cerrahi aşama ayrı bir özen ve dikkat gerektirmektedir. Kanama bu tür cerrahilerde en fazla görülen komplikasyondur ve çok küçük kanamalar bile infantil çağda beraberinde ciddi komplikasyonlar doğurmaktadır. Bunun dışında enfeksiyon, hipotermi, beyin omurilik sıvısı (BOS) fistulü, intrakranial yaralanma, venöz yaralanmalar, nöbet, hava embolisi, kranyal defektin kapanmaması ve istenilen kozmetik ve fonksiyonel sonuca ulaşılamaması da diğer komplikasyonlar arasındadır.
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    Lesional resective epilepsy surgery in childhood: Comparison of two decades and long-term seizure outcome from a single center
    (Elsevier, 2022) Günbey, Ceren; Bilginer, Burçak; Karlı Oğuz, Kader; Söylemezoğlu, Figen; Ergün, Eser Lay; Akalan, Nejat; Topçu, Meral; Turanlı, Güzide; Yalnızoğlu, Dilek
    Objective: Epilepsy surgery has shown efficacy in children. We aimed to assess long-term seizure outcome in children who underwent epilepsy surgery and determine predictive factors for seizure freedom.& nbsp;Methods: This is a retrospective study of 196 children who underwent epilepsy surgery between 1994 and 2015 and had a minimum postoperative follow-up of 5 years.& nbsp;Results: The median age at the time of surgery was 9.5 (0.08-19.8) years; 110 (56.1%) had temporal, 62 (31.6%) had extratemporal resections, and 24 (12.2%) had hemispheric surgery. The duration of postsurgical follow-up was between 5 and 20 years (mean +/- SD: 7 +/- 3.2). Overall, 129 of 196 (65.8%) patients had Engel class I outcome at final visit. Among patients who underwent temporal, extratemporal and hemispheric surgery; 84 of 110 (76.4%), 34 of 62 (54.8%), and 11 of 24 (45.8%) patients had complete seizure freedom, respectively (p: 0.016). Patients with tumors had the best outcome, with 83.1% seizure freedom. The number of preoperative antiseizure medications (OR 3.19, 95% CI 1.07-9.48), the absence of postoperative focal epileptiform discharges (OR 8.98, 95% CI 4.07-19.79) were independent predictors of seizure freedom. Across two decades, the age at surgery was decreased (p: 0.003), overall seizure freedom (61.8% vs 68%) did not differ. In the past decade, a higher proportion of malformations of cortical development was operated (14.7% vs 35.9%, p: 0.007).& nbsp;Significance: Our findings showed favorable long-term seizure outcome in children who underwent epilepsy surgery. The results are encouraging for developing centers with limited resources to establish pediatric epilepsy programs.
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    Long-term effects of vagus nerve stimulation in refractory pediatric epilepsy: A single-center experience
    (Academic Press Inc Elsevier Science, 2020) Yalnızoğlu, Dilek; Ardıçlı, Didem; Bilginer, Burçak; Konuşkan, Bahadır; Karlı Oğuz, Kader; Akalan, Nejat; Turanlı, Güzide; Saygı, Serap; Topçu, Meral
    Introduction: Vagus nerve stimulation (VNS) has been used as an adjunctive therapy for both children and adults with refractory epilepsy, over the last two decades. In this study, we aimed to evaluate the long-term effects and tolerability of VNS in the pediatric drug-resistant epilepsy (DRE) and to identify the predictive factors for responsiveness to VNS.Methods: We retrospectively reviewed the medical records of pediatric patients who underwent VNS implantation between 1997 and 2018. Patients with >= 50% reduction of seizure frequency compared with the baseline were defined as "responders". The clinical characteristics of responders and nonresponders were compared.Results: A total of 58 children (male/female: 40/18) with a mean follow-up duration of 5.7 years (3 months to 20 years) were included. The mean age at implantation was 12.4 years (4.5 to 18.5 years). Approximately half (45%) of our patients were responders, including 3 patients (5.8%) who achieved seizure freedom during follow-up. The age of seizure-onset, duration of epilepsy, age at implantation, and etiologies of epilepsy showed no significant difference between responders and nonresponders. Responders were more likely to have focal or multifocal epileptiform discharges (63%) on interictal electroencephalogram (EEG), when compared to nonresponders (36%) (p = .07). Vocal disturbances and paresthesias were the most common side effects, and in two patients, VNS was removed because of local reaction.Conclusion: Our series had a diverse etiological profile and patients with transition to adult care. Long-term follow-up showed that VNS is an effective and well-tolerated treatment modality for refractory childhood onset epilepsy. Age at implantation, duration of epilepsy and underlying etiology are not found to be predictors of responsiveness to VNS. Higher response rates were observed for a subset of patients with focal epileptiform discharges.
