Background and Objective:Cavernous malformations (CMs) are relatively common in the brain parenchyma, whereas lesions strictly confined to the optic canal are exceptionally rare. Although only a few intracanalicular vascular malformations have been reported, detailed descriptions of pure optic canal CMs remain scarce. We report a pure optic canal CM successfully managed by endoscopic endonasal surgery to further highlight the surgical feasibility and clinical efficacy of this strategy. Case Description:A 48-year-old woman presented with a 3-month history of progressive right visual decline that accelerated shortly before admission. Ophthalmological examinations showed decreased best-corrected visual acuity, a relative afferent pupillary defect, concentric visual field narrowing, and thinning of the ganglion cell layer on optical coherence tomography. Magnetic resonance imaging (MRI) demonstrated a well-circumscribed, homogeneously gadolinium-enhancing mass entirely within the right optic canal, whereas computed tomography showed no calcification or canal enlargement. Vision improved transiently after systemic corticosteroids but relapsed with tapering, suggesting a compressive lesion. Given the rapid progression of vision loss, endoscopic endonasal surgery was conducted. Results:Through a right nasal approach, the optic canal was unroofed and a dark-reddish, well-circumscribed lesion with minimal adhesion was removed en bloc. There was negligible blood loss and no intraoperative or postoperative cerebrospinal fluid leakage. A CM was confirmed by histopathology. Postoperatively, visual acuity and field recovered fully, and MRI confirmed gross total resection with complete decompression of the optic nerve. Conclusion:This case adds an additional well-documented example of a pure optic canal CM and supports the endoscopic endonasal approach as a safe and useful option for achieving complete resection with excellent visual recovery.
Introduction:The semi-sitting position in neurosurgery remains a topic of debate. Despite advantages such as improved surgical accessibility and visibility, it is associated with risks such as venous air embolism. This study provides an overview of the current use, benefits, challenges, and future prospects of the semi-sitting position, based on insights from a sample of international neurosurgeons. Methods:A structured questionnaire was distributed via social media channels to neurosurgeons worldwide, collecting data on demographics, usage frequency, indications, reasons for use or nonuse, feared complications, alternative positions, and treated pathologies. Responses from 141 neurosurgeons were analyzed, comparing developed and developing countries. Results:Overall, 81.6% of neurosurgeons reported using the semi-sitting position, with a significantly higher frequency in developed countries (p < 0.001). A total of 97.9% of participants used this position for infratentorial pathologies. Major barriers included fear of complications (44.3%), insufficient anesthesia team training (42.9%), and lack of appropriate equipment (31.4%). Significant regional differences were observed, with training deficits (p = 0.007), lack of equipment (p = 0.001), and limited experience (p = 0.008) reported more frequently in developing countries. Perioperative monitoring practices showed variability; however, most modalities did not differ significantly between groups, including intraoperative transesophageal echocardiography (p = 0.091). Among nonusers, 44% expressed willingness to adopt the semi-sitting position with appropriate training and support. Conclusion:Despite its challenges, the semi-sitting position offers significant advantages for specific neurosurgical procedures. Successful implementation requires an experienced surgical and anesthesiology team. Efforts to enhance training, improve technology, and provide adequate infrastructure could facilitate broader adoption of the semi-sitting position.
Background:Subdural empyema is a neurosurgical emergency traditionally managed with craniotomy and prolonged intravenous antibiotic therapy. Minimally invasive approaches may represent an alternative in selected cases, particularly when combined with timely diagnosis and targeted antimicrobial treatment. Patients:We report two cases of subdural empyema treated with minimally invasive burr-hole evacuation. Case 1:A 22-year-old man with developmental anomalies and postischemic stroke history presented with intermittent high fever for 2 weeks. Rapid neurological deterioration over 24 hours led to coma (Glasgow Coma Scale 5). Cranial computed tomography (CT) revealed a right-sided subdural empyema with significant mass effect. Emergency burr-hole evacuation was performed, followed by broad-spectrum antibiotics later tailored to Staphylococcus aureus. Case 2:A 40-year-old man presented with hypertensive intracranial syndrome and febrile episodes for 1 week. CT and magnetic resonance imaging revealed a left hemispheric subdural collection suggestive of empyema, likely secondary to otitis media from suspected Streptococcus anginosus. Burr-hole evacuation and empiric triple antibiotic therapy were initiated. Results:In both cases, postoperative imaging confirmed complete evacuation without residual collection. The first patient required prolonged intensive care with gradual neurological improvement over several weeks, whereas the second patient achieved immediate postoperative recovery. At 2-year radiological follow-up, no recurrence was observed in either patient. Conclusion:Minimally invasive burr-hole evacuation, combined with culture-guided antibiotic therapy, can be effective in selected cases of subdural empyema, yielding favorable clinical and radiological outcomes.
Background:In recent years, numerous advanced techniques supporting surgery (TSS) have been utilized to maximize glioma resection. However, the impact of the multimodal use of TSS, such as awake surgery, intraoperative neurophysiological monitoring, neuronavigation, fluorescence-guided surgery, functional magnetic resonance imaging m(fMRI), and diffusion tensor tractography (DTT), on improving overall survival (OS) remains uncertain. Methods:In retrospective analysis of 81 patients with supratentorial WHO grade 4 gliomas, we assessed the effect of age, sex, tumor location, number of TSS used, extent of resection (EOR), postoperative Karnofsky performance scale (KPS), IDH1 status, and use of postoperative adjuvant therapy (PAT), i.e., radiotherapy and chemotherapy, on overall survival. Kaplan-Meyer plots with F-Cox test and Cox proportional hazards model were used for univariate and multivariate survival analyses. Results:We used none, one, two, three, or four TSS in 30, 20, 15, 9, and 7 patients, respectively. The number of TSS used (none vs. 1-2 vs. 3-4) correlated with OS in eloquent areas (p = 0.029, univariate; p = 0.006, multivariate) with median survival of 194, 364, and 674 days, respectively, whereas no correlation was observed in non-eloquent areas. In univariate analysis but not in multivariate analysis, significant factors for OS in gliomas in eloquent areas were younger age (p = 0.026), EOR (gross total vs. subtotal vs. partial resection) (p = 0.015), and PAT use (p = 0.00066), and in gliomas in non-eloquent areas were EOR (p = 0.01), postoperative KPS (≥70 vs. <70) (p = 0.023), and PAT use (p = 0.015). Conclusion:The simultaneous use of multiple TSS appears to be associated with improved overall survival in patients with supratentorial WHO grade 4 gliomas in eloquent areas, in contrast to non-eloquent areas.
Background:Unilateral monosegmental radiculopathy, caused by foraminal soft disc nerve root compression, can be treated with posterior cervical foraminotomy (PCF). Conventional fluoroscopy is widely used for level localization and verifying decompression extent intraoperatively. However, the failure rate increases, especially in obese patients and the lower cervical spine. Can intraoperative three-dimensional (3D) navigation improve outcomes in PCF compared with conventional fluoroscopy? Materials and Methods:In this retrospective study, we analyzed two groups: 42 patients (mean age: 54 ± 10 years) who underwent PCF using intraoperative 3D navigation (study group) and 63 patients (mean age: 51 ± 11 years) who underwent PCF with conventional fluoroscopy (control group). Each cohort was divided into upper (C3-C6) and lower cervical spine (C6-T1) subgroups. Differences were explored by Mann-Whitney U and Friedman tests. Results:Both groups experienced significant postoperative symptom improvement, with no significant neurological differences. Subgroup analyses revealed no significant differences between surgeries in the upper (C3-C6) and lower (C6-T1) cervical spine. Only blood loss in the C3-C6 group differed significantly between control and study groups. Conclusion:Intraoperative 3D navigation was successfully used for PCF, resulting in significant symptom relief. Outcomes after PCF with 3D navigation appeared comparable to those achieved with conventional fluoroscopy, without statistical evidence of a clear advantage. Thus, technical complexity should be considered when selecting the surgical method.
Background Giant cell tumors (GCTs) of the bone, though typically benign and found at the ends of long bones, are rare in the lumbar spine. Despite their benign nature, they can exhibit local aggressiveness and cause pathological fractures and compression. The treatment is individualized, considering anatomical localization, tumor extension, and clinical symptoms. Case Report We present the case of a 41-year-old female, a genuinely unique instance of a GCT of the L4 body extending into the retroperitoneum. This rarity in itself is a point of interest. The patient underwent an initial posterior en bloc resection with lumbar arthrodesis, followed by a second anterior L4 corpectomy and anterior cylinder fusion. Conclusion The combination of radical surgery with adjuvant therapies such as radiotherapy and bisphosphonates has been described to enhance long-term outcomes and reduce recurrence. Still, surgery remains the mainstay of treatment of this entity.
Background The introduction of minimally invasive techniques in lumbar stenosis has had a significant impact in terms of reducing perioperative morbidity and the incidence of iatrogenic instability. According to the principle of keyhole surgery, minor variations in technique can result in significant variations in surgical outcomes. Aims A comparative anatomical study was conducted to assess the impact of an innovative, more lateral entry point (angular-laminar access, ALA) on surgical maneuverability during minimally invasive circumferential microdecompression using a crossover technique. Methods The anthropometric measurements were acquired on preoperative baseline CT images. A comparative study was conducted between the standard technique (marginal-laminar access, MLA) and the present one, applying the operability score (OS) principles. An illustrative case is reported to demonstrate the feasibility of the technique. Results The ALA was found to increase maneuverability area (MA), maneuverability arc (MAC), and surgical angle of attack (SAA), reducing the conizing effect of the portal system, with a non-significant increase in the depth of the surgical field (D). The direction of the surgical corridor allows for better control over the contralateral recess, the increased range of motion (ROM) of the system optimizes visibility of potential blind corners. Conclusion The ALA provides improved operability and surgical exposure in minimally invasive microdecompression using the crossover technique.
Background and Importance Closed reduction is an important adjunct in the surgical management of traumatic cervical facet dislocations, particularly jumped and locked facets. By restoring normal spinal alignment, successful closed reduction allows the surgeon to proceed with surgical stabilization via an anterior-first approach, obviating the need to rotate a dislocated, biomechanically unstable cervical spine, thereby minimizing the risk of iatrogenic spinal cord injury. While closed reduction has traditionally been achieved with Gardner-Wells tongs and weights, this reduction method requires the patient to remain bedbound for prolonged periods of time, is not MRI-compatible, and is associated with inconsistent results. Clinical Presentation We present two patients with bilaterally jumped and locked cervical facets, in whom a closed manual reduction technique was used, allowing rapid spinal realignment prior to surgical stabilization. We provide a detailed video illustration of this technique, emphasizing the steps involved and relevant technical nuances. While this technique might have been previously used and rarely reported, it has not, to the best of our knowledge, been described in a detailed, step-by-step fashion. Conclusion Closed manual reduction of traumatic cervical facet dislocations can be performed safely and effectively in the operating room prior to definitive surgical stabilization of the spine. This technique should not be attempted in patients with severe spinal cord compression or neurologic compromise. The importance of adequate muscle relaxation provided by general anesthesia and continuous intraoperative feedback provided by live fluoroscopy and neurophysiologic monitoring cannot be overemphasized.
Objective:Various studies have shown a beneficial effect of statins in patients with chronic subdural hematoma (cSDH) who do not require surgery. In surgical cohorts, however, the results of statin treatment in cSDH have been inconsistent, and meta-analyses showed no significant effect. It has been hypothesized that this lack of effect may be due to a higher proportion of patients in the statin group taking antithrombotic medication. Therefore, we designed a study to analyze the impact of statins on surgical cSDH patients who did not receive antithrombotic drugs. Methods:We conducted a retrospective chart review of patients who received cSDH evacuation via burr-hole trepanation with the implantation of a subdural drain at our institution from 2012 through 2021. The data were pooled with a previously analyzed cohort to result in a two-center analysis. Patients who received antithrombotic medication were excluded. We separated the patients into a statin group and a control group based on whether they received a statin as part of their home medication and evaluated the rate of reoperations for any reason as the primary outcome parameter, and reoperations for residual hematoma and hematoma recurrence, respectively, as secondary outcome parameters. Results:We identified 614 patients in the total cohort, of whom 297 did not take antithrombotic medication. The mean age of these patients was 71.75 ± 13.27 years, and 195 were male (65.66%). A total of 42 patients took statins (14.14%). A reoperation was necessary in 5 patients in the statin group (11.90%) and 35 patients in the control group (13.73%), p = 0.749. Residual hematoma after the initial surgery was ascertained in 2 patients in the statin group (4.76%) and 17 in the control group (6.67%), p = 0.640, whereas 3 patients in the statin group (7.14%) and 18 patients in the control group (7.06%) experienced hematoma recurrence, p = 0.984. Logistic regression analysis revealed no significant associations with reoperation. Conclusion:We found no evidence of a beneficial effect of statins in patients undergoing surgery for cSDH, regardless of the use of antithrombotic medication.
Background Stimulation of the left vagus nerve is a well-established therapy for patients with drug-resistant epilepsy who are not candidates for resective or disconnection surgery. Right-sided vagus nerve stimulation is generally avoided due to concerns about serious cardiac side effects, as the right vagus nerve is anatomically associated with the innervation of the sinoatrial node. Only a few cases of right-sided vagus nerve stimulation in drug-resistant epilepsy have been reported to date. Materials and Methods An 8-year-old child with drug-resistant epilepsy and a left-sided Port-a-Cath positioned in the left internal jugular vein underwent uneventful insertion of a right-sided vagus nerve stimulator device. Results The vagus nerve stimulator was deactivated due to postoperative cardiac side effects, which subsequently resolved. Conclusion We report the first case of a child with drug resistant epilepsy in whom a right-sided vagus nerve stimulator was deactivated due to postoperative cardiac effects. Nonetheless, right-sided implantation may be a viable therapeutic option when left-sided implantation is contraindicated, provided careful cardiac monitoring and individualized risk-benefit analysis are undertaken.
Abstract:This study reports a 55-year-old patient admitted to our outpatient clinic with unilateral tongue atrophy. He had undergone various workups without any result for diagnosis prior to presenting to our clinic.
Background:The anchor at C2 often serves as a key stabilizer in cervical spine fusion surgery. Although the pedicle screw is considered the standard fixation method at C2, the laminar screw is also a widely used alternative due to its biomechanical stability, comparable to that of C2 PS. However, malpositioning of C2 LS carries a risk of neural injury and compromised fixation stability, and the use of surgical assistance has been reported to improve placement accuracy. The robotic system is a relatively new technology for PS placement, and its application has recently expanded to the cervical spine. The present study aimed to investigate the accuracy of C2 laminar screw placement with robot assistance. Methods:This prospective study evaluated 11 C2 laminar screws in 11 patients who underwent cervical fusion surgery with the robot assistance between March 2024 and June 2025. Results:All 11 C2 laminar screws were successfully placed with no cortical breaches and no screw-related complications. The mean deviations at both the entry point and at a depth of 20 mm were less than 1.0 mm in both the axial and sagittal planes. Conclusions:The results of this study suggest that the robotic system is a potential tool to facilitate accurate C2 laminar screw placement in clinical settings.
Background:Pediatric meningiomas are extremely rare. The clinical features and prognosis of these patients remain unclear, especially due to the lack of large-scale clinical data. Methods:Pediatric and adult patients with meningiomas diagnosed between 2000 and 2021 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The clinical characteristics (age, sex, race, tumor laterality, tumor behavior, treatment methods, etc.) of the included patients were reviewed, and the survival analysis was estimated via the Kaplan‒Meier method. Results:A total of 364 pediatric patients were identified from the database. Pediatric meningiomas accounted for 0.2% to 0.6% of all meningiomas per year. The average age of pediatric patients was 12 years, and that of adult patients was 65 years. Adult meningioma patients were more commonly female, whereas no significant gender difference was observed in pediatric cases (p < 0.001). Moreover, a higher proportion of borderline and malignant tumors was found in pediatric meningioma patients compared with adults (p < 0.001). Survival analysis revealed that pediatric patients had a better survival prognosis than adult patients (p < 0.001). Pediatric patients with coexisting tumors had a worse prognosis than those without coexisting tumors (p < 0.001). Conclusion:This study comprehensively investigated the clinical features and survival outcomes of pediatric meningioma patients. Pediatric meningiomas are extremely uncommon and account for 0.2% to 0.6% of all meningiomas annually. Pediatric meningiomas have different clinical characteristics and better survival prognoses than those of adult patients.
Background and Study Aims:The high-intensity zone (HIZ) in a lumbar intervertebral disc on T2-weighted magnetic resonance images has been associated with discogenic low back pain. However, its clinical significance remains uncertain. Histological studies reveal inflammatory changes surrounding the HIZ, suggesting a potential link to disc degeneration. Recent advancements in full-endoscopic spine surgery (FESS) have enabled more detailed intradiscal observations. The purpose of this study is to examine the characteristics of endoscopic findings in the HIZ. Materials and Methods:Eighty-six patients who underwent FESS between January 2020 and August 2022 were investigated. We defined intradiscal bleeding and/or inflammation as "red annulus fibrosus" (RAF) and compared its occurrence between patients with HIZ and without HIZ. In 45 patients with HIZ, the ratio of the signal intensity of the HIZ to that of cerebrospinal fluid (the HIZ/CSF ratio) was compared according to RAF status. Results:RAF was observed in 54.7% of all patients, with a higher prevalence in those with an HIZ (73.3 vs. 34.1%, p < 0.01). The HIZ/CSF ratio was significantly higher in patients with RAF than in those without RAF (0.64 vs. 0.46, p = 0.03). The receiver-operating characteristic curve for the ability of the HIZ/CSF ratio to predict intradiscal bleeding had an area under the curve of 0.74, with a cutoff value of 0.48 providing 72.7% sensitivity and 66.7% specificity. Conclusion:Intradiscal bleeding and inflammation were observed more often in patients with an HIZ, suggesting an association with degenerative changes. An HIZ/CSF ratio > 0.48 on preoperative magnetic resonance images may predict intradiscal bleeding.
Purpose: Differentiating between pilocytic astrocytomas (PA) and hemangioblastomas (HB) during surgery is challenging due to their radiological similarities but distinct vascular characteristics and surgical considerations. This study explores the application of indocyanine green (ICG) fluorescence angiography for intraoperative differentiation of these tumors. Methods: Four patients with cerebellar cystic masses underwent surgical resection using ICG video angiography. ICG fluorescence patterns were observed intraoperatively to distinguish vascular characteristics. Homogeneous enhancement in HB was hypothesized to contrast with the nonenhancing nodules of PA. The findings were correlated with preoperative imaging and histopathology. Results: In cases of HB, ICG angiography demonstrated early-phase homogeneous fluorescence, highlighting the tumor's high vascularity and aiding complete resection while preserving vascular integrity. In contrast, PA showed no fluorescence in the tumor nodule, enabling piecemeal resection with minimal blood loss. Histopathological diagnoses confirmed the intraoperative findings. The technique was safe, with no complications reported. Conclusion: This study demonstrates the utility of ICG video angiography as an intraoperative adjunct for differentiating PA from HB. Compared with digital subtraction angiography, ICG offers a cost-effective, safe, and efficient alternative, without the need for specialized equipment or radiation exposure. ICG fluorescence enhances intraoperative decision-making and optimizes surgical outcomes for challenging posterior fossa lesions. Further studies are warranted to validate these findings and expand the role of ICG in neurosurgical practice.
Background:Vertical atlantoaxial distraction (AAD) represents a rare and severe form of craniocervical injury caused by high-energy trauma. It involves vertical separation of the atlas and axis due to complete rupture of the ligamentous stabilizers and poses an immediate risk of neurological or vascular compromise. Case Description:A 33-year-old male sustained multiple injuries following a suicidal jump from 10 m, including a Type III vertical AAD with 6 mm distraction between the C1 and C2 lateral masses. Imaging revealed complete rupture of the alar, apical, and posterior longitudinal ligaments, bilateral facet joint capsule disruption, and a Gehweiler Type I anterior arch fracture of C1. A traumatic dural tear with suspected cerebrospinal fluid (CSF) leak was also identified. Initial anterior stabilization was performed with mini-fragment screws, followed by delayed posterior C1/C2 fusion via transarticular screws 1 week later due to clinical instability. Intraoperative correction of a 10-degree C1-C2 rotational deformity was achieved, and dural repair was completed using TachoSil and muscle graft. The patient remained neurologically intact and had an uneventful recovery. Follow-up imaging at 1 year demonstrated stable alignment of the construct without signs of hardware loosening, failure, or new neurological findings. At the 6-year follow-up, the patient remained neurologically intact with preserved cervical rotation up to 50 degrees. Conclusion:This case highlights the diagnostic complexity and management challenges associated with vertical AAD. A classification-based surgical strategy supported by high-resolution imaging and intraoperative navigation led to successful stabilization and excellent neurological outcome.
Objective An exact classification for estimating the risk of shunt-dependent hydrocephalus (SDHC) after endovascularly treated aneurysmal subarachnoid hemorrhage (aSAH) is still missing, although studies underline that the type of aneurysm care (clipping/coiling) has a decisive influence on the development of an SDHC. Methods A total of 91 patients who underwent an endovascularly treated aSAH at the Department of Neurosurgery of the University Hospital Augsburg from January 2010 to July 2015 were selected. Clinical variables, radiographic features, and amount of cerebrospinal fluid (CSF) drainage via external ventricular drainage (EVD) were included in the scoring process. We determined the optimal cutoff values by an univariate logistic regression for each dichotomized variable and the Akaike Information Criterion (AIC). Finally, the "Endovascular Treatment and Risk of Shunt" (EROS) score was established. Results A ventricular score >0.6 ( p < 0.001), poor Glasgow Coma Scale (GCS) score (<10; p = 0.001), age over 46 years ( p < 0.001), cerebral vasospasm ( p < 0.001), and a CSF drainage volume over 180 mL per day ( p = 0.001) in the first week of treatment, were identified to be risk factors of shunt dependency. Out of these independent risk factors, the EROS score was developed. The area under the receiver operating curve (AUROC score = 0.90) shows a good performance of this score. Patients with >3 points showed a significantly high risk of shunt dependency. Conclusion The EROS score is easy to determine and showed a good predictive value in the investigated patient population. Prospective validation is still needed.
Background The temporal stem is a critical structure within the brain, connecting the frontal, temporal, and occipital lobes via various fiber tracts. This study aims to evaluate the use of photogrammetry surface scanning and magnetic resonance imaging (MRI)-based tractography in presenting the layered anatomy of the fibers comprising the temporal stem. Objective This study aimed to clearly present the layered anatomy of the fibers comprising the temporal stem through photogrammetry surface scanning methods and MRI-based tractography studies. Materials and Methods Three body donor-based brain dissections were documented with photogrammetry surface scanning and compared with MRI-based diffusion tensor imaging tractography. High-resolution three-dimensional (3D) models were created using both techniques to visualize the layered fiber architecture of the temporal stem. Tractography data were processed using DSI Studio software based on population-averaged white matter templates from open-access databases. Results Seven photorealistic 3D models were generated through photogrammetry, complemented by detailed coronal sections of an MRI-based 3D tractography model. These models revealed the anatomical organization of critical fiber tracts, including the inferior fronto-occipital fasciculus, uncinate fasciculus, anterior commissure, and Meyer's loop of the optic radiation. Conclusion The temporal stem is a crucial anatomical region comprising important white matter tracts. Their layered anatomical course can be clearly demonstrated by stratigraphical dissections and surface scanning methods, as well as augmented with 3D segmentation of MRI data. White matter dissection perfectly fits photogrammetry, permitting stratification and creating a truly interactive experience, allowing a more precise 3D representation of individual fibers, their orientation, and position, surpassing the limitations of 2D representations of anatomy.
