Abstract
Background
Studies reported that sphenoid sinus pneumatization (SSP) affects paraclinoid structures, including the optic canal (OC), the anterior clinoid process (ACP), the optic strut (OS), and the sella turcica (ST). We aimed to analyze this assesment based on sagittal and coronal SSP (SSSP and CSSP) patterns considering gender, laterality, and age.
Methods
Computed tomography (CT) images of 154 patients (78 males and 76 females), the dimensions of ST, OC, and ACP were measured, and caroticoclinoid foramen (CCF) and OC protrusion (OCP) were detected, as well as the prevalence of SSSP, CSSP, and ACP pneumatization (ACPP).
Results
The prevalence of ACPP and OCP significantly increased with the degree of SSSP and CSSP. The ACPP was found to be linked to the OCP and sulcal/postsulcal OS (p < 0.05). Also, CCF types were more common in sellar and postsellar SSSP (p = 0.041). The ST and OC dimensions were found to be influenced negatively by an increased degree of SSSP. As the degree of ACPP increased, the OC diameters and ST height decreased, while the OC and ACP lengths increased. The probability of having postsellar SSSP (p = 0.029), postrotundum CSSP (p = 0.000), and ACPP (p = 0.036) decreased with ageing. We found that the OC diameters and ST dimensions increased, while the lengths of the OC and ACP decreased with age.
Conclusion
Our results suggest that morphology and dimensions of paraclinoid structures can be predicted based on SSSP and CSSP in relation to gender and age. This is essential for improved treatment planning and avoidance of iatrogenic injury during surgery.
Keywords: Sphenoid sinus pneumatization, Anterior clinoid process, Optic strut, Sella turcica, Computed tomography, Caroticoclinoid foramen
Introduction
Sella turcica (ST) is a saddle-shaped depression in the upper portion of the sphenoid bone that hosts the pituitary gland [1]. The literature states that the development of the pituitary gland is directly related to the morphology of the ST, which can be affected by skeletal malocclusion, gender and ethnicity [2]. Moreover, it can be influenced by the sphenoid sinuses (SS), which have highly variable pneumatization and do not reach maturity until 14 years of age [3]. Depending on the extent of the sphenoid sinus pneumatization (SSP) in relation to the ST on the sagittal plane, the authors have classified the following four types: conchal, presellar, sellar, and postsellar type [4–10]. Moreover, various patterns of the SSP were identified, including pneumatic extensions into the anterior clinoid process (ACP), the greater wings, and the pterygoid processes of the sphenoid bone on the coronal plane [4, 6, 9]. Previous studies reported that high variability of the SSP may be result in the protrusion or dehiscence of adjacent bony structures such as such as the carotid canal (CC), the optic canal (OC), the vidian canal (VC) and the foramen rotundum (FR). The spread of pathology from the SS to these adjacent neurovascular structures is also influenced by the degree of the SSP [4–10].
The anatomy of the sellar region is quite complex, and there is a lot of variation in its structures. This means that there are also a lot of different surgical approaches to accessing the region. Lesions that cause compression of the lower and medial parts of the OC, the pituitary gland, and the suprasellar region are often accessed via the transsphenoidal approach [4–6]. A good understanding of the SSP pattern, the morphology and morphometry of the ST, OC, and ACP in the parasellar region is crucial to prevent possible iatrogenic complications that may occur during transsphenoidal surgery, which is the most widely used method for removing pituitary gland tumours, as well as endoscopic sinus surgery [1–5, 9, 10]. Moreover, there is a bony compartment in the middle of the SS, which is mostly not in the midline, and it may also be attached to the bony wall around these adjacent structures. This may result in injury to the relevant neurovascular structure during surgery, which could be detrimental to the patient’s health and well-being [4, 10].
Anterior clinoidectomy is carried out to allow sufficient surgical exposure of the paraclinoid region in the surgical treatment of conditions such as optic nerve decompression, cavernous sinus diseases and skull base tumours. Moreover, it is performed so that inappropriate retraction can be prevented and easier mobilisation of the intracranial internal carotid artery and optic nerve can be provided in surgeries for paraclinoid aneurysms [11, 12]. Previous studies have reported that the ACP must be evaluated preoperatively in order to estimate the extent of drilling required. The risk of injury to the internal carotid artery, optic nerve and oculomotor nerve, as well as the risk of rhinorrhoea following this procedure, is increased by the ACP pneumatization (ACPP) and the presence of variations such as caroticoclinoid foramen (CCF) and interclinoid osseous bridge [12–14]. In addition, the extensive pneumatization of the SS and the presence of CCF make it difficult to visualize other variations, such as the accessory OC, which may cause serious complications if not recognized [14]. The optic strut (OS) connects the ACP to the body of the sphenoid bone. The categorization of intradural and extradural aneurysms depends on the position of this anatomical landmark, which is also removed during anterior clinoidectomy [15, 16]. Furthermore, one study found that the degree of ACPP affected the location of the OS [17]. Another study classified OS and reported that sulcal angle was larger in cases with presulcal OS [15].
These paraclinoid structures, ST and SS can be easily viewed thanks to the integration of computed tomography (CT) into surgical interventions. This allows for the evaluation of the association between anatomical variations in relation to sagittal and coronal SS pneumatization (SSSP and CSSP) patterns. To predict the size of the surgical window and choose the safest surgical approach, while preventing iatrogenic injury, a detailed CT analysis of this relationship is needed [15].
Considering all the information, there is no agreement on the impact of SSSP and CSSP on the morphology of the ACP, ST and CCF, and the position of OS. We therefore set out to evaluate the SSP patterns and the prevalence of OC, OS, CCF, and ST variants. We also attempted to determine the coexistence of these variables and the influence of age, laterality, and gender using three dimensional (3D) CT images. Avoidance of misinterpretation during surgical procedures in the anterior and middle cranial fossa is dependent on knowledge of the relationship between these structures. It is also vital to consider the impact of gender and age on this association.