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    Pediatric arteriovenous malformations
    (Springer, 2017) Çakıcı Başak, Nazlı; Akalan, Nejat
    Contrary to their embryological origin, cerebral arteriovenous malformations have traditionally been regarded as an adult disease. Among various types of congenital vascular disease, classified based on their histopathologic features, “true” arteriovenous malformations (AVM’s) are the most challenging in terms of treatment. Most AVMs present in adulthood, with a mean age of patients at presentation of approximately 30-40 years. Nevertheless, the previously reported incidence rates in population based studies are increasing most probably due to detection of asymptomatic cases. Especially availability and extensive utilization of the non-invasive, highly diagnostic magnetic resonance (MR) imaging almost as a screening test enabled to detect AVMs far before they become symptomatic. This is especially true for the pediatric cases; while in previously reported series consisting of mostly symptomatic cases less than 10% would be children, this percentage is almost doubled in more recent reports [1, 2]. Added the difficulties of treating immature child brain with diverse physiology and metabolism, increasing number of asymptomatic AVMs brings more challenge to decision making for treatment. Nevertheless, spontaneous intracerebral hemorrhage is far more common as the initial sign in pediatric population associated with higher morbidity and mortality [1]. This chapter focuses on unique properties of pediatric AVMs contributing the treatment of choice with various modalities.
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    Pediatric brain tumors: A bibliometric analysis
    (Springer Science and Business Media Deutschland GmbH, 2022) Özbek, Muhammet Arif; Yardibi, Fatma; Genç, Berkhan; Başak, Ahmet Tulgar; Tahta, Alican; Akalan, Nejat
    Purpose The purpose of this study was to identify tendency and current issues in research on pediatric brain tumors over the past 20 years and to help researchers and investors explore new directions for future research in this subject. Methods Web of Science Core Collection was used for article selection and CiteSpace 5.8.R 1 was used for bibliometric analyses with these articles. Results The overall h-index was found to be 131 in the analysis made in a total of 4019 publications on the subject between the years 2000 and 2021. A total of 16,101 authors have published articles on pediatric brain tumors. The most active author in this field was Michael D. Taylor (h-index: 105). The publication which received the strongest citation burst among publications was published in 2016 by Louis et al. published in Acta Neuropathologica, and its content is the World Health Organization's classification of central nervous system tumors. Considering the country contribution, the USA is seen in the leading position. The most publications on the subject were followed by the Journal of Clinical Oncology. Conclusion By examining the studies on childhood brain tumors carried out around the world, the subjects that can be determined as the focus were tried to be highlighted. And it has been seen that the scientific and industrial community should work together and the financial support for multidisciplinary studies should increase.
