Management of unruptured intracranial aneurysms (UIAs) requires weighing rupture risk against treatment risk. As endovascular techniques have evolved, microsurgical intervention has become increasingly concentrated at high-volume centers and reserved for complex cases, potentially representing a higher-risk endeavor than reflected in earlier series. A contemporary evaluation of patient and aneurysm-related features associated with surgical risk and postoperative outcomes is needed. We conducted a single-centre retrospective review of 404 UIAs across 347 patients treated between 1998–2024 at TWH. Demographics, aneurysm characteristics, treatment details, and functional outcome (modified Rankin Scale [mRS] at 4–6 weeks) were recorded. Multivariable Firth penalized logistic regression identified factors associated with postoperative dependency (mRS ≥ 3). Aneurysm size greater than 1 cm was independently associated with worse postoperative outcomes (OR 2.4, 95
Traumatic venous sinus thrombosis (tCVST) is a recognised complication of traumatic brain injury (TBI), usually secondary to adjacent skull fractures or intracranial haemorrhage. The optimal timing of diagnostic CT venography (CTV) and anticoagulation initiation remains uncertain. A retrospective cohort study was performed at Queen Elizabeth Hospital Birmingham, a UK Major Trauma Centre, including patients aged > 16 years with radiologically-confirmed tCVST between January 2020-December 2023 who survived ≧48 h after TBI. Demographics, injury characteristics, treatment, radiological and functional outcomes were analysed. Five inpatient anticoagulation pathways were recorded descriptively and collapsed into three clinically interpretable categories for comparative analyses: no LMWH, prophylactic LMWH only and any therapeutic-dose anticoagulation exposure. 56/1411 TBI admissions (4
End-to-side (ETS) anastomosis is a prevalent approach in cerebral revascularization; nevertheless, the effects of interrupted suturing (IS) versus continuous suturing (CS) methods on perfusion in tiny vessels are still contentious. This study aims to examine the effects of IS and CS procedures on the perfusion of the jugular vein (JV) to common carotid artery (CCA) ETS anastomosis in rats. Sixteen rats were randomly allocated into two groups to undergo ETS anastomosis via IS or CS. The laser speckle contrast imaging equipment was employed for postoperative perfusion evaluation by delineating the region of interest at the proximal and distal ends of the anastomosed artery and JV immediately postoperation, as well as at 1, 2, 4, and 6 h thereafter. No statistically significant difference was observed in the diameter of the anastomotic stoma between the two groups. The perfusion volume of the donor and recipient vasculature increased throughout time, especially during the first two postoperative hours. No statistically significant differences were observed in vascular perfusion at both the proximal and distal ends of the anastomosed artery, as well as at JV, between the IS and CS groups at multiple monitoring intervals during a 6-h postoperative timeframe. The current short-term study indicates that there are no statistically significant differences in the perfusion of donor and recipient arteries shortly after surgery between the IS and CS groups in the JV-CCA ETS model in rats.
Neuromuscular choristoma (NMC) is a rare developmental peripheral nerve lesion characterized by muscle tissue within the affected nerve and a recognized association with NMC-associated desmoid-type fibromatosis (NMC-DTF). Its clinicoradiologic profile and comparison between published and institutional cases remain incompletely defined. A systematic review of the peripheral nerve NMC literature, excluding central nervous system cases, was performed in accordance with PRISMA principles using PubMed and Google Scholar. Published cases meeting imaging and/or biopsy-based diagnostic criteria were compared with retrospectively identified institutional cases. Demographic, clinical, imaging, pathologic, and molecular variables were extracted. Twenty-nine articles reporting 48 literature cases and 30 institutional cases were included. In both cohorts, NMC most commonly involved large proximal nerves, particularly the sciatic nerve and brachial plexus, and was frequently associated with weakness, nerve-territory undergrowth, and NMC-DTF. Institutional cases were more likely to undergo MRI and PET imaging, and be managed without biopsy. MRI was performed in all institutional cases and in 35 literature cases, whereas PET was used in 12 and 2 cases, respectively. CTNNB1 alterations were identified in both NMC and NMC-DTF. NMC is a rare but distinctive lesion with a recognizable clinicoradiologic phenotype, most commonly affecting the sciatic nerve. Contemporary diagnosis appears increasingly imaging-based, supporting a no-touch approach and reinforcing the biologic link between NMC and NMC-DTF.