Methods
Study design and inclusion criteria for patients
Ethics committee approval for this retrospective study was obtained by Necmettin Erbakan University’s Drug and Non-Medical Device Research Ethics Committees with the registration number 2020/2927. This study was carried out in compliance with the principles of the Helsinki Declaration, relevant Turkish legislation, and General Data Protection Law regulations on medical research. Due to the study’s use of retrospective and anonymized patient information obtained from electronic records, the Ethics Committee did not consider it necessary to obtain written informed consent from patients, and clinical trial numbers were not applicable. A minimum of 123 subjects was deemed sufficient for the study, given the statistical power of 80% and the alpha level set at 0.05, as determined by G power (version 3.1.9.2). The paranasal sinus CT images of 154 patients (78 males and 76 females; aged between 18 and 89 years) that were stored in the database of the Radiology Department of University between January 2019 and November 2020 were evaluated. The inclusion criteria were as follows: age ≥ 18 years, no history of surgical procedures or prior fracture of bony structures, no marked pathology, tumor, or maxillofacial deformity in this region, and the absence of any artifacts in CT images with complete visibility of the SS. All measurements were made by an experienced radiologist and anatomist. To assess intra-observer reliability, the same observer reevaluated the images after two-weeks interval. Each measurement was performed twice and the average value was calculated. The inter-observer reliability of the measurements was assessed (Cronbach’s α ranged from 0.750 to 0.907) and a statistical analysis was performed once reliability had been verified.
CT imaging and analysis
All CT images were obtained using Somatom Drive (Siemens Healthineers, Germany) 256 multislice CT scanner with the following study parameters; exposure 120 kV, 74 mA, 60 mAs; rotation time 0.28 s; slice thickness 0.625 mm. The consequent images were saved in DICOM format and were uploaded to a Snygo Via workstation (Siemens, Germany). Image parameters of sagittal, coronal and axial sections obtained using Multiplanar Reconstruction (MPR) and images converted to 3D format with VRT (volume rendering technique). All variations were detected and morphometric parameters were measured for each individual sinus in the subject’s half-sides (308 hemi-sinuses).
Morphometric measurements that were used for an identification of the optic canal, anterior clinoid process and sella turcica
ACPL and ACPWbase: The length and base width of the ACP where they were clearly visualized on axial image (Fig. 1A).
Fig. 1.
A Axial CT image shows the measurement of the width (a) and length (b) of the anterior clinoid process, the anterior (c) and posterior (d) diameters and the length (e) of the optic canal, B sagittal CT images show the length (red line), diameter (yellow line) and height (green line) of sella turcica, C the measurement of the sulcal angle (SA)
OCDant and OCDpost: The anterior and posterior transverse diameters of the OC (Fig. 1A),
OCL: The length between the anterior and posterior openings of the OC (Fig. 1A),
STL, STD and STH: The length, diameter, and height of the ST where they were clearly visualized on sagittal image (Fig. 1B).
SA: Sulcal angle formed by the intersection of the line extending posteriorly from the planum sphenoidale and the straight line connecting the limbus sphenoidale to the tuberculum sellae on sagittal image (Fig. 1C).
Classification of the morphological variations
SSSP patterns was classified into 4 types as follows;
Conchal type (C): SSP is minimal or absent (Fig. 2A).
Presellar type (PreS): The posterior wall of the SS is located in front of the anterior wall of the ST (Fig. 2B).
Sellar type (S): The posterior wall of the SS is located between the anterior and posterior walls of the ST (Fig. 2C).
Postsellar type (PostS): The posterior wall of the SS is located behind the posterior wall of the ST (Fig. 2D).
Fig. 2.
Sagittal CT images show types of sagittal sphenoid sinus pneumatization, A conchal, B presellar, C sellar, D postsellar
CSSP patterns was classified into 3 types as follows;
Prepterygoid: Pneumatization extending up to the medial edge of the VC (Fig. 3A),
Prerotundum: Pneumatization extending up to the medial edge of the FR (Fig. 3B),
Postrotundum: Pneumatization extending further than the lateral edge of the FR (Fig. 3B).
Fig. 3.
Coronal CT images show the coronal sphenoid sinus (CSSP) and anterior clinoid process pneumatization (ACPP) types A bilateral prepterygoid CSSP (white arrowheads), bilateral optic canal protrusion (stars), right anterior root ACPP (red thin arrow), left absent ACPP, B right prerotundum CSSP (blue thick arrow) and left postrotundum CSSP (red thick arrow), bilateral optic canal protrusion (stars), right optic strut ACPP (green thin arrow), left full ACPP (yellow thin arrow), FR foramen rotundum, VC vidian canal
OC protrusion (OCP) into the SS were noted as absent and present (Fig. 3B).
ACP pneumatization (ACPP) on coronal images were classified into four types as follows:
Absent: No pneumatization in the ACP (Fig. 3A).
ARP: Pneumatization extending through the anterior root of the ACP (Fig. 3A).
OSP: Pneumatization extending through the OS (Fig. 3B).
FULL: Full pneumatization in the ACP (Fig. 3B).
The attachment of the OS (OSA) to the sphenoid body was classified into three types as follows:
Presulcal: The OS is aligned with or anterior to the limbus sphenoidale (Fig. 4A).
Sulcal: The OS is attached to the anterior 2/3 of the prechiasmatic sulcus (Fig. 4B).
Postsulcal: The OS is attached to the posterior 2/3 of the prechiasmatic sulcus (Fig. 4C).
Fig. 4.
Axial 3D CT images show optic strut attacment (OSA) types, caroticoclinoid foramen (CCF) types, optic foramen (OF) shapes A bilateral presulcal OSA (red dotes), right absent CCF (red arrowhead) and left complete CCF (yellow arrowhead), B bilateral sulcal OSA (green dotes), bilateral absent CCF (blue arrowheads), C bilateral postsulcal OSA (blue dotes), right incomplete CCF (purple arrowhead) and left contact CCF (green arrowhead), D round OF (blue thick arrow), E oval OF (green thick arrow), F tear OF (red thick arrow),
The type of the CCF was classified into four types as follows:
Absent: Absence of the CCF (Fig. 4A).
Complete CCF: There is complete fusion between the ACP and middle clinoid process (Fig. 4A).
Incomplete CCF: There is a gap between the ACP and middle clinoid process (Fig. 4C).
Contact CCF: There is a suture between the ACP and middle clinoid process (Fig. 4C).
The shape of the optic foramen (OF) was noted as round, ovoid and tear (Fig. 4D-F). The ST figure (STF) was categorized into five types as; normal (N), oblique anterior wall (O), double contour of the ST floor (D), irregular posterior wall (I), and pyramidal shape of the dorsum sella (P) (Fig. 5).
Fig. 5.
Sagittal CT images show types of sella turcica figures, A normal, B oblique anterior wall, C irregular posterior wall, D pyramidal shape of the dorsum sella E double contour of the sella turcica floor
Statistical analysis
Statistical analysis of the study data was performed using SPSS (version 25.0 Inc., Chicago, IL, USA). The data obtained were expressed as mean ± standard deviation (SD) for numerical variables. The intraclass correlation coefficient (ICC) test was used to quantify intra- and inter-observer reliability. For categorical variables, descriptive statistics were given as frequency (%) distribution with respect to gender, age groups, and lateralization. Unpaired and paired t tests were used to compare the differences between genders and laterality, respectively. One way ANOVA was performed to determine any differences between the mean of the groups according to the variations of the OC, ACP, age groups, and the CSSP. Differences in variables were evaluated using Chi-square test. The data were considered statistically significant with p < 0.05.
Results
The detailed informations regarding the statistical analysis of the data based on gender was given in Table 1. The most common SSSP type was sellar (51.3%), followed by postsellar (38.3%), presellar (7.8%), and conchal (2.6%). Females had higher prevalence of postsellar SS than males, while other SSSP types were significantly more prevalent in males with a significant difference (p = 0.002, χ²=15.352). Conversely, there was no significant difference between genders in the CSSP, ACPP and CCF types. The prevalence of presulcal and postsulcal OS were higher in males than in females, while sulcal OS was more prevalent in females (p = 0.067, χ2 = 5.411). Moreover, the prevalence of the OCP was significantly higher in males than females (p = 0.010, χ²=6.627). Conversely, irregular ST was more prevalent in females, exhibiting a significant difference. All of morphometric parameters except ST dimensions were measured significantly higher in males than in females (Table 1).
Table 1.
Statistical analysis of variations and morphometric measurements according to sex
| Female (n = 76) | Male (n = 78) | p value | ||
|---|---|---|---|---|
| SSSP | Conchal | 0 (0.0%) | 4 (5.1%) |
p = 0.002* χ2 = 15.352 |
| Presellar | 4 (5.3%) | 8 (10.3%) | ||
| Sellar | 37 (48.7%) | 42 (53.8%) | ||
| Postsellar | 35 (46.1%) | 24 (30.8%) | ||
| CSSP | Prepterygoid | 12 (7.9%) | 20 (12.8%) |
p = 0.238 χ2 = 2.871 |
| Prerotundum | 98 (64.5%) | 102 (65.4%) | ||
| Postrotundum | 42 (27.6%) | 34 (21.8%) | ||
| OCP | Absent | 98 (64.5%) | 80 (51.3%) |
p = 0.010* χ2 = 6.627 |
| Present | 54 (35.5%) | 76 (48.7%) | ||
| ACPP | Absent | 112 (73.7%) | 120 (76.9%) |
p = 0.428 χ2 = 2.771 |
| Optic strut | 20 (13.1%) | 12 (7.7%) | ||
| Anterior root | 12 (7.9%) | 10 (6.4%) | ||
| Full | 8 (5.3%) | 14 (9%) | ||
| OSA | Presulcal | 6 (4%) | 16 (10.2%) |
p = 0.067 χ2 = 5.411 |
| Sulcal | 97 (61.8%) | 82 (52.6%) | ||
| Postsulcal | 52 (34.2%) | 58 (37.2%) | ||
| CCF | Absent | 118 (77.6%) | 134 (85.9%) |
p = 0.151 χ2 = 5.308 |
| Complete | 12 (8%) | 12 (7.7%) | ||
| Incomplete | 8 (5.2%) | 4 (2.6%) | ||
| Contact | 14 (9.2) | 6 (3.8%) | ||
| STF | Normal | 36 (47.4%) | 46 (59%) |
p = 0.039* χ2 = 10.090 |
| Oblique anterior wall | 1 (1.3%) | 4 (5.1%) | ||
| Double contour of the floor | 1 (1.3%) | 1 (1.3%) | ||
| Irregular posterior wall | 35 (46.3%) | 24 (30.8%) | ||
| Pyramidal dorsum sellae | 3 (3.9) | 3 (3.8%) |
| Morphometric measurements | Female (n = 76) | Male (n = 78) | p value | |
|---|---|---|---|---|
| Anterior diameter of optic canal (mm) | 3.8 ± 0.7 | 4.2 ± 0.7 | 0.000* | |
| Posterior diameter of optic canal (mm) | 4.9 ± 0.9 | 5.5 ± 1 | 0.000* | |
| Optic canal length (mm) | 8 ± 1.5 | 8.5 ± 1.7 | 0.003* | |
| Anterior clinoid process length (mm) | 14.3 ± 2.5 | 13.5 ± 2.4 | 0.004* | |
| Anterior clinoid process base width (mm) | 5.7 ± 1.3 | 6.1 ± 1.6 | 0.012* | |
| Sella turcica length (mm) | 10.1 ± 1.6 | 10.4 ± 1.8 | 0.109 | |
| Sella turcica diameter (mm) | 12.6 ± 1.8 | 12.9 ± 1.8 | 0.903 | |
| Sella turcica height (mm) | 8.1 ± 1.4 | 8.3 ± 1.3 | 0.331 | |
| Sulcal angle (mm) | 28.5 ± 11.7 | 32.0 ± 12.9 | 0.013* | |
* Statistically significant p value < 0.05, χ2 Pearson chi-square test result, Student t-test result, SSSP sagittal sphenoid sinus pneumatization types, CSSP coronal sphenoid sinus pneumatization types, OCP optic canal protrusion into the sphenois sinus, ACPP anterior clinoid process pneumatization types, OSA optic strut attachment types, CCF caroticoclinoid foramen types, STF sella turcica figure types
The distribution of morphological data according to laterality is given in Table 2. The most common CSSP type was prerotundum (64.9%), while sulcal OS and round OF were found to be the most prevalent. With regard to laterality, all variants except ACPP and CCF were more likely to be bilateral (p < 0.05). Additionally, there was no significant difference between the mean value of morphometric parameters according to laterality.
Table 2.
Distribution of the study sample variants according to the laterality
| Right n (%) |
Left n (%) |
Bilateral n (%) |
Total n (%) |
||
|---|---|---|---|---|---|
| CSSP | Prepterygoid | 2 (10.5%) | 4 (21.1%) | 13 (68,4%) | 19 (9.8%) |
| Prerotundum | 28 (23.1%) | 14 (11.6%) | 79 (65.3%) | 121 (62.4%) | |
| Postrotundum | 14 (25.9%) | 18 (33.3%) | 22 (40.7%) | 54 (27.8%) | |
| OCP | Absent | 16 (15.8%) | 8 (7.9%) | 77 (76.2%) | 101 (54.1%) |
| Present | 14 (16.3%) | 28 (32.6%) | 44 (51.2%) | 86 (45.9%) | |
| ACPP | Absent | 20 (15%) | 14 (10.5%) | 99 (74.4%) | 133 (65.8%) |
| Optic strut | 10 (35.7%) | 14 (50%) | 4 (14.3%) | 28 (13.9%) | |
| Anterior root | 12 (54.5%) | 10 (45.5%) | 0 (0%) | 22 (10.9%) | |
| Full | 6 (31.6%) | 10 (52.6%) | 3 (15.8%) | 19 (9.4%) | |
| OSA | Presulcal | 0 (0%) | 0 (0%) | 11 (100%) | 11 (6.9%) |
| Sulcal | 2 (2.2%) | 3 (3.3%) | 87 (94.6%) | 92 (57.5%) | |
| Postsulcal | 2 (3.5%) | 2 (3.5%) | 53 (93%) | 57 (35.6%) | |
| CCF | Absent | 4 (2.9%) | 24 (17.1%) | 112 (80%) | 140 (74.1%) |
| Complete | 12 (60%) | 4 (20%) | 4 (20%) | 20 (10.6%) | |
| Incomplete | 5 (50%) | 3 (30%) | 2 (20%) | 10 (5.3%) | |
| Contact | 12 (63.2%) | 6 (31.6%) | 1 (5.3%) | 19 (10%) | |
| OF | Round | 4 (3.8%) | 0 (0%) | 100 (96.2%) | 104 (65.8%) |
| Ovoid | 0 (0%) | 2 (5%) | 38 (95%) | 40 (25.3%) | |
| Tears | 0 (0%) | 2 (14.3%) | 12 (85.7%) | 14 (8.9%) |
CSSP coronal sphenoid sinus pneumatization types, OCP optic canal protrusion into the sphenois sinus, ACPP anterior clinoid process pneumatization types, OSA optic strut attachment types, CCF caroticoclinoid foramen types, OF optic foramen
Assessment of the sample variants based on sagittal/coronal sphenoid sinus pneumatization and anterior clinoid process pneumatization types
The detailed information regarding the statistical analysis of the association between sample variants was shown in Table 3; Figs. 6 and 7. A comparison of the frequency of CSSP types within SSSP types revealed that prepterygoid type was not found in postsellar type, while prerotundum and postrotundum were more prevalent in sellar and postsellar types, respectively (p < 0.05). The ACPP, OCP, irregular ST, and CCF types were mostly observed in sellar and postsellar types with a significant difference, while OSA and OF types did not show a significant difference between SSSP types (Fig. 6). Regarding CSSP types, the presence of ACPP, OCP, and irregular ST was more prevalent in prerotundum and postrotundum types, while other variants did not show a significant difference (Fig. 7). As seen in Table 3; Fig. 7, ACPP was accompanied by significant coexistence with OCP (p = 0.000), sulcal and postsulcal OS (p = 0.040), but not CCF types (p = 0.619).
Table 3.
The relationship between sagittal sphenoid sinus pneumatization, coronal sphenoid sinus pneumatization, anterior clinoid process pneumatization types and sample variants
| Relationship | p | df | CC |
|---|---|---|---|
| CSSP and SSSP types | 0.000* | 6 | 0.540 |
| ACPP and SSSP types | 0.000* | 9 | 0.344 |
| OCP and SSSP types | 0.048* | 3 | 0.201 |
| OSA and SSSP types | 0.063 | 6 | 0.193 |
| CCF and SSSP types | 0.041* | 9 | 0.205 |
| SF and SSSP types | 0.001* | 12 | 0.311 |
| OF and SSSP types | 0.335 | 6 | 0.147 |
| ACPP and CSSP types | 0.000* | 6 | 0.408 |
| OCP and CSSP types | 0.000* | 2 | 0.289 |
| OSA and CSSP types | 0.827 | 4 | 0.070 |
| CCF and CSSP types | 0.904 | 6 | 0.083 |
| SF and CSSP types | 0.016* | 8 | 0.240 |
| OF and CSSP types | 0.127 | 4 | 0.151 |
| OCP and ACPP types | 0.000* | 12 | 0.545 |
| OSA and ACPP types | 0.040* | 6 | 0.203 |
| CCF and ACPP types | 0.619 | 9 | 0.151 |
* Statistically significant p value < 0.05, χ2 Pearson chi-square test result, SSSP sagittal sphenoid sinus pneumatization, CSSP coronal sphenoid sinus pneumatization, ACPP anterior clinoid process pneumatization, OCP optic canal protrusion into the sphenois sinus, OSA optic strut attachment, CCF caroticoclinoid foramen, SF sphenoid sinus figure, OF optic foramen
Fig. 6.
Bar diagram shows the relationship of sagittal sphenoid sinus pneumatization (SSSP) with coronal sphenoid sinus pneumatization (CSSP), anterior clinoid process pneumatization (ACPP), optic canal protrusion (OCP) and caroticoclinoid foramen (CCF)
Fig. 7.
Bar diagram shows the relationship of coronal sphenoid sinus pneumatization (CSSP) with anterior clinoid process pneumatization (ACPP), optic canal protrusion (OCP) and the relationship of ACPP with OCP, optic strut attachment (OSA) and caroticoclinoid foramen (CCF)
The influence of sagittal/coronal sphenoid sinus pneumatization and anterior clinoid process pneumatization on morphometric data
As the degree of SSSP increased, the mean value of all measurements, except for ACPWbase, decreased significantly, as shown in Table 4. Increases in CSSP from prepterygoid to postrotundum types were accompanied by a decrease in the mean OCDpost, STL, STD and STH values, while the mean ACPL increased significantly (p < 0.05). A decrease in the mean OCDant, OCDpost and STH values was observed, while an increase in the mean OCL and ACPL values was observed with an increase in the degree of ACPP (Table 4). Furthermore, no significant difference in the mean value of SA was found between OSA types or between ACPP types.
Table 4.
Relationship of the morphometric data with sagittal and coronal sphenoid sinus and anterior clinoid process pneumatization types
| OCDant (mm) Mean ± SD |
OCDpost (mm) Mean ± SD |
OCL (mm) Mean ± SD |
ACPL (mm) Mean ± SD |
ACPWbase (mm) Mean ± SD |
STL (mm) Mean ± SD |
STD (mm) Mean ± SD |
STH (mm) Mean ± SD |
SA (o) Mean ± SD |
||
|---|---|---|---|---|---|---|---|---|---|---|
| SSSP | Conchal | 4.3 ± 0.7 | 6.1 ± 0.7 | 9 ± 1.3 | 14 ± 1.5 | 5.2 ± 0.8 | 11.7 ± 1.8 | 13.2 ± 3.3 | 9.6 ± 1.4 | 39.75 ± 5.63 |
| Presellar | 4.5 ± 0.7 | 5.8 ± 0.9 | 8.5 ± 1.8 | 14.7 ± 1.6 | 5.9 ± 1.4 | 10.5 ± 2.7 | 13.1 ± 2.8 | 8.6 ± 1.5 | 31.39 ± 13.82 | |
| Sellar | 4.1 ± 0.7 | 5.3 ± 1 | 8.2 ± 1.5 | 13.5 ± 2.2 | 5.8 ± 1.6 | 10.4 ± 1.4 | 13.1 ± 1.6 | 8.5 ± 1.3 | 29.69 ± 10.88 | |
| Postsellar | 3.8 ± 0.7 | 4.9 ± 0.9 | 7.5 ± 1.3 | 12.7 ± 2.6 | 6 ± 1.3 | 9.8 ± 1.7 | 12.2 ± 1.7 | 7.7 ± 1.3 | 22.42 ± 7.11 | |
| p value | *0.000 | *0.000 | *0.024 | *0.000 | 0.412 | *0.002 | *0.001 | *0.000 | *0.001 | |
| CSSP | Prepterygoid | 4.2 ± 0.7 | 5.6 ± 0.9 | 8.1 ± 1.3 | 13.1 ± 2.1 | 5.6 ± 1.4 | 11 ± 22.5 | 13.5 ± 2.8 | 8.9 ± 1.5 | 30.61 ± 12.46 |
| Prerotundum | 4 ± 0.7 | 5.3 ± 1 | 8.3 ± 1.7 | 13.8 ± 2.5 | 5.9 ± 1.4 | 10.3 ± 1.4 | 12.8 ± 1.6 | 8.3 ± 1.3 | 29.83 ± 12.35 | |
| Postrotundum | 3.9 ± 0.8 | 4.8 ± 0.9 | 8.4 ± 1.8 | 14.4 ± 2.4 | 6.1 ± 1.6 | 9.8 ± 1.8 | 12.3 ± 1.8 | 7.8 ± 1.5 | 29.05 ± 12.98 | |
| p value | 0.097 | *0.000 | 0.695 | *0.028 | 0.215 | *0.002 | *0.007 | *0.001 | 0.760 | |
| ACPP | Absent | 4.1 ± 0.7 | 5.4 ± 0.9 | 8 ± 1.5 | 13.6 ± 2.4 | 5.9 ± 1.4 | 10.3 ± 1.8 | 12.8 ± 1.9 | 8.4 ± 1.3 | 29.91 ± 12.89 |
| Optic strut | 4 ± 0.6 | 4.9 ± 0.9 | 8.5 ± 1.9 | 14.6 ± 2.3 | 5.8 ± 1 | 10.2 ± 1.3 | 12.7 ± 1.4 | 8.0 ± 1.6 | 33.29 ± 11.21 | |
| Anterior root | 3.7 ± 0.8 | 4.9 ± 1 | 9.3 ± 1.5 | 14.9 ± 2.5 | 5.7 ± 1.8 | 10.1 ± 1.7 | 12.4 ± 2 | 7.5 ± 1.1 | 29.55 ± 12.08 | |
| Full | 3.8 ± 0.6 | 4.5 ± 0.8 | 9.4 ± 2 | 15.1 ± 3 | 6.4 ± 2.1 | 10.1 ± 1.6 | 12.3 ± 2.1 | 7.7 ± 1.6 | 30.39 ± 9.87 | |
| p value | *0.041 | *0.000 | *0.000 | *0.002 | 0.353 | 0.921 | 0.561 | *0.001 | 0.555 |
* Statistically significant p value < 0.05, ANOVA test results, OCDant anterior diameter of the optic canal, OCDpost posterior diameter of the optic canal, OCL length of the optic canal, ACPL length of the anterior clinoid process, ACPWbase base width of the anterior clinoid process, STL length of sella turcica, STD diamater of the sella turcica, STH height of sella turcica, SA sulcal angle, SSSP sagittal sphenoid sinus pneumatization types, CSSP coronal sphenoid sinus pneumatization types, ACPP anterior clinoid process pneumatization types
Age distribution
The mean age of the sample, which was divided into three age groups, was 41.82 ± 14.52 (40.09 ± 15.33 for females, 43.51 ± 13.59 for males). There are 54 patients in Group I (aged 18–34), 48 in Group II (aged 35–49) and 52 in Group III (aged 50–89). As Table 5 shows, the degree of SSSP, CSSP and ACPP decreased significantly with increasing age, and in a similar way, the likelihood of the presence of OCP and irregular ST decreased with no significant difference. With regard to morphometric data, the OCDant, OCDpost, STL, and STD values were lowest in Group I (p = 0.000). Meanwhile, the OCL and ACPL values decreased significantly with increasing age (p < 0.05).
Table 5.