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    Preoperative and postoperative high angular resolution diffusion imaging tractography of cerebellar pathways in posterior fossa tumors
    (Wiley, 2022) Ortuğ, Alpen; Yüzbaşıoğlu, Neslihan; Akalan, Nejat; Levman, Jacob; Takahashi, Emi
    This study aimed to utilize high angular resolution diffusion magnetic resonance imaging (HARDI) tractography in the mapping of the pathways of the cerebellum associated with posterior fossa tumors (infratentorial neoplasms) and to determine whether it is useful for preoperative and postoperative evaluation. Retrospective data from 30 patients (age 2-16 yr) with posterior fossa tumor (17 low grade, 13 high grade) and 30 age-sex-matched healthy controls were used. Structural and diffusion-weighted images were collected at a 3-tesla scanner. Tractography was performed using Diffusion Toolkit software, Q-ball model, FACT algorithm, and angle threshold of 45 degrees. Manually assessed regions of interest were placed to identify reconstructed fiber pathways passing through the superior, medial, and inferior cerebellar peduncles for the preoperative, postoperative, and healthy control groups. Fractional anisotropy (FA), apparent diffusion coefficient (ADC), and track volume measures were obtained and analyzed. Statistically significant differences were found between the preop/postop, preop/control, and postop/control comparisons for the volume of the tracts in both groups. Displacement and disruption of the pathways seemed to differ in relation to the severity of the tumor. The loss of pathways after the operation was associated with selective resection during surgery due to tumor infiltration. There were no FA differences but significantly higher ADC in low-grade tumors, and no difference in both FA and ADC in high-grade tumors. The effects of posterior fossa tumors on cerebellar peduncles and reconstructed pathways were successfully evaluated by HARDI tractography. The technique appears to be useful not only for preoperative but also for postoperative evaluation.
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    Prognostic value of Ki-67 index in primary intracranial tumors of infants
    (Springer, 2023) Tahta, Alican; Akalan, Nejat
    Objective Primary intracranial tumors are rare tumors in infants. They differ from those found in other pediatric age groups in terms of clinical presentation, histopathological diagnosis, adjuvant therapies, and outcome. Ki-67 index has also shown promising results as a prognostic factor in different types of intracranial tumors in children and adults. However, the importance and the best cutoff point of Ki-67 index in primary intracranial tumors of infants remains unclear. We aimed to analyze prognostic value of Ki-67 index in primary intracranial tumors of infants. Methods This study retrospectively reviewed the records of 28 infants undergoing surgical resection for primary intracranial tumors between April 2016 and March 2021. We analyzed clinical characteristics, tumor location, extent of resection, histopathological diagnosis, Ki-67 index, and overall survival (OS). To define the most relevant cutoff value for Ki-67 index, "Cutoff Finder " was used. Results The median age at diagnosis was 188 days for all patients. Fifteen of the patients were boys and 13 were girls. Tumors were located supratentorial in 13 patients and infratentorial in 15 patients. Gross total resection was performed in 7 of 13 supratentorial tumors and 9 of 15 infratentorial tumors. The mean Ki-67 index of the supratentorial tumors was 49.6%, the median was 55%; for infratentorial tumors, the mean was 49.9%, and the median was 70%. Tumor grade (p = 0.019) and Ki-67 index (p = 0.003) were found as significant predictors of OS in log-rank testing for Kaplan-Meier survival analysis. Univariate cox regression analysis identified high Ki-67 index as prognostic factor for worse OS, with hazard ratio of 8.852 (95% CI 1.95-64.80; p = 0.0108). High Ki-67 index was found as independent prognostic factor for worse OS in multivariate cox regression analysis (HR 7.036; 95% CI 1.229-65.82; p = 0.0457). Conclusion High-grade and high Ki-67 index were associated with worse outcome. Ki-67 index did show a distinct prognostic value for OS within our cohort at a cutoff value of 72.5%.
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    Semiological seizure classification of epileptic seizures in children admitted to video-EEG monitoring unit
    (Turkish Journal of Pediatrics, 2015) Alan, Serdar; Yalnızoğlu, Dilek; Turanlı, Güzide; Karlı-Oğuz, Kader; Lay Ergün, Eser; Söylemezo?lu, Figen; Akalan, Nejat; Topçu, Meral
    We aimed to determine seizure characteristics of pediatric patients with epilepsy, and evaluate if Semiological Seizure Classification (SSC) system is applicable in this cohort. We retrospectively studied 183 patients, aged between 3 months-18 years, admitted to the video-EEG monitoring unit (VEMU). Most patients suffered from intractable epilepsy with comorbidities, and had structural lesions. Seizures were classified based on ictal video-EEG recordings by using SSC system; 157 patients had only one seizure type, 26 had more than one seizure types. Overall 211 seizures and 373 semiologies were analyzed; 114 seizures (54%) had more than one semiological subtype. The most frequent semiology was motor seizures (78%), followed by dialeptic seizures (12%). The most common subtypes were simple motor seizures (49%); tonic seizures constituted (28.4%) of all semiologies. We conclude that SSC system is applicable for children with epilepsy admitted to VEMU; complementary EEG and imaging data are required for evaluation of patients with epilepsy.