Interposition during microvascular decompression (MVD) is effective but may be associated with recurrence and may be insufficient for large or ectatic vessels. The tuck-in-pocket (TIP) technique uses a Teflon sling secured within a small dural pocket in the petrous dura or tentorium to transpose the offending vessel after standard retrosigmoid exposure. The TIP technique provides a simple, fixation-free method for vascular transposition and may serve as a feasible and safe alternative MVD method in neurovascular compression syndromes.
Ludvig Puusepp is usually remembered through a single chronological claim: his 1910 appointment in St. Petersburg as the first holder of a professorship specifically designated for surgical neurology. However, this framing does not fully explain the academic, linguistic, and political settings that shaped his role in the early development of neurosurgery. This historical review reassesses Puusepp through primary and near-primary sources, including his German-language monographs, Folia Neuro-Chirurgica/Folia Neuropathologica Estoniana, archival biographical material, and institutional histories of St. Petersburg and Tartu/Dorpat. The historical analysis indicates that Puusepp’s early career materialized Vladimir Bekhterev’s model of surgical neurology in imperial St. Petersburg, where neurological diagnosis, localization, operative treatment, teaching, and clinic organization were conceived as a single program. His later work in Tartu/Dorpat developed this model within a Baltic academic environment historically connected to German-language scholarship and, after 1919, to independent Estonian medicine. His major writings should therefore be interpreted not merely as bibliographic achievements, but as tools of specialty formation. The Soviet occupation of Estonia disrupted the European-oriented academic conditions under which the Tartu school had operated. Puusepp’s legacy lies not only in chronological priority, but in his role as a trans-imperial institutional actor who linked St. Petersburg surgical neurology, Baltic-German academic culture, independent Estonian medicine, and the political rupture of early neurosurgical institutions.
The semi-sitting position offers distinct microsurgical advantages for vestibular schwannoma resection but predisposes to postoperative intracranial air accumulation. While pneumocephalus is commonly regarded as an expected radiographic finding, its volumetric burden and the determinants of patient- and procedure-specific factors remain incompletely characterized. We retrospectively analyzed 48 consecutive vestibular schwannoma resections performed in the semi-sitting position at a single tertiary center. Postoperative pneumocephalus. was quantified using CT-based volumetric segmentation. Air burden was analyzed both categorically (> 10 mL vs ≤ 10 mL) and continuously (log-transformed volume). Candidate predictors were assessed using univariate and multivariable Firth penalized logistic regression, complemented by robust linear regression to evaluate continuous dose–response relationships. Collinearity was formally assessed prior to multivariable modeling. High postoperative pneumocephalus (> 10 mL) occurred in 12.5
Impairments in executive functioning (EF) and inhibitory control (IC) negatively affect patients’ health-related quality of life. We introduced an intraoperative Stroop task (iST) as means of monitoring IC. This study summarizes lessons learned over the past decade since implementation of iST. We focus on its feasibility, potential in preserving EF and anatomical correlates of intraoperative errors. We retrospectively examined 119 treatment-naïve WHO grade II-IV glioma patients, undergoing awake surgery and perioperative neuropsychological testing between 2010–2020. We compared clinical characteristics between iST and non-iST patients. We examined EF including IC at both group and individual level. Patients underwent magnetic resonance scanning according to clinical routine, from which preoperative glioma location and iST error type maps were constructed. The iST appeared feasible where it was planned to be performed in a broad glioma population (118/119; 99
Idiopathic intracranial hypertension (IIH) typically affects obese women of reproductive age. Ventriculoperitoneal (VP) shunting is an established surgical treatment for severe or medically refractory cases. There is limited knowledge regarding the management of these patients when they become pregnant. Here, we report our multidisciplinary experience in this subgroup of IIH. Our database on IIH was retrospectively screened for women who were diagnosed and treated with a VP shunt from 2005 to 2025. We analyzed onset of IIH in relation to pregnancy, number of pregnancies resulting in live births before and after VP shunting, and the mode of delivery. Overall 61 women with IIH underwent VP shunting during the study period. Nine women had 12 pregnancies resulting in live births at a median of 40.5 months after VP shunting (range 6–108). Onset of IIH was not related to the occurrence of pregnancies in all but one patient. 9/12 pregnancies resulted in vaginal delivery. Adjustment of the shunt valve was not required in these patients. One patient experienced progressive visual loss refractory to acetazolamide treatment during the first trimester. VP shunting at 11 weeks of gestation facilitated stabilization of her visual symptoms and delivery via elective Caesarean section. There were no peripartum cases of infection or malfunction of the shunt system. The complexity of IIH during pregnancy requires a multidisciplinary approach in order to achieve an optimal outcome. In our cohort of previously shunted IIH patients with programmable valves and gravitational units, neither the occurrence of a pregnancy nor a vaginal delivery increased the risk for disease recurrence or deterioration. In severe cases, VP shunting remains a treatment option during pregnancy when clinically indicated.
In neuroendoscopic surgeries, instrument-endoscope interference can prevent instruments from reaching certain areas visible within the endoscopic view, leading to the perception of a “restricted zone” (RZ). We aimed to visualize and quantitatively evaluate the RZ, thereby enabling intuitive understanding of instrument–endoscope interference. Cadaver studies were conducted to investigate the typical endoscope-target distance, a key factor affecting RZ formation. Based on this distance, a simulated surgical field was created using an endoscope and light source, with light projected from the instrument’s entry point. Illuminated regions represented areas accessible to a straight instrument, while shadows cast by the endoscope or other instruments indicated unreachable areas—RZs—visualized within the endoscopic view. The study examined changes in the RZs under various conditions. In cadaver experiments, the typical endoscope-target distance was approximately 7–20 mm. The visualized RZ consistently appeared on the side opposite the instrument in the endoscopic view regardless of endoscopic tip movement. Under typical conditions, the RZ occupied 6.0–28.2
Abstract Purpose Simple generalized thresholds for assessing functional impairment in clinical testing are limited, as they fail to consider patient-specific properties such as age, body height, and body mass index. A previously developed machine learning-based model for personalized testing using the five-repetition sit-to-stand (5R-STS) test, that estimates personalized upper limits of normal (ULN) to identify objective functional impairment (OFI) was externally validated to evaluate its performance and generalizability across cohorts. Methods Only healthy individuals were included in the study. After the machine learning-based model was applied to this external dataset, expected and observed 5R-STS test times were compared using standardized performance assessment metrics including root mean square error (RMSE), mean absolute error (MAE), and R 2 values. Additionally, a Bland–Altman analysis was performed to assess agreement between observed and expected values. Validation of the expected ULN involved comparing the proportion of individuals exceeding their personalized thresholds with the corresponding proportion based on the generalized threshold. Subgroup analyses by test setting and country of residence were additionally performed, along with a graphical assessment of model performance. Results Application of the model to 171 healthy individuals resulted in an RMSE of 2.33 (95% CI: 1.93 to 2.73) seconds, MAE of 1.70 (95% CI: 1.47 to 1.94) seconds, and R 2 of 0.064 (95% CI: -0.25 to 0.15). The Bland–Altman analysis demonstrated a mean bias of -1.1 s. Based on the personalized ULNs, OFI was classified in 17.5% of individuals, compared to 6.4% when using the generalized threshold of 10.4 s. These analyses indicated limited external generalization, with acceptable approximation for some faster and mid-range test times but systematic underestimation of slower test times. Multivariable regression analyses showed that remote testing was independently associated with greater prediction bias and higher odds of personalized ULN exceedance compared with supervised testing (adjusted mean difference: − 0.90 s; adjusted OR: 10.7). Exploratory country-of-residence analyses showed differences across the three largest national subgroups. 130 (76.1%) rated ease of use as excellent, and 145 (84.9%) rated clarity of instructions as excellent. 143 participants (83.6%) indicated that they prefer the 5R-STS over a battery of questionnaires. Conclusions In the context of personalized testing, moving toward individually focused precision assessment of patients requires rigorous external validation to ensure the robustness of such applied computational methods. In this external validation, the model demonstrated limited generalization including a systematic underestimation of slower test times and insufficient personalized ULN calibration. These findings indicate that external validity of models derived from single-center data can be limited, underscoring the importance of comprehensive external validation and, potentially, multicenter retraining before clinical implementation.
Obstructive sleep apnea (OSA) is associated with various cardiovascular and cerebrovascular conditions; however, its prevalence among patients with intracranial aneurysms (IAs) remains insufficiently characterized. Emerging evidence suggests that OSA may contribute to IA formation, progression, and outcomes after rupture. This study included 244 participants: 84 IA patients without prior clinical suspicion of OSA and 160 OSA-symptomatic comparators. Overnight respiratory polygraphy (RP) was used to assess apnea–hypopnea index (AHI) and presence of OSA. Group differences were analyzed using models adjusted for age, BMI, and sex. Among IA patients, 50.0
Traumatic brain injury (TBI) presents competing risks of venous thromboembolism (VTE) and intracranial haemorrhage progression, rendering pharmacological thromboprophylaxis (PTP) timing uniquely contentious. The dilemma is most acute in severe TBI, where both risks are greatest. This systematic review and meta-analysis (PROSPERO: CRD420261388300) evaluates early versus late PTP on VTE, intracranial haemorrhage progression, and mortality in adults with severe TBI, applying a strict severity definition (Glasgow Coma Scale (GCS) 8 or less in 100
Ernst Rektoržik was a 19th-century surgeon-anatomist. His name lives on eponymously in association with the venous plexus he first described, traveling with the petrous part of the internal carotid artery. As very little has been published about this historical figure beyond this eponymous usage, the following article provides an overview of his life and contributions to surgical anatomy. Additionally, an English translation of his paper describing the above-noted venous plexus is included. Standard search engines were used to review the available literature on Ernst Rektoržik. This literature was analyzed, and a narrative review was created. It is on pioneers such as Rektoržik that our current knowledge of skull base anatomy is based.
Anterior clinoid meningiomas (ACM) and tuberculum sella meningiomas (TSM) are anterior skull base tumors that commonly cause visual deterioration. The supraorbital keyhole approach may be used to resect these tumors but is limited by restricted intraoperative maneuverability. To describe and demonstrate the safety and efficacy of our modified minimally invasive cranio-orbital craniotomy compared to traditional approaches. All patients with an ACM or TSM treated with a modified cranio-orbital or traditional fronto-orbital (FO) craniotomy by the senior author were included. A literature review was conducted for ACMs and TSMs treated by transcranial (TC), endoscopic endonasal approach (EEA), and supraorbital keyhole (SoK) approaches. Visual outcomes, extent of resection, and complications were compared. Six patients who underwent modified cranio-orbital craniotomy and 4 patients who underwent FO were included. Amongst patients with preoperative visual deficits, 2/4 modified cranio-orbital patients experienced postoperative visual improvement, compared to 3/3 FO patients (p = 0.43). Extent of resection was similar between groups. Complications related to superficial tissue dissection were less common in the modified cranio-orbital group (p = 0.03). In the literature, EEA approaches were associated with higher rates of visual improvement compared to TC or SoK approaches, but EEA was associated with higher rates of postoperative CSF leak. Rate of visual improvement in our modified cranio-orbital patients were similar to those reported in the literature. Our modified cranio-orbital craniotomy is a safe and effective approach that should be considered when planning for resection of ACMs and TSMs.
Glioblastoma (GBM) is characterized by near-universal recurrence after surgical resection, necessitating close postoperative surveillance. Although MRI remains the gold standard for detecting tumor progression, fixed imaging intervals may delay recognition of recurrence. Sonolucent cranial implants enable transcranioplasty ultrasound (TCUS), offering a potential point-of-care adjunct for interval monitoring between scheduled MRI studies. We evaluated the feasibility of identifying sonographic findings concordant with MRI-confirmed GBM recurrence during routine outpatient follow-up. We conducted a retrospective review of prospectively registered consecutive GBM patients who underwent tumor resection with placement of a sonolucent cranial implant (ClearFit®, Longeviti Inc., Baltimore, MD) at a single tertiary center (February 2023–November 2025). Patients were included if they developed MRI-confirmed recurrence and underwent TCUS within 6 weeks before or after the recurrence-detecting MRI. TCUS examinations were performed during routine outpatient visits and interpreted by a clinician blinded to MRI findings. MRIs were independently reviewed by board-certified neuroradiologists. TCUS findings were qualitatively compared with MRI-defined recurrence. Of 13 patients with sonolucent implants, 8 developed MRI-confirmed recurrence within 13 months of resection, with a range of 1 to 13 months. Four underwent TCUS within six weeks of the recurrence-detecting MRI. In all four cases, TCUS demonstrated hyperechoic abnormalities spatially concordant with MRI-defined recurrence. Examinations were safely performed (n = 4) in the outpatient setting. TCUS through sonolucent cranial implants may demonstrate concordant findings with MRI-confirmed GBM recurrence. This preliminary series supports its spatial correlation to inform future studies that evaluate TCUS as a point-of-care adjunct for interval surveillance. Prospective studies are warranted to define standardized protocols and diagnostic performance.
The occipital transtentorial approach (OTA) is a useful surgical corridor for deep-seated lesions involving the pineal region, thalamus, ventral temporal structures, and posterior fossa. Although occipital lobe injury is a recognized complication of OTA, its relationship with postoperative epilepsy has not been systematically investigated. We examined the association between postoperative occipital lobe injury and de novo epilepsy following OTA. Thirty-two consecutive OTA procedures performed in 31 patients between 2013 and 2025 were retrospectively reviewed. Clinical records, operative videos, and magnetic resonance imaging studies were analyzed. Postoperative occipital injury was assessed using the final follow-up fluid-attenuated inversion recovery (FLAIR) MRI. Patients were classified according to postoperative FLAIR lesion volume (0 mL, < 2 mL, and ≥ 2 mL). Factors associated with de novo epilepsy and postoperative FLAIR lesions ≥ 2 mL were evaluated. De novo postoperative epilepsy developed after 4 of 32 procedures (12.5
This study aims to develop and validate a more efficient diagnostic system for suspected ventriculoperitoneal shunt dysfunction by integrating traditional radionuclide shuntgraphy with SPECT imaging. This retrospective study examined patients with suspected shunt malfunction admitted to our neurosurgery department from 2021 to 2024, who underwent SPECT/CT imaging of the ventricular shunt. SPECT/CT results were categorized as three groups based on tracer behavior: normal shunt function, partial obstruction, and shunt obstruction. Baseline data, imaging characteristics and clinical management were recorded. Diagnostic agreement with surgery was analyzed only in patients who underwent revision, the only subgroup with a definitive intraoperative reference standard. A study of 46 SPECT/CT images from 42 patients found 14 normal shunt functions, 23 with partial obstruction, and 9 with complete obstruction. Nineteen patients underwent surgery, and SPECT/CT demonstrated good agreement with intraoperative findings (16/19), corresponding to a sensitivity of 88.9
Mild Traumatic Brain Injury (mTBI) neurosurgical referrals are increasing. This study aimed to externally validate a radiological scoring system to define a ‘neurosurgically significant’ mild TBI and evaluate its impact on referral outcome if implemented. Retrospective, external validation of the UK Liverpool Head Injury Tomography Score (LIV-HITS). Consecutive neurosurgery referrals to a tertiary neurosurgery centre for mild TBI were included (1st January 2022—30th June 2022). Mechanism of injury, LIV-HITS and management decision were identified, and diagnostic accuracy determined. A total of 1547 referrals were included. 147 (9.5
Proximal catheter-related complications of ventriculoperitoneal shunt (VPS) and Ommaya reservoir implantation remain an important factor leading to reoperation rates and morbidity. Conventional fixation methods often fail to provide adequate mechanical stability. A shallow outer burr hole is created to accommodate a catheter with right-angle guide. A smaller inner burr hole is then drilled at the centre to expose the dura and allow catheter passage. The connector is anchored to the preserved pericranium using nonabsorbable sutures, followed by reapproximation of the periosteal flap. This technique provides a robust, multiplanar mechanical barrier against catheter migration and kinking.