Statistical analysis of variations and morphometric measurements according to age groups
| Morphological Data | Group I (18–34 years) |
Group II (35–49 years) |
Group III (50–89 years) |
p | |
|---|---|---|---|---|---|
| SSSP | Conchal | 1 (1.9%) | 1(2.1%) | 2 (3.8%) |
p = 0.029* χ2 = 11.127 |
| Presellar | 1 (1.9%) | 3 (6.3%) | 8 (15.4%) | ||
| Sellar | 21 (38.9%) | 30 (62.5%) | 28 (53.9%) | ||
| Postsellar | 31 (57.4%) | 14 (29.2%) | 14 (26.9%) | ||
| CSSP | Prepterygoid | 5 (4.6%) | 12 (11.5%) | 15 (15.6%) |
p = 0.000* χ2 = 14.854 |
| Prerotundum | 59 (54.6%) | 64 (66.7%) | 77 (74.0%) | ||
| Postrotundum | 44 (40.7%) | 17 (17.7%) | 15 (14.4%) | ||
| ACPP | Absent | 73 (67.6%) | 72 (75.0%) | 87 (83.7%) |
p = 0.036* χ2 = 9.773 |
| Optic strut | 14 (13.0%) | 10 (10.4%) | 7 (6.7%) | ||
| Anterior root | 10 (9.3%) | 7 (7.3%) | 5 (4.8%) | ||
| Full | 11 (10.2%) | 7 (7.3%) | 5 (4.8%) | ||
| OCP | Absent | 60 (55.6%) | 56 (58.3%) | 62 (59.6%) |
p = 0.831 χ2 = 1.825 |
| Present | 48 (44.4%) | 40 (41.7%) | 42 (40.4%) | ||
| OSA | Presulcal | 4 (3.7%) | 10 (10.4%) | 8 (7.7%) |
p = 0.435 χ2 = 4.106 |
| Sulcal | 68 (63.0%) | 54 (56.3%) | 53 (51.0%) | ||
| Postsulcal | 36 (33.3%) | 32 (33.3%) | 43 (41.3%) | ||
| CCF | Absent | 91 (84.3%) | 78 (81.3%) | 83 (79.8%) |
p = 0.810 χ2 = 2.057 |
| Complete | 7 (6.5%) | 7 (7.3%) | 8 (7.7%) | ||
| Incomplete | 3 (2.8%) | 4 (4.2%) | 7 (6.7%) | ||
| Contact | 7 (6.5%) | 7 (7.3%) | 6 (5.8%) | ||
| STF | Normal | 22 (40.7%) | 30 (62.5%) | 30 (57.7%) |
p = 0.002* χ2 = 13.697 |
| Oblique ant wall | 2 (3.7%) | 0 (0.0%) | 3 (5.8%) | ||
| Double contour | 1 (1.9%) | 0 (0.0%) | 1 (1.9%) | ||
| Irregular post wall | 25 (46.3%) | 18 (37.5%) | 16 (30.8%) | ||
| Normal | 4 (7.4%) | 0 (0.0%) | 2 (3.8%) | ||
| OF | Round | 67 (62.0%) | 61 (63.5%) | 76 (73.1%) |
p = 0.189 χ2 = 5.289 |
| Ovoid | 33 (30.6%) | 24 (25.0%) | 22 (21.2%) | ||
| Tears | 8 (7.4%) | 11 (11.5%) | 6 (5.8%) | ||
| Morphometric measurements | Group I | Group II | Group III | ||
| Anterior diameter of optic canal (mm) | 3.8 ± 0.6 | 4.2 ± 0.7 | 4.2 ± 0.8 | 0.000* | |
| Posterior diameter of optic canal (mm) | 4.9 ± 0.9 | 5.4 ± 1 | 5.4 ± 1 | 0.000* | |
| Optic canal length (mm) | 8.5 ± 1.7 | 8.3 ± 1.6 | 8.0 ± 1.6 | 0.042* | |
| Anterior clinoid process length (mm) | 14.7 ± 2.3 | 13.6 ± 2.3 | 13.3 ± 2.6 | 0.000* | |
| Anterior clinoid process base width (mm) | 5.9 ± 1.5 | 5.8 ± 1.4 | 5.9 ± 1.6 | 0.611 | |
| Sella turcica length (mm) | 9.7 ± 1.8 | 10.5 ± 1.6 | 10.6 ± 1.6 | 0.000* | |
| Sella turcica diameter (mm) | 12.1 ± 1.8 | 13.1 ± 1.7 | 12.8 ± 1.9 | 0.000* | |
| Sella turcica height (mm) | 8.1 ± 1.4 | 8.4 ± 1.2 | 8.2 ± 1.4 | 0.247 | |
| Sulcal angle (mm) | 29.98 ± 11.69 | 31.98 ± 14.53 | 28.96 ± 11.02 | 0.221 | |
* Statistically significant p value < 0.05, χ2 Pearson chi-square test result, SSSP sagittal sphenoid sinus pneumatization, CSSP coronal sphenoid sinus pneumatization, ACPP anterior clinoid process pneumatization, OCP optic canal protrusion into the sphenois sinus, OSA optic strut attachment, CCF caroticoclinoid foramen, SF sphenoid sinus figure, OF optic foramen
Discussion
The dimensions and degree of pneumatization of the sellar region and its surrounding structures can vary greatly. This complex anatomy makes surgical procedures in the region challenging. Previous studies have mentioned many factors affecting ST morphometry and morphology, including pneumatization, gender, age, laterality and surgical interventions. A review of the literature revealed a lack of publications addressing the association between ST morphology, SSP, OCP, ACPP, OSA and CCF from an overall perspective and in a comprehensive manner. The dimensions and morphological features of these structures could be influenced by each other because of their close proximity [17–19]. Our study revealed that subjects with postsellar SSSP and postrotundum CSSP exhibited a significantly higher prevalence of ACPP, which was largely comprised of OCP. Conversely, subjects with conchal and presellar SSSP were less likely to have ACPP or OCP, as these were linked to prepterygoid CSSP. Furthermore, we found that a higher degree of SSSP and CSSP was associated with smaller ST dimensions and OC diameters.
Although previous studies employed different methods, they reported that an imbalance in craniofacial growth and development can result in different pneumatization patterns of the SS and variable positions of adjacent neurovascular structures. This imbalance can be caused by impaired paranasal ventilation or alterations in the direction of facial growth. The SS’s sagittal and coronal extensive pneumatization can result in protrusion of these structures, potentially injuring neurovascular structures during surgery. This could be harmful to the patient’s health and well-being [4–10]. In terms of SSSP, the most commonly observed type was sellar (51.3%), followed by postsellar (38.3%), presellar (7.8%) and conchal (2.6%) in this study. These results are similar to those of some studies that reported the prevalence of sellar as the most common type, ranging between 39.4% and 77.3 [4, 7, 9, 10, 18]. However, they are not consistent with the study that found the postsellar type to be the most common, with a frequency of 67.5% [8]. Furthermore, we noticed that postsellar SSSP was more frequently seen in females (p = 0.002). Conversely, the lowest prevalence of postsellar types was observed in older patients (p = 0.049). A significant decrease in the values of all morphometric parameters except ACPWbase was observed as the degree of SSP increased (p < 0.05).
Asal et al. categorized CSSP into three types as prepterygoid, prerotundum, and postrotundum [6]. The most prevalent type we observed was the prerotundum (64.9%), followed by the postrotundum (24.7%) and the prepterygoid (10.4%) types. This contrasts with the results of the study by Asal et al. [6], which found the postrotundum to be the most common. Although there were no significant gender differences between the CSSP types, the frequencies of the prepterygoid and prerotundum types were higher among older subjects (p = 0.000). As with the CSSP, the ST dimensions and OC diameters decreased, while the ACPL increased significantly as the degree of pneumatization increased (p < 0.05). Furthermore, our findings demonstrated a notable association between SSSP and CSSP. Specifically, prerotundum was found to be more prevalent in sellar types, while postrotundum was observed in equal numbers in sellar and postsellar types (p = 0.000).
The degree of the ACPP or communication with the SS increases the risk of rhinorrhoea following anterior clinoidectomy. The presence of CCF can make it difficult to visualize adjacent structure variations during surgery. So, having both ACPP and CCF increases the likelihood of injury to the internal carotid artery, optic nerve, and oculomotor nerve [11–14]. Asal et al. found that ACPP was present in 47.2% of males and 39.7% of females. They also found that bilateral pneumatization was present in 25.7% of males and 22.7% of females [6]. On the other hand, Suprasanna and Kumar reported that full pneumatization was never observed, and no significant gender differences were found in the presence of ACPP [12]. In our study, we classified the ACPP into four types absent, OSP, ARP, and Full. Although no significant gender differences were found, the prevalence of all types of ACPP was found to be lowest in the elderly group. Furthermore, a significant relationship was found between ACPP, SSSP, CSSP, and OCP. ACPP prevalence was 2.6% in the presellar type, 34.2% in the sellar type, and 63.2% in the postsellar type. Similarly, ACPP mostly coexisted with postrotundum (52.6%), followed by prerotundum (43.4%). Notably, 47% of OCPs coexisted with ACPP, demonstrating a significant difference (p < 0.05). Suprasanna et al. measured the ACPWbase and ACPL and found no gender differences [13]. By contrast, the results of earlier researches suggested that males had a wider ACPWbase and a smaller ACPL compared to females [11, 19]. In line with these findings, we found that the mean ACPWbase value was higher in males, while the ACPL was longer in females, showing a significant gender difference. Additionally, there was also a significant decrease in mean ACPL with increasing age. Sabancioglu et al. found that cases of elevated ACPP exhibited a higher ACPWbase, with ACPP being more prevalent in males [11]. Conversely, we found no significant difference in mean ACPWbase between ACPP types. It was shown by our findings that as the degree of ACPP increased, the OC diameters and STH decreased, while the OC and ACP lengths increased.
Previous studies reported that the position of the OS is vital for categorizing intradural and extradural internal carotid artery aneurysms. It is used as a surgical landmark and removed during transsphenoidal approach, anterior clinoidectomy, and optic nerve decompression [13, 15–17, 19]. Suprasanna et al. classified the OSA types into three groups as sulcal, presulcal, and postsulcal according to the attachment site of OS to the sphenoid bone. Their results revealed that the sulcal type was the most common, and that SSP was more severe in cases of presulcal OS [13]. Our study revealed that sulcal OS was more prevalent in females, while presulcal and postsulcal OS were more common in males with no significant difference. Furthermore, there was no significant difference according to age groups, SSSP and CSSP types in terms of the prevalence of OSA types. However, our results revealed that an increased degree of ACPP was mostly associated with an increased prevalence of sulcal and postsulcal OSA. In contrast, the presulcal type was exclusively associated with ACP without pneumatization. Kanellopoulou et al. detected 8.3% presulcal, 40% sulcal, and 51.7% postsulcal in their study sample. They also found that the presulcal OS had a significantly greater SA than the sulcal and postsulcal types [15]. Adanır et al. stated that ACPP influences the location of the OS but has no impact on SA. They also found that the SA was larger in males than in females [17]. Consistent with this study, we found that males exhibited larger SA, demonstrating a significant gender difference (p = 0.013). Additionally, the mean SA value decreased significantly as the degree of SSSP increased (p = 0.001). On the other hand, we did not demonstrate a significant difference in the mean SA value for the different ACPP and OSA types and age groups.
As reported by many publications, the prevalence of OCP increases when the degree of SSP increases. Asal et al. [6] reported that the OC protrusion/dehiscence was significantly higher in males than in females. Conversely, A study by Tursun et al. [20] revealed that OC protrusion/dehiscence was found to be significantly more prevalent in females than in males when CT images of 86 children were analysed. Fadda et al. [10] classified OC into three types: normal, protruded, and dehiscent, which had a prevalence of 83.5%, 13%, and 15%, respectively. Açar et al. [9] reported a significant increase in the prevalence of the OCP, particularly in postsellar and Type 5 CSSP. In this study, it was found that postsellar SSSP and postrotundum CSSP were a significant predictive variables for the presence of ACPP followed by OCP. Furthermore, OCP was more likely to be bilateral (p = 0.000), as were the CSSP and OSA types. The OCP was also more prevalent in males, with a significant difference (p = 0.010), while no significant difference was found between age groups. The diameters of the OC at the level of the anterior, middle and posterior apertures of the orbit were measured by Radunovic et al. [21]. A study of CT images of 335 subjects found that the mean length and diameter of the OC were 5.67 mm and 3.33 mm, respectively [22, 23]. Another study found that the OCDant was significantly larger in males than in females (p = 0.001) and increased with increasing age (p = 0.00) [6]. Sthapak et al.‘s study revealed that males had higher mean OCDpost, OCDant and OCL values than females, but there was no statistically significant difference according to laterality [24]. All morphometric parameters of the OC and ACP dimensions were found to be higher in males than females, except for ACPL, which was higher in females. Furthermore, our study determined that mean OCDant and OCDpost values increased substantially with advancing age, while OCL values declined. Conversely, an increase in the degree of SSSP, CSSP and ACPP was associated with a decrease in the mean OCDant and OCDpost values. The mean OCL and ACPL values decreased as the degree of SSSP increased, while the degree of ACPP caused a significant increase in OCL and ACPL.
Gibelli et al. [25] divided the population into three age groups and examined the frequency of CCF. They found the CCF rate to be 8.7% (26/300), with bilateral CCF detected in 92.3% (24/26) of these cases. No statistically significant relationship was found between gender and CCF, but CCF was found to be more prevalent in cases with ST bridge than those without. In a study conducted on CT images of 54 paraclinoid aneurysms, CCF types were divided into three groups as complete, incomplete and contact. This study observed no gender differences in the presence of CCF, but found it most common in clinoid aneurysms [12]. In a further classification study, complete CCF was detected in 10 cases; incomplete CCF in 24 cases; and contact CCF in 8 cases [13]. In another study, no significant difference was observed between the distribution of CCF for both sides and age or gender [19]. Similar to this study, no significant difference was found between the prevalence of CCF types in relation to gender, laterality, and age groups. However, we found a statistically significant difference between CCF and SSSP types, with all types of CCF most prevalent in the postsellar followed by the sellar type (p = 0.041). Our results underscore the importance of preoperative CT in recognising the impact of SSP, gender and age on the morphology of paraclinoid structures, which helps to identify the safest surgical route and avoid complications.