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    The endoscopic trans-sinusoidal trans-pterygopalatine route to the foramen rotundum approach in trigeminal neuralgia treatment
    (Turkish Neurosurgical Society, 2022) Özbek, Muhammet Arif; Başak, Ahmet Tulgar; Çakıcı, Nazlı; Şakul, Bayram Ufuk; Akalan, Nejat
    AIM: To describe a new, minimally invasive, and safe access to foramen rotundum via the endoscopic endonasal trans-sinusoidal route for trigeminal nerve blockage. MATERIAL and METHODS: We studied 5 fresh cadavers bilaterally, and 10 pterygopalatine fossae and maxillary nerves using the endoscopic endonasal trans-sinusoidal trans-pterygopalatine approach. RESULTS: The proposed approach enabled the maxillary nerve to be visualized after revealing the foramen rotundum with the help of some craniometric measurements. Distance between sphenoid sinus lateral wall and maxillary sinus posterior wall was measured. This measurement was found to be an important triangulation point to determine the location of the entrance to the pterygopalatine fossa. The distance between the foramen rotundum and the sphenopalatine artery was found to be significant. The foramen rotundum diameter was calculated, and the maxillary nerve was found to be situated inferolateral to the foramen rotundum. Therefore, the safe entry zone was determined superomedially. No significant difference was found between male and female and the right and left nostrils. CONCLUSION: Various surgical procedures have been applied to treat drug-resistant trigeminal neuralgia. Nevertheless, their cure rates remain less than anticipated. Recurrences up to 30% have been reported in the literature. In this study, the endoscopic endonasal transmaxillary trans-pterygopalatine route offers a new perspective on the foramen rotundum approach and provides a panoramic and safe view in previously high-risk percutaneous interventions.
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    The seizure semiology consistent with frontal lobe symptomatogenic zone in children
    (The Turkish Journal of Pediatrics, 2016) Öztoprak, Ülkühan; Yalnızoğlu, Dilek; Karlı Oğuz, Kader; Lay Ergün, Eser; Söylemezoğlu, Figen; Bilginer, Burçak; Akalan, Nejat; Topçu, Meral; Turanlı, Güzide
    The aim of this study is to analyze the seizure semiology consistent with frontal lobe symptomatogenic zone in childhood. We analyzed 549 videotaped seizures from 79 patients (mean age 9.9 +/- 3.8 years). Magnetic resonance imaging was normal in 30 patients. The seizures in the time interval of 10 p.m. to 6 a.m. were considered as nocturnal. The mean number of seizures per patient was 6.8 +/- 7.3. The mean seizure duration was 25.7 +/- 26.9 sec; postictal confusion was 27 +/- 16.1 sec (7-92 seconds). The seizures were observed in sleep with a rate of 56.8%; 43.1% of them were during wakefulness. Overall 50.4% of the seizures occured during night-time sleep. Tonic seizure (77.2%) was the most frequent simple motor seizure. Versive seizures were the second most frequent type of simple motor seizure (26.7%). Clonic seizures were 17.7%, complex motor seizures were 20.5%, and dialeptic seizures were 3% of all the seizures. Epileptic spasm, myoclonic seizures, aphasia, and akinetic semiologies were not observed. Vocalization was observed in 16% of the seizures. Frontal lobe seizures in childhood have a short duration, occur frequently, especially during night time sleep, and have a brief postictal period. Tonic semiology, versive semiology are the most frequent seizure semiologies; hypermotor and secondary generalized tonic clonic seizures and vocalizations are observed less in children compared to adults.
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    Trigeminal nevralji cerrahi tedavisinde endoskopik endonazal transsinüzoidal transpterigopalatin yol ile foramen rotundum yaklaşımı
    (İstanbul Medipol Üniversitesi Tıp Fakültesi, 2018) Özbek, Muhammet Arif; Akalan, Nejat
    Fizyopatolojisi kesin olarak bilinmeyen trigeminal nevralji tedavisinde birçok yöntem denenmesine rağmen fikir birliği sağlanmış bir seçenek yoktur. Bu çalışma ile, ilaca dirençli trigeminal nevralji hastalığının cerrahi tedavisine minimal invaziv endoskopik yeni bir yaklaşım ortaya konması amaçlanmıştır. Endoskopik endonazal transmaksiller transptreygopalatin yolla, foramen rotunduma çevre vasküler ve nöral dokulara zarar vermeden ulaşılması için kraniometrik ölçümler yapılmış, nirengi noktaları belirlenmiştir. Bu nirengi noktaları ve bu noktaların foramen rotundum ile olan ilişkileri araştırılarak endoskopik yaklaşım ile güvenli ve hedefe yönelik minimal invaziv cerrahi alan oluşturmak amaçlanmıştır Bu çalışma Medipol Üniversitesi Tıp Fakültesi Anatomi Anabilim Dalın'da 5 adet fikse edilmemiş kadavra başı kullanılarak yapılmıştır. Bütün kadavralara aynı cerrahi prosedür uygulandı. İlk çalışılan kadavra başında pterigopalatin fossaya giriş noktasını tespit etmek amaçlı bilateral olarak subtemporal kraniotomi yapılarak ekstradural ilerlendi ve foramen rotundum bulundu. Foramen rotundumdan sitilet gönderilerek transnazal olarak ulaşacağımız nokta önceden teyit edildi. Endoskopik olarak transnazal olarak girildikten sonra sfeniod ostium bulundu duvarları teyit edildi. Posterior sfenoidotomi yapılarak optik protuberens, karotid protuberens ve sfenoid sinüs lateral duvarı ortaya konuldu. Orta konka medialize edildikten sonra maksiller sinüsün anterior duvarı açıldı. İlk kadavrada ekstradural olarak gönderilen sitilet tanınarak maksiller sinüsün posterior duvarı açıldı ve foramen rotundumun önceden belirlenen landmarklara uzaklıkları ölçüldü ve n. maksillarisin pozisyonu belirlendi. Daha sonraki kadavralarda sitilet kullanılmadan ölçümler tamamlandı. Yapılan ölçümler doğrultusunda sfenoid sinüs lateral duvarının maksiller sinüsün posterior duvarı arasındaki mesafe ortalama 4.32 mm SD : 1.29 mm olarak hesaplandı. Sfenopalatin arterin foramen rotundum ile arasındaki mesafe ortalama 3.7 mm SD: 0.81 mm olarak hesaplandı. Foramen rotundumun ölçülen çapları ortalaması 2.57 mm SD: 0.74 mm olarak bulundu. Pterigopalatin kanal – fissür ile foramen fotundum arasındaki ölçülen ortalama mesafe 1.36 mm SD: 0.47mm olarak saptandı. 2 Maksiller sinir çıkış pozisyonu olarak foramen rotundumun inferiolateralinde tespit edilmiştir. Çalışmamızda belirttiğimiz gibi, endoskopik endonazal transmaksiller transptreygopalatin yolla, foramen rotunduma ulaşılırken sfenoid sinüs lateral duvarı , sfenopalatin arter ve pterigopalatin kanal önemli kılavuz anatomik noktalardır. Bu çalışma ile gösterildiği üzere, foramen rotundum ortaya konduktan sonra maxiller sinir panoromik olarak vizüalize edilebilmekte ve maksiller sinir trasessi açıkça anlaşılmaktadır. Bu kadaverik çalışma amaçlanan yeni endoskopik cerrahi tedavilerin yöntemlerinin önünün açılmasıdır. Endoskopik taze kadavra çalışmaları yüksek deneyim ve cerrahi nosyon gerektirdiğinden bu alanda daha fazla çalışma yapılarak yaklaşımın geliştirilmesi ve klinikte uygulanmaya başlanması ile birlikte cerrahi prensipler yerine oturacaktır.