Idiopathic intracranial hypertension (IIH) is a neurological disorder characterized by elevated intracranial pressure (ICP) without a discernible structural cause. Historically referred to as pseudotumor cerebri, IIH primarily affects young women with obesity, reflecting its close association with metabolic and hormonal imbalances. Clinical manifestations include headaches, visual disturbances, and papilledema, which, if untreated, can lead to irreversible vision loss.Pathophysiological insights reveal a complex interplay of venous hypertension, glymphatic dysfunction, cerebrospinal fluid (CSF) dynamics, and metabolic and hormonal contributions. Transverse sinus stenosis exemplifies this complexity, acting as both a cause and consequence of elevated ICP. Dysfunction in the glymphatic system, impaired CSF reabsorption, and obesity-related hormonal dysregulation further elucidate IIH's multifactorial nature. Innovations like venous sinus stenting and pharmacological interventions targeting pathways like glucagon-like peptide-1 (GLP-1) show promise in managing refractory cases.Advances in diagnostics have refined IIH identification, integrating neuro-ophthalmological assessments, lumbar puncture, and imaging modalities such as magnetic resonance imaging (MRI), magnetic resonance venography (MRV), and optical coherence tomography (OCT). These tools enhance the detection of key findings like transverse sinus stenosis, optic nerve sheath dilation, and papilledema severity. Emerging non-invasive methods offer safer, real-time monitoring potential, including ultrasound-based optic nerve sheath diameter (ONSD) measurement and machine learning-based ICP estimation.Despite the significant and recent advances, challenges in standardizing diagnostic criteria and therapeutic approaches persist. This review integrates recent research to highlight critical developments, underscoring unresolved questions on pathophysiology and advocating for a multidisciplinary approach for the diagnosis. Future directions include hybrid diagnostic strategies and leveraging artificial intelligence to refine non-invasive monitoring and therapeutic precision.
Paediatric movement disorders (PMDs) encompass a wide range of diseases resulting from countless aetiologies. These are distinct from their adult counterparts, with a far greater proportion of genetic mutations, perinatal injuries, metabolic disorders, and in many cases, undefined neurodevelopmental abnormalities. Given the complexity of both the diagnostic process and management pathway of PMDs, early identification is critical to guide appropriate intervention in a timely manner. Through early recognition and management, clinicians positively impact neurodevelopment, quality of life, and long-term functional outcomes in children with PMDs.Effective management of PMDs necessitates the cooperation of an extensive multidisciplinary team of healthcare professionals, including neurologists, physiotherapists, occupational therapists, psychologists, and neurosurgeons. Each specialist brings their own perspective and expertise to best manage these complex patients.The initial treatment of paediatric movement disorders is widely centred on pharmacotherapy, with medications guided by underlying aetiology and symptoms. As such, medical management can be seen as treating either the manifestation and symptoms of the movement disorder, or in the case of autoimmune or inflammatory aetiologies, the underlying disease process. As a result, by the time patients have been referred for a neurosurgical opinion they have often trialled a number of different pharmacotherapies.Surgical intervention in paediatric movement disorders is considered when conservative treatment has failed to provide adequate symptom control or when the disorder significantly impairs the child's quality of life. The decision to proceed with surgery is multifaceted, involving careful patient selection, multidisciplinary evaluation, and consideration of the specific movement disorder phenotype.This chapter integrates contemporary literature to propose a reliable framework with which neurosurgeons can approach paediatric movement disorders, with a specific focus on neurosurgical options, including deep brain stimulation (DBS), pallidotomy, and rhizotomy.
Blast injuries present a unique challenge in trauma care due to their complex pathophysiology and potential to cause multisystem damage. Unlike conventional trauma, explosions generate a combination of penetrating, blunt, thermal, and barotrauma injuries, requiring a multidisciplinary approach. The increasing prevalence of terrorist attacks, military conflicts, and industrial explosions has contributed to a global rise in blast-related casualties, affecting both military personnel and civilians.This chapter integrates clinical experience, current evidence, and established guidelines to provide a comprehensive framework for evaluating and managing blast injuries. Key areas discussed include the epidemiology, classification, injury mechanisms, and organ-specific impact of blast trauma, with a focus on neurotrauma, pulmonary injuries, cardiovascular compromise, auditory and ocular trauma, and musculoskeletal damage.Additionally, we present a pragmatic protocol for initial trauma bay management, emphasizing early recognition, timely interventions, and coordinated multidisciplinary care. Given the complexity of blast injuries, we advocate for the establishment of a research consortium to refine current management strategies and optimize patient outcomes. Through a deeper understanding of blast physics, injury patterns, and treatment approaches, clinicians can improve survival and long-term recovery for both military and civilian blast victims.
As the leading cause of disability and death in children, paediatric traumatic brain injury (pTBI) is a clinical concern that impacts children on a global scale [1]. The incidence of TBI varies dramatically both between and within countries, ranging between 47 and 280 per 100,000 children, and is generally more common in males [1]. All ages are affected by TBI throughout childhood, though typically two peaks during infancy (0-2 years) and adolescence (15-18 years) are the most common intervals [1]. Mild TBIs (mTBIs) are the most frequently diagnosed, accounting for between 75 and 90% of cases, with a vast majority demonstrating no pertinent radiological findings and discharged home without follow-up.
Pineal parenchymal tumors (PPTs) are rare central nervous system neoplasms encompassing a histologically diverse group ranging from WHO grade 1 to 4 lesions. This chapter provides a comprehensive review of the epidemiology, clinical presentation, diagnostic workup, histopathological and molecular features, and treatment strategies of PPTs, with emphasis on surgical approaches and prognostic factors.An extensive review of recent literature was performed, incorporating updated WHO 2021 classifications and data from large multicenter cohorts. Particular attention was given to the inclusion of newly recognized tumor types, such as desmoplastic myxoid tumor of the pineal region, SMARCB1-mutant.PPTs present variably by age and histological subtype. Pineocytomas typically occur in adults and have excellent outcomes following gross total resection. Pineoblastomas, the most aggressive form, are predominantly pediatric and carry a high risk of CSF dissemination and poor prognosis without aggressive multimodal therapy. Pineal parenchymal tumors of intermediate differentiation and papillary tumors show variable behavior and benefit from maximal safe resection and selective adjuvant therapy. Surgical management remains the cornerstone of treatment, with the infratentorial supracerebellar approach favored for midline lesions. Endoscopic-assisted techniques are increasingly used for resection and biopsy, particularly in the presence of obstructive hydrocephalus. Endoscopic third ventriculostomy (ETV) offers an effective minimally invasive solution for hydrocephalus management. Prognostic outcomes are strongly influenced by tumor subtype, extent of resection, and use of adjuvant therapy.Conclusions: PPTs require individualized, multidisciplinary management strategies. Gross total resection remains the optimal surgical goal when safe, while the role of adjuvant therapy is determined by tumor type and grade. Future directions include improving the molecular characterization of rare subtypes and refining endoscopic and minimally invasive techniques. Multicenter studies are needed to establish evidence-based treatment protocols and better define prognostic markers.
Endoscopic endonasal approaches (EEAs) are a safe and effective method for treating skull base lesions, including those in the sellar and parasellar areas. Pioneered initially for the treatment of skull base pathology in adults, these approaches have shown clear advantages including cost-effectiveness, limited blood loss, and improved visualization allowing for a better plane of dissection and clearing anatomical landmarks. However, in younger patients, this approach could be limited due to their developing anatomy, small anatomical corridors, or peculiarities of specific lesions which could not be amenable for a simple approach.The width of the piriform aperture, sphenoid bone pneumatization, and intercarotid distances at different coronal planes should all be considered during preoperative evaluation of pediatric patients for EEAs. EEAs below the age of 2 years at parasellar ICA level and below 4 years at paraclinoid ICA level should deserve particular attention. As children grow, the progressive pneumatization of paranasal sinuses expands the anatomy of these corridors and it is generally assumed that anatomical factors would not restrict an endoscopic transsphenoidal approach in children older than 5 years of age.The pediatric population offers unique challenges because of the smaller working spaces and the smaller size of the skull base involved.
Hydrocephalus is one of the most common pediatric neurosurgical conditions worldwide, with an incidence of approximately 6000 new cases in infants annually, 50% of which are congenital. While shunt placement remains a standard treatment, endoscopic third ventriculostomy (ETV) combined with choroid plexus cauterization (CPC) has emerged as a less invasive and durable alternative in selected cases. However, ETV-CPC is technically demanding and requires extensive surgical training, especially for pediatric populations. This chapter explores an innovative, mixed-reality simulation model that combines a physical baby simulator with an expert AI-driven avatar to reduce the learning curve for pediatric neuroendoscopy. The training model, designed specifically for use in under-resourced regions such as the Brazilian Amazon region, was evaluated and showed a 41.65% average decrease in surgical errors post-training. This chapter also discusses the global implications of this methodology for neurosurgical training and equitable medical education.
Pineal region tumors represent a diverse group of neoplasms arising from the pineal gland and its surrounding structures, posing unique diagnostic and surgical challenges due to their deep midline location and proximity to critical venous and neural anatomy. Advances in neuroimaging, microsurgical technique, and endoscopic technology have transformed their management, substantially improving outcomes compared to historical experiences of high morbidity and mortality. This chapter reviews the anatomical, diagnostic, and surgical principles essential to the contemporary management of pineal region lesions. Detailed descriptions are provided for key operative corridors, including the endoscopic third ventriculostomy with biopsy, supracerebellar infratentorial, occipital transtentorial, posterior interhemispheric transsplenial, anterior transchoroidal, and combined supra-/infratentorial approaches. Institutional experience and outcome data are presented to guide approach selection. Ultimately, optimal management depends on an individualized, anatomy-driven strategy integrating tumor pathology, patient presentation, and the surgeon's familiarity with each corridor.
The brainstem is a complex anatomical structure, and tumors in this region account for approximately 12% of all pediatric brain tumors. In this chapter, we detail both the intrinsic and extrinsic anatomy of the brainstem, propose a new redivision into eight anatomical compartments, and describe ten traditional safe entry zones-adding two novel approaches: the supratrigeminal zone for anterior-superior pontine lesions and the interpeduncular cerebellar route for lesions located between the middle and superior cerebellar peduncles. Anatomic knowledge of intrinsic and extrinsic brainstem structures, in association with refined microsurgical technique, intraoperative neurophysiological monitoring, and preoperative planning based on magnetic resonance imaging (MRI) and tractography, has enabled broader resection of brainstem lesions with low mortality and acceptable morbidity rates. However, it is the surgeon's responsibility to select the most appropriate surgical trajectory to maximize resection while minimizing functional impairment.
Training in neurosurgery is increasingly challenged by the complexity of cranial anatomy, the rarity of certain pathologies, ethical constraints on cadaveric dissection, and limited operative exposure. Advances in three-dimensional (3D) printing have enabled the development of patient-specific anatomical models derived from computed tomography and magnetic resonance imaging, offering realistic, reproducible platforms for surgical training and preoperative planning. This chapter reviews contemporary applications of 3D-printed, hybrid, and multimodal simulation models in neurosurgical education, with particular emphasis on complex craniofacial and encephalocele procedures. Through illustrative case reports-including frontoethmoidal and transsphenoidal meningoencephaloceles, metopic craniosynostosis, and late encephalocele correction-the chapter demonstrates how multimaterial 3D-printing, hybrid silicone-resin constructs, and integration with augmented and mixed reality can enhance spatial understanding, tactile feedback, and procedural rehearsal. Evidence from these cases indicates that patient-specific simulation can alter surgical strategy, reduce operative time and blood loss, and improve multidisciplinary communication. Educational benefits extend beyond surgeons to trainees and allied health professionals, supporting structured skill acquisition and competency-based assessment. The chapter also discusses the relevance of low-cost 3D-printing solutions for low- and middle-income countries, highlighting open-source software and affordable fabrication techniques as tools to reduce global disparities in neurosurgical care. Limitations related to cost, material fidelity, imaging quality, and technical expertise are addressed, alongside future directions for research and curriculum integration. Overall, 3D-printed and hybrid simulation models represent a transformative approach to neurosurgical training and patient-specific surgical planning, with significant implications for education, safety, and global health equity.
Cranial nerve (CN) functional diseases, comprising trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GN), are frequently caused by neurovascular conflicts (NVCs) in the posterior fossa. This chapter examines surgical and non-surgical procedures for these conditions, emphasizing minimally invasive retrosigmoid approach (RA) for microvascular decompression (MVD) as the gold standard for definitive treatment for all of them. MVD achieves long-term pain relief in more than 80% of classical TN cases, though efficacy decreases significantly in multiple sclerosis (MS)-related TN. Technical nuances of MVD, such as patient positioning, craniectomy location, and conflict visualization via microscopic, endoscopic, or exoscopic systems, are detailed, alongside strategies to minimize complications (CSF leakage, vascular or nerve injuries). Percutaneous techniques (radiofrequency thermorhizotomy, balloon compression) and stereotactic radiosurgery offer viable alternatives, albeit with variable durability on symptoms control. Special considerations for MS-related TN, tumor-associated cases, and recurrent disease underscore the need for tailored algorithms integrating intraoperative imaging and tools. Advances in endoscopic and exoscopic visualization systems enhance intraoperative precision and ergonomics, though mastery remains technically demanding. A multidisciplinary framework is critical for optimizing outcomes.
Endoscopic third ventriculostomy with choroid plexus coagulation/cauterization (ETV-CPC) is a well-established technique for treating certain types of infant hydrocephalus-a significant global issue. Since its first use by Dr. Benjamin Warf in Uganda over 20 years ago, pediatric neurosurgeons around the world have incorporated it into their practices. The primary benefit of the technique is the avoidance of indwelling shunts, which carry upfront costs that can be prohibitive in many parts of the world, and unpredictable long-term failure rates that are undesirable in any setting. Questions remain, however, about the comparative efficacy of ETV-CPC versus shunt and the factors predicting success or failure. This chapter reviews the history of the technique's development to provide context for its inception; summarizes the literature on its use in different geographic and etiologic populations; and highlights gaps in our knowledge that warrant further investigation. In summary, ETV-CPC is a safe and effective technique in the management of some forms of infant hydrocephalus, but surgeons should consider individual patient characteristics and family preferences when deciding between endoscopic treatment versus a shunt.
Anterior third ventricular tumors, encompassing colloid cysts, gliomas, craniopharyngiomas, and neurocytomas, are rare intracranial neoplasms that present significant diagnostic and therapeutic challenges due to their deep-seated location and proximity to critical neurovascular structures. This chapter synthesizes current literature on their natural history, diagnostic approaches, and management strategies, integrating our clinical experience with 193 cases treated between 1995 and 2023. We explore observation, microsurgical resection, endoscopic surgery, and stereotactic radiosurgery (SRS), providing an in-depth analysis of surgical techniques, their nuances, benefits, and risks. The commonest diagnosis in our series was colloid cyst (72.5%). We achieved a 81.5% complete resection rate with 12% complications overall. Major studies are reviewed to compare outcomes, and a management algorithm is proposed to guide individualized treatment, emphasizing tumor control and quality of life (QOL) preservation. Additionally, emerging molecular and genetic insights into these tumors, pediatric-specific considerations, quality-of-life outcomes, long-term follow-up strategies, and novel surgical or radiological techniques, reflecting the latest evidence-based advancements in the field, are discussed.
Brain arteriovenous malformations (BAVM) are congenital vascular malformations in which abnormal communication is formed between arteries and veins. Pediatric BAVM was more prone to hemorrhage than adult BAVM. And the natural course of pediatric BAVM was more severe than that of adult BAVM.Among the three main treatment options, surgical resection offers the highest cure rate. Surgical resection was prioritized when the total score of the supplementary Spetzler-Martin grade was ≤6. This approach was especially emphasized for children with ruptured AVMs and for younger patients who were not suitable candidates for stereotactic radiotherapy. However, for unruptured BAVMs located near functional areas, stereotactic radiotherapy could be considered the preferred treatment option.A hybrid operating room allows the simultaneous performance of open surgery and interventional procedures. The primary benefit of a hybrid operating room is the ability to determine residual BAVM through intraoperative DSA, ensuring complete resection. Furthermore, for BAVMs with higher Spetzler-Martin grades, those located in eloquent areas, with complex structures or diffuse types, or those that have previously undergone surgery, these cases are particularly well-suited for procedures performed in a hybrid operating room. For patients with large hematomas requiring emergency decompression, emergency surgery in a hybrid operating room is a more reasonable option. In such a setting, preoperative DSA, surgical resection, and postoperative DSA can be performed within the same session.From 2015 to 2024, a total of 123 cases of surgical resection of BAVM in children were performed at this center using a hybrid operating room. Residual BAVM was identified during the first intraoperative DSA in 10 cases (8%). There were 8 cases (6.5%) of confirmed recurrence by DSA.BAVM remains the most challenging disease for neurosurgeons. Individualized treatment strategy needs to be formulated for each pediatric patient.
Cerebrovascular surgery has shifted a lot from the microsurgical aspects to the endovascular surgeries in nearly most of the cases. However, there are still some major controversies when one sees the long-term follow-up of microsurgical and endovascular procedures.MC aneurysms, PICA VA junction and PICA aneurysms, IC aneurysms with good cross flow (trapping), revascularisation surgery, dural AVF (coagulation or coiling), ICH evacuation timing, and recent changes in mechanical thrombectomy timing are a few of these examples. This chapter will comprehensively aim to provide an outlook on the best possible modality in these controversial aspects of cerebrovascular surgery.
INTRODUCTION:Odontoid fractures (OFs) are one of the most common fractures of the upper cervical spine, estimated to represent 9-15% of all cervical fractures. Although their relative frequency, its optimal management is still debated. When surgery is required, anterior odontoid screw fixation (AOSF) offers several advantages, such as preservation of neck rotation, reduced surgical risk, and shorter hospital stay. However, only well-selected patients are eligible for this procedure, and an accurate interpretation of imaging as well as an optimal surgical timing should be taken into account to identify who may be the "best candidates". METHODS:The aim of this narrative review is to report the current advances in the treatment of OFs by AOSF. We will focus on surgical details, including minimally invasive surgery, as well as on pre- and postoperative critical aspects. RESULTS:With regard to preoperative imaging, type II b OFs (with fracture line oriented from anterior superior to posterior inferior) typically present favourable configuration to be treated by AOSF. Furthermore, a fracture gap >2 mm, an angulation >11° and a displacement >2 mm as well as timing duration from injury to surgery >7 days are predictors of non-union after AOSF. With regard to surgical technique, compared to traditional open technique, MIS procedures are more and more reported. This approach can be performed percutaneously under fluoroscopy or navigation guidance. Finally, the use of a single, bicortical lag screw is strongly suggested to compress the fractured bone surfaces, to reduce the fracture gap and to obtain the best mechanical stability. CONCLUSION:Our review suggests that AOSF is an effective option in the treatment of type II OFs. However, a meticulous assessment of preoperative images is mandatory, and particular attention has to be paid to fracture configuration, gap, angulation, displacement and ligament integrity. With regard to elderly population, the possibility of wearing rigid collar should be considered, and recent literature reports encouraging results even without any treatment. If a surgical intervention is required, the timing from injury to the operation represents a crucial parameter, making early decisions an important element in the management of type II OFs. Compared to the traditional open approach, minimally invasive AOSF is reliable, promotes faster recovery and in select cases can be performed even under sedation.
Hybrid operating rooms (HORs) combine a conventional state-of-the-art microsurgical theater and advanced imaging technologies, usually an intraoperative digital subtraction angiography (DSA) system. Initially developed for peripheral vascular surgery, HORs are gaining popularity among neurosurgical teams around the world. Based on their recent experience, the authors describe the launch of such a hybrid room in the University Hospital of Dijon Bourgogne and, through a narrative review of the pertinent literature, try to define the specific vascular neurosurgery conditions that may benefit from this highly demanding multidisciplinary environment. The association between intraoperative diagnostic and interventional endovascular capabilities and microsurgical management in the same location provides the possibility of immediate assessment of the surgical results, the immediate conversion to one or other technique if needed without transferring the patient, and appears to provide a very high cure rate of neurovascular malformations while minimizing the morbidity and mortality.
INTRODUCTION:Glioblastoma (GB) remains the most prevalent and aggressive primary tumor of the central nervous system, with median overall survival between 14 and 20 months. Maximal extent of resection is associated with extended overall survival. Lobectomy may lend itself in the management of patients with glioblastomas in certain anatomical areas for accomplishing maximal or even supramaximal resection. PATIENT SELECTION:Patients with good preoperative KPS, with a tumor confined to one lobe, and no infiltration of the subependymal zone are good candidates for lobectomy.Preoperative considerations: A thorough medical history, a detailed neurological examination, along with diagnostic work-up is essential in decision-making and proper surgical planning. Neurocognitive evaluation is also of paramount importance.Frontal lobectomy: High-speed drill is used for performing a frontotemporal craniotomy in non-dominant cases, while a more extensive fronto-parieto-temporal osseous flap is required in dominant cases for detailed cortical and subcortical mapping via an awake procedure. A corticectomy is then performed along with subpial resection of the white matter of the involved lobe.Temporal lobectomy: The same craniotomy strategy is used in temporal lobectomies. A corticectomy is performed through the inferior temporal gyrus, removal of the underlying white matter, and entrance to the ipsilateral temporal horn. After the neocortical resection, the mesial temporal structures have to be removed under the microscope. The importance of subpial resection technique cannot be overemphasized. COMPLICATIONS:Complications such as neurocognitive deficits, paresis, dysphasia, infections, hydrocephalus, and hemorrhage are mainly reported in lobectomies performed for epilepsy. In GB lobectomy studies, no statistically significant differences were observed regarding complications. RESULTS:In the pertinent literature, lobectomy demonstrates a mean overall survival of 25 months, compared to 13.72 months for gross total resection (GTR), and a progression-free survival of 16.13 months, compared to 8.77 months for GTR.
This paper provides an overview of optic pathway hypothalamic gliomas (OPHGs), neoplastic lesions that are mainly low-grade gliomas with predominance of pilocytic astrocytomas. They typically occur more frequently in children, but arise also in adults. While some tumors affect the optic nerve alone, the majority of them invade the hypothalamus and optic chiasm as well as adjacent structures. According to the pertinent literature, most authors consider extensive or curative tumor resection not feasible because of high risk for visual loss or severe hypothalamic side effects. Therefore, radiochemotherapy is a widely used modality to treat these challenging lesions. The authors of the present article describe a different strategy of selecting and treating surgically patients with OPHG. Similar to their management of low-grade gliomas in other intracranial location, they have treated a number of OPHGs microsurgically with curative intention. The present patient series comprises 56 individuals (42 pediatric and 14 adult patients). The authors achieved microsurgical gross total (99-100% tumor volume reduction) and near total tumor resection (90-98% volume reduction) in 42 patients (75.0%). There was no surgical mortality, and the rate of complications was low. Postoperatively, the patient's visual and endocrine function remained either intact or at a very satisfactory level in the vast majority of cases. These results differ from those found in previous publications dealing with OPHGs. In the author's experience, proper patient selection played an important role in achieving a good outcome. They conclude that microsurgical management should be considered an important part of the treatment plan in OPHGs. Patients should undergo surgery in an early stage before irreversible symptoms have occurred, and gross total tumor resection should be attempted in well-selected cases. Intentional partial OPHG resection and repeat surgery may help prolonging the symptom-free and tumor progression-free intervals.
Colloid cysts of the third ventricle are benign and rare lesions of the central nervous system. Although gross total resection is the standard treatment of these lesions, there are multiple surgical routes proposed and discussed in the literature. Similarly, the origin of these colloid cysts remains a topic of debate. Long-term outcomes of anterior transcallosal approach have been analyzed and compared with the recent meta-analyses published in the literature. Additionally, the origin of these cysts is explored using immunohistochemical analysis.Eighty operations on 76 patients by a single surgeon over 37 years have been studied and the long-term outcomes have been presented. Additionally, ependyma, choroid plexus, and colloid cyst specimen have been compared using immunohistological staining with cytokeratin, S100, and PAX-7.The long-term outcomes with comparison with the literature show that microsurgical gross total resection using anterior transcallosal approach is the ideal treatment over other modalities. Preoperative hydrocephalus is a strong indicator for the location of the colloid cyst within the anterior third ventricle and for the selection of transforaminal versus interforniceal approach. In pathological study, the clear staining with PAX-7 points to this pathology being a remnant of the paraphysis.