Yasa et al. found no statistically significant difference in terms of gender, but they observed that all dimensions of the ST increased significantly with age [2]. Gargi et al. [26] found no significant relationship between ageing and ST dimensions, but found that STH was significantly greater in males than in females. Another study found a substantial size difference between males and females, with STD proving notably larger in females [27]. The study by Al-Mohana et al. [1] revealed higher STL in males and higher STH in female patients with a significant difference. Another study revealed the STL was smaller in females than males, and the STD was significantly larger in older subjects [3]. This study revealed no significant gender difference between the ST dimension parameters, while the mean value of the STL and STD exhibited notable increases with age. On the other hand, a significant decrease in all ST dimension parameters was observed when the degrees of both SSSP and CSSP increased. Additionally, ACPP had no influence on ST dimensions except for STH, which decreased significantly. Gargi et al. [26] examined the ST shape in CT images of 100 individuals, detecting normal ST in 69% of cases, followed by oblique anterior wall (14%), double-contoured base (9%), pyramidal shape (4%), and irregular ST (4%). Another study found that irregularity in dorsum sellae (p = 0.037) and pyramidal dorsum sellae (p = 0.022) were significantly more prevalent in females than in males [28]. Al-Mohana et al. [1], found no significant relationship between gender, skeletal malocclusion, age groups, and ST shape. In our study, the ST bridge was not detected. The most common STF was found to be irregular posterior wall ST, which was more prevalent in females, while its prevalence decreased with increasing age. Furthermore, we did not observe a significant difference in STF distribution between SSSP, CSSP and ACPP types.
Our approach differs from that of previous studies in that we analyse the statistical interaction between paraclinoid structures, including the SSSP, CSSP, ACPP, OCP, OSA, CCF and STF, in relation to their impact on the SA, ST, OC and ACP dimensions. Therefore, we could not find any studies with which to compare all our results. Our findings suggest that the greater the degree of pneumatization—particularly in sellar and postsellar SSSP, as well as in prerotundum and postrotundum CSSP—the greater the probability of ACPP and OCP, while the CCF types were more prevalent in sellar and postsellar SSSP. However, the ACPP was found to be significantly associated with the presence of OCP, as well as sulcal and postsulcal OS. The presence of demographic factors, such as gender and age, can offer valuable insights to inform the planning of personalised surgeries. The results showed that the prevalence of postsellar SSSP was higher in females, but this prevalence decreased significantly with age. Furthermore, the OCP was also more prevalent among males, though no significant difference was found between age groups. From a clinical standpoint, it is advisable to carefully evaluate patients, especially those with postsellar SSSP and postrotundum CSSP, for an increased risk of ACPP, OCP and CCF. A high level of doubt regarding decreased ST dimensions and OC diameters might be sustained for these patients. For elderly patients, who are mostly linked with the lowest prevalence of ACPP types, as well as postsellar and postrotundum types, increased ST dimensions and OC diameters can be considered. Previous studies reported that the prevalence of the ACPP and CCF in the cases of paraclinoid aneurysms were notable. During anterior clinoidectomy, the mobilisation or retraction of the internal carotid artery is restricted by the CCF. Furthermore, the removal of the ACPP would lead to mucosal tears, which would subsequently result in rhinorrhea [12, 13, 19]. We found that an increased ACPP was mostly associated with a greater prevalence of sulcal and postsulcal OS. Our results suggest that an increase in the degree of ACPP, where the OC diameters decreased while the lengths of the OC and ACP increased, may further exacerbate intra- and post-operative complications. It is particularly important to pay attention to the association between the ACPP, SSSP, and paraclinoid region morphometry.
The current study has certain limitations. First, causal inference is limited by its retrospective design, and longitudinal changes in paraclinoid structures cannot be evaluated. Second, the data were obtained from a single center with a moderate sample size of healthy adults, which was restricted to a specific racial group. This limits the data’s generalizability and external validity across different ethnic or geographic cohorts. Moreover, given the absence of clinical or surgical data, additional multicenter, prospective cohort studies comparing unhealthy and control groups across a wide age range are needed to validate these findings and make them more representative of diverse populations.
Conclusion
Our results suggest that the morphology and dimensions of paraclinoid structures can be predicted based on SSSP, CSSP and ACPP types, in relation to gender and age, within the studied population, using 3D CT technology. A high level of doubt regarding both ACPP and OCP might be sustained for younger females who mainly display postsellar SSSP and postrotundum CSSP. Conversely, larger OC diameters and ST dimensions may be presumed for prepterygoid and prerotundum CSSP, which is linked mostly with presellar SSSP in older patients. Additionally, we observed CCF types predominantly in sellar and postsellar SSSP, whereas sulcal and postsulcal OSA were more prevalent in ACPP. It is suggested by our findings that a longer OC and ACP may be the result of ACPP. These findings emphasise the complex nature of the SS and paraclinoid morphology and underscore the significance of incorporating functional variables such as SSSP, CSSP, ACPP, CCF, and OCP into individualised surgical treatment planning, along with their impact on the dimensions of the ST and OC. In the paraclinoid region, improvements in treatment outcomes with minimal risk of iatrogenic complications in clinical practice may be achieved by taking into account age-related and sex-specific changes in the SS and ACP pneumatization patterns. A comprehensive understanding of the impact of SSP on paraclinoid structures, and the manner in which these alterations vary based on factors such as age and sex, can help surgeons ensure the safety of surgical procedures.
Acknowledgements
None.
Author contributions
F.İ, G.A, A.S.G: Methodology, Software; F.İ, A.S.G, D.A: Visualization, Investigation; F.İ, A.E.Ç, D.A: Data curation, Original draft preparation; F.İ, G.A, A.E.Ç: Validation, Supervision; F.İ, A.S.G, G.A: Figures and Tables preparation; F.İ, G.A, A.S.G, A.E.Ç, D.A: Writing-Reviewing and Editing.
Funding
No funding was obtained from any funding agency in the public and commercials.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article and also from the corresponding author.
Declarations
Ethical approval
This retrospective study was approved by the Research Ethics Committee of Necmettin Erbakan University Faculty of Medicine (approval number 2020/2927). The study was conducted in accordance with the “Declaration of Helsinki”.
Consent to participate
The need for informed consent was waived by the Research Ethics Committee due to the study’s use of retrospective and anonymized patient information obtained from electronic records.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article and also from the corresponding author.