Postoperative stereotactic radiotherapy (SRT) is widely used after resection of limited brain metastases, but the optimal fractionation remains uncertain. Single-fraction stereotactic radiosurgery (SF-SRS) is convenient and well established, whereas hypofractionated stereotactic radiotherapy (HF-SRT) may improve dose delivery and normal tissue tolerance in larger or more complex cavities. This systematic review and meta-analysis compared these two postoperative approaches. PubMed, Scopus, and Embase were searched from inception to December 23, 2025. Original comparative studies enrolling adults treated with postoperative cavity-directed stereotactic radiotherapy were included. Risk of bias was assessed using ROBINS-I. Seven retrospective comparative studies met the inclusion criteria, representing 589 patients and 649 resection cavities. The most common primary tumor was non-small cell lung cancer followed by melanoma and breast cancer. The RT dose in the single fraction population was between 15 and 20 Gy across the studies. Also, the hypofractionated regimen consisted of 3 to 6 fractions with the total dose being anywhere from 14 to 32.5 Gy. At 6 months, local control was marginally higher with SF-SRS than HF-SRT (RR 1.05, 95
This study aims to compare the risk of instrumentation failure between dynamic and rigid posterior spinal stabilization systems using propensity score matched cohorts, and to investigate the role of spinopelvic parameters and patient-related factors in construct longevity. A retrospective analysis was conducted on 952 patients who underwent thoracic, thoracolumbar, thoracolumbosacral, lumbar, or lumbosacral instrumentation between 2018 and 2024. Instrumentation failure (rod fracture, screw fracture, migration, pull-out, or loosening) was identified in a subgroup of 106 patients. Propensity score matching (1:1 nearest-neighbor, caliper 0.1) was applied using age, sex, osteoporosis, number of instrumented segments, and involvement of S1 as the lowest instrumented vertebra, yielding two matched cohorts of 196 dynamic and 196 rigid stabilized cases with improved baseline comparability. Survival differences were assessed by Kaplan-Meier and log-rank tests, and multivariable Cox regression was performed in both the full cohort and matched groups to identify potential risk factors. The overall failure rate was 11.1
Definitive treatment for aneurysmal subarachnoid hemorrhage (aSAH) includes microsurgical clipping and endovascular treatment (EVT). In randomized trials such as ISAT and BRAT, EVT showed superiority in short-term outcomes and comparable or favorable long-term results. Delayed cerebral ischemia is one of the most important determinants of clinical outcomes after treatment for aneurysmal subarachnoid hemorrhage caused by ruptured intracranial aneurysms. Although its pathophysiology is multifactorial, cerebral vasospasm has long been considered a major contributing factor. In Japan, fasudil has traditionally been used as a perioperative pharmacological agent for the prevention of cerebral vasospasm; since 2022, clazosentan has also become available. This study aimed to compare outcomes between clipping and EVT before and after the introduction of clazosentan in patients with aSAH. Using RECOVER registry data, we analyzed patients with aSAH who underwent definitive treatment with clipping or EVT within 48 h of onset and received either fasudil or clazosentan between 2021 and 2024. The primary endpoint was a favorable functional outcome at discharge, defined as a modified Rankin Scale (mRS) score of 0–2. Secondary endpoints included cerebral vasospasm, delayed cerebral ischemia (DCI), pulmonary complications, hypotension, cerebral edema, and new intracranial hemorrhage. In multivariable analyses, we adjusted for age, World Federation of Neurosurgical Societies (WFNS) grade, Fisher group, anterior circulation aneurysm, and the use of cerebrospinal fluid drainage. The study period was divided into the fasudil era and the clazosentan era, corresponding to the periods before and after the introduction of clazosentan, respectively. A total of 496 patients were analyzed, of whom 57.5
Penetrating injury to the dural venous sinuses (DVS) commonly occurs at the superior sagittal sinus (SSS), transverse sinus (TS), and torcular confluence. While rare, DVS penetrating injuries carry high risk of intracranial hemorrhage, air embolism, and venous infarction. The current literature pertaining to penetrating DVS injury consists primarily of isolated case reports and small series. This scoping review consolidates published cases to characterize mechanisms, management strategies, and clinical outcomes pertaining to penetrating DVS injury. A scoping literature search of PubMed, PubMed Central, Embase, and Scopus was performed through September 2025. English-language case reports, case series, and retrospective studies describing penetrating cranial trauma involving the SSS, TS, or torcula were included. Data were summarized descriptively. Twenty-five studies met inclusion criteria, encompassing low-velocity penetrating injuries, civilian firearm trauma, captive-bolt injuries, and wartime shrapnel. Low-velocity injuries were typically managed with wide exposure, circumferential sinus control, and either flow-preserving repair or selective SSS ligation, with favorable neurological outcomes. Firearm-related injuries demonstrated greater variability, ranging from excellent recovery after torcular reconstruction to delayed sinus thrombosis and fatal pulmonary air embolism following incomplete SSS sealing. Reconstruction was generally favored for posterior SSS, torcular, and dominant TS injuries, whereas ligation was better tolerated for anterior or mid-SSS lesions. Penetrating DVS injuries require early venous imaging, meticulous sinus control, and segment-specific decisions regarding repair versus ligation. Flow-preserving reconstruction is increasingly feasible and may optimize survival and neurological recovery.
Psychiatric morbidity following craniectomy remains underexplored, with physical disability outcome measures forming the mainstay of follow-up tests used during rehabilitation. There are no predictive models to identify patients at a higher risk of new psychiatric drug initiation. We investigated new psychiatric drug initiation in a mixed-indication cohort following craniectomy and developed a risk stratification model. Our retrospective single-centre study identified 145 patients who underwent a supratentorial craniectomy between 2020 and 2025. Predictor variables were selected based on clinical plausibility, including age, Glasgow Coma Scale (GCS), pupillary response, American Society of Anaesthesiologists (ASA) grade, Index of Multiple Deprivation (IMD) rank, indication for surgery, laterality, and comorbidities. The primary outcome was new psychiatric medication initiation in patients without a pre-existing psychiatric diagnosis. Logistic regression and LASSO penalised modelling were performed. The model was internally validated using bootstrap optimism correction and regression coefficient shrinkage. Across the whole cohort, 33.8
Spinal intramedullary melanocytoma (SIM) is an exceptionally rare benign melanocytic tumor of the central nervous system, with only a limited number of cases reported to date. Diagnosis is frequently delayed and relies on histopathological confirmation to differentiate SIM from other melanocytic lesions, including malignant melanoma. Owing to the rarity of this entity, its natural history, optimal management, and follow-up strategies remain insufficiently defined. We aimed to systematically synthesize the available evidence on clinical presentation, treatment strategies, and outcomes of SIM. A systematic review was conducted according to PRISMA guidelines. PubMed and Cochrane Library were searched up to April 15th, 2026 for reports of histologically confirmed SIM. Case reports and case series in English, French, and Spanish were included. Extracted data comprised demographics, tumor location, clinical presentation, treatment, extent of resection (EOR), adjuvant therapy, and outcomes. Descriptive statistics with 95
Delayed cerebral infarction (DCI) is a major cause of poor outcome after aneurysmal subarachnoid hemorrhage (aSAH) and is closely associated with intracranial blood burden. Pressure-controlled cerebrospinal fluid (CSF) irrigation techniques have been developed to actively accelerate blood clearance; however, their overall clinical effectiveness and safety profile have not been comprehensively evaluated in a comparative framework. Accordingly, we performed a systematic synthesis of the available evidence focusing on both clinical efficacy and treatment-related safety outcomes. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines to evaluate both safety and efficacy. PubMed/MEDLINE, Embase, and Scopus were searched from inception through October 15, 2025. Studies comparing pressure-controlled active CSF irrigation techniques (including stereotactic ventriculocisternostomy, cisterno-ventricular catheter systems, ventriculo-lumbar irrigation, and lumbo-lumbar irrigation) with non-pressure-controlled management were included. The primary radiographic outcome was delayed cerebral infarction. Secondary outcomes captured both additional efficacy endpoints and safety, including symptomatic vasospasm, in-hospital mortality, functional outcome, and procedure-related complications. Arm-specific outcome prevalences were pooled descriptively using random-effects models, while comparative treatment effects were synthesized as odds ratios from direct within-study comparisons between pressure-controlled and non-pressure-controlled management. Risk of bias was assessed using ROBINS-I and RoB 2. Nine studies comprising 2,033 patients were included; most evidence was observational and at serious risk of confounding. In direct within-study comparative meta-analyses, pressure-controlled irrigation was associated with lower odds of delayed cerebral infarction (OR 0.36, 95
Spinal metastases are a common and morbid manifestation of advanced prostate cancer. Stereotactic body radiotherapy (SBRT), including single-fraction stereotactic radiosurgery (SRS), has emerged as a high-precision modality capable of delivering ablative doses with excellent local control. However, outcomes following spinal SBRT may differ according to hormonal sensitivity, particularly between hormone-sensitive prostate cancer (HSPC) and castration-resistant prostate cancer (CRPC). To systematically evaluate outcomes following stereotactic body radiotherapy for prostate cancer spinal metastases and assess differences between hormone-sensitive and castration-resistant disease. A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Scopus, Web of Science, Cochrane Library, and Embase databases were searched on 20/06/2025. Eligible studies included adult patients with spinal metastases from prostate adenocarcinoma treated with SBRT/SRS and reported outcomes stratified by hormonal status where available. Data extracted included local control (LC), overall survival (OS), progression to castration resistance, pain response, treatment-related toxicity, and radiation dose–fractionation parameters including biologically effective dose (BED₃). Study quality was assessed using the ROBINS-I tool. Five studies including 322 patients and 501 spinal lesions were included. Spinal SBRT achieved high local control, with 1–2-year LC typically exceeding 90
Purpose: Idiopathic spinal cord herniation (iSCH) is a rare cause of myelopathy characterized by protrusion of the spinal cord through a focal defect in the dura mater. Its pathogenesis remains poorly understood. In this study, we present evidence supporting an acquired mechanism involving dural dissection. Methods: We conducted a single-center case series of patients diagnosed with iSCH, with a focus on clinical and radiological features that provide insight into the condition’s etiology and natural history. Results: We identified 18 patients with iSCH, including 15 who underwent surgical treatment. In 14 patients (78
Achieving biochemical remission in growth hormone-secreting pituitary neuroendocrine tumors (GH-PitNETs) with cavernous sinus invasion (Knosp grade 3–4) remains a significant surgical challenge. The objective was to evaluate the outcomes of the endoscopic endonasal transcavernous approach (transcavernous-EEA) and identify predictors of postoperative biochemical remission. This retrospective study included 50 patients with Knosp grade 3–4 GH-PitNETs. Patients were divided into two cohorts: Group 1 (prior to October 2020) received conventional EEA, while Group 2 (after October 2020) underwent transcavernous-EEA. The biochemical remission rate was significantly higher in Group 2 (64.7
Extracranial-intracranial (EC-IC) bypass surgery within the middle cerebral artery (MCA) territory is the gold standard for treating Moyamoya patients once hemodynamic insufficiency is confirmed. Although the anterior (ACA) and posterior cerebral arteries (PCA) are frequently involved, revascularization of these territories is not yet part of the standard treatment regimen; most centers focus exclusively on the MCA. Our approach, however, targets all hemodynamically compromised regions by providing tailored, multi-territorial revascularizations. Indications for additional ACA and/or PCA bypasses are determined by advanced imaging, such as PET-CT or CO2-triggered breath-hold MRI (bh-fMRI), to precisely evaluate cerebrovascular reserve. Here, we present the results of the first large case series focusing on non-MCA revascularization in adult Moyamoya patients. A total of 233 Moyamoya patients were analyzed, of whom 66 (28.3
Immune checkpoint inhibitors (ICIs) are promising for leptomeningeal disease (LMD), but systemic delivery is limited by poor cerebrospinal fluid penetration and treatment-related toxicity. This study evaluates the safety and efficacy of adjunctive intrathecal (IT) ICI therapy compared with systemic ICI alone. We report two institutional cases of melanoma-associated LMD treated with IT ICI alongside systemic therapy. Following PRISMA guidelines, PubMed, Embase, and Scopus were systematically reviewed, identifying 28 eligible studies consisting of case reports, small series, and early phase trials. Of 542 patients screened, 201 received ICI therapy: 161 systemic ICI alone and 40 IT ICI with concurrent systemic therapy. Patient-level and aggregate data were extracted to compare adverse events (AEs), progression-free survival (PFS), and overall survival (OS). Exploratory time- and dose-adjusted analyses accounted for differences in treatment exposure. IT ICI therapy demonstrated a favorable safety profile. At the patient level, adjunct IT delivery was associated with a non-significant trend toward reduced grade ≥ 3 AE risk (RR 0.50; 95
Spinal dural arteriovenous fistulas (SDAVFs) are underrecognized, and delayed diagnosis can result in irreversible neurological deficits. Magnetic resonance angiography (MRA) provides noninvasive, high-resolution vascular imaging of SDAVFs. Digital subtraction angiography (DSA) is the diagnostic gold standard; however, it is invasive and may yield nondiagnostic results. This is the first study to systematically compare the diagnostic accuracy of DSA and MRA using surgically confirmed SDAVFs as the reference standard. Following PROSPERO registration (CRD42023474375), PubMed, Embase, and Web of Science were searched from inception to March 2024 for adult studies reporting MRA and/or DSA alongside surgically confirmed vertebral-level localization, using PRISMA guidelines. Primary outcomes were pooled sensitivity, positive predictive value (PPV), and accuracy for lesion detection and localization. Thirteen studies comprising 133 patients met inclusion criteria. Across these studies, 102 patients underwent MRA and 83 underwent DSA. Pooled PPV was 0.806 for MRA (95
To externally validate the HATCH score for predicting 6-month neurological outcomes in patients with aneurysmal subarachnoid hemorrhage in a multicenter Latin American cohort, and to compare its performance with the Hunt–Hess and WFNS scales. Retrospective study across three Argentine hospitals (2011–2024). Adults with aSAH admitted to the ICU were included. The primary outcome was 6-month functional status (mRS 0–3 vs. 4–6); the secondary outcome was 12-month mortality. Discrimination was assessed with AUROC (DeLong test), and calibration with calibration-in-the-large (CITL) and slope, using risks from original derivations. 177 patients were analyzed; 57
The optimal timing of surgical intervention for peripheral nerve injuries (PNIs) after gunshot wounds (GSWs) is controversial. Although delayed intervention has traditionally been preferred, recent reports suggest earlier intervention may improve outcomes. This study compares early (≤ 3 months) versus delayed (> 3 months) surgical management of PNIs following GSWs. We retrospectively reviewed patients treated at a tertiary academic center between 2000 and 2023 who underwent surgical intervention for PNIs secondary to GSWs. A systematic review was conducted following PRISMA guidelines. PubMed, Embase, and Web of Science databases were searched for clinical studies reporting outcomes of PNIs after GSWs. A proportional meta-analysis was performed using a random-effects model. Fifteen patients (mean age of 38.3 years) underwent surgical intervention at a mean of 4.6 months post-injury. Seven patients were treated early, and 7 underwent delayed intervention. At follow-up, improvement in motor and/or sensory function was observed in 5 out of 7 early cases and 6 out of 7 delayed cases (p = 1.000). Eleven studies published between 1995 and 2023, involving 271 nerves, were included in the meta-analysis. Functional improvement occurred in 58.7
Adult thalamic gliomas (ATGs) are rare and biologically heterogeneous tumors. Although the 2021 World Health Organization (WHO) classification designates all diffuse midline gliomas (DMGs), H3-altered, as grade 4, accumulating evidence suggests that adult thalamic DMGs may exhibit more indolent clinical behavior, compared with glioblastomas or pediatric DMGs. In this study, we aimed to characterize the clinical, radiological, pathological, and molecular features of ATGs and identify clinically relevant prognostic markers, with particular focus on H3K27M and TERT promoter (TERTp) mutations. We retrospectively analyzed 45 adult patients (≥ 18 years) who underwent surgical resection or biopsy for ATGs between 2007 and 2023. Clinical, radiological, pathological, and molecular data were collected, and prognostic factors for overall survival were evaluated. Patients with thalamic DMG demonstrated significantly longer overall survival (OS) than those with glioblastoma (median OS, 24.6 vs. 12.4 months; p = 0.035). In multivariate Cox regression analysis adjusted for age, WHO grade, H3K27M status, and TERTp status, TERTp mutation emerged as an independent predictor of poor survival (hazard ratio [HR], 1.81; p = 0.026), whereas H3K27M mutation was not significantly associated with outcome (HR, 0.93; p = 0.77). Younger age (< 45 years) was independently associated with longer OS, and WHO grade 4 with shorter survival; however, the survival curves overlapped substantially across histological grades. In ATGs, TERTp mutation was an independent predictor of poor survival and provided prognostic information beyond H3K27M status. These findings support incorporating TERTp status into risk stratification for ATGs.
Idiopathic normal pressure hydrocephalus (iNPH) is commonly treated with ventriculoperitoneal shunt (VPS) implantation, yet accurate patient selection remains challenging because conventional diagnostic tests are variably standardized and partly subjective. We evaluated whether wearable step-count monitoring may provide an objective assessment of real-life mobility and help identify patterns of postoperative mobility improvement. In this prospective pilot study, perioperative mobility was recorded using a wrist-worn wearable tracker (Garmin Vivofit 4). The primary endpoint was change in mean daily step count after VPS implantation. Secondary analyses included comparison between objective responders and non-responders, characterization of the postoperative time course of mobility change, association between objective and subjective clinical response, and exploratory receiver operating characteristic (ROC) analysis to identify a preoperative step-count threshold associated with postoperative mobility improvement. Clinical trial number: not applicable. Twelve patients completed the study protocol. In the overall cohort, postoperative step count increased numerically but did not differ significantly from baseline. Objective responders (n = 8) showed a significant increase in daily step count from 1656 ± 356 to 2311 ± 373 steps/day (p < 0.05), whereas non-responders (n = 4) showed no improvement. Responders had significantly lower preoperative daily step counts than non-responders (median 1118 [IQR 563–1869.5] vs. 5148 [IQR 4202.25–5796.5] steps/day; p = 0.049). In responders, mobility gains became significant from postoperative week 9 onward (F(12,84) = 9.75, p < 0.001), peaking at approximately 2.5-fold baseline by week 11. Objective mobility response was associated with subjective clinical improvement: 7 of 8 objective responders (87.5
The optimal treatment strategy for ruptured middle cerebral artery (MCA) aneurysms remains debated, with microsurgical clipping offering superior occlusion and stroke rates in exchange for a more invasive experience. Although several landmark trials showed an overall benefit for coiling as compared to clipping, MCA aneurysms were underrepresented, and more granular data regarding the impact of the MCA morphology and risk factors have complicated interpretation of preceding data. We sought to perform a comprehensive contemporary meta-analysis comparing clinical and radiographic outcomes after clipping and coiling of ruptured MCA aneurysms. A PRISMA-compliant systematic review and meta-analysis was conducted using MEDLINE and EMBASE through March 2026. Studies reporting occlusion rates, clinical outcomes, and complications for both clipping and coiling in ruptured MCA aneurysms were included. Statistical analysis was performed using a random-effects model with risk ratios (RR) and odds ratios (OR) reported with 95
Gamma Knife radiosurgery (GKRS) is an established treatment for trigeminal neuralgia (TGN); however, no validated biomarkers exist to predict outcomes. In vivo confocal microscopy (IVCM) allows noninvasive quantification of corneal subbasal nerve plexus (SBP) and dendritic cell (DC) density, potentially reflecting trigeminal nerve integrity. This study investigated whether IVCM-derived corneal parameters correlate with and predict pain relief after GKRS in medically refractory TGN. 27 patients with medically refractory idiopathic TGN and 40 healthy controls underwent ophthalmologic examination and IVCM imaging. Pre-treatment parameters included corneal nerve fiber density (CNFD), branch density (CNBD), fiber length (CNFL), total branch density (CTBD), fiber area (CNFA), fiber width (CNFW), fractal dimension (CNFrD), and DC density. GKRS was performed with a single 4-mm collimator shot targeting the retrogasserian portion of the trigeminal nerve (80–90 Gy). Clinical outcomes were assessed using the Barrow Neurological Institute (BNI) Pain Intensity Scale at 12 months. Associations between IVCM parameters and change in BNI score (ΔBNI) were evaluated using correlation and regression analyses, with Benjamini-Hochberg correction for multiple comparisons. A complementary responder-based analysis defined favorable response as BNI I-IIIb at 12 months. Compared with controls, TGN eyes exhibited significantly lower CNFD, CNBD, CNFL, CNFA, and CNFrD (all p < 0.05). Following GKRS, CNFD further decreased (p = 0.034), while DC density increased (p = 0.025). ΔBNI correlated negatively with baseline CNFD (r = -0.526, unadjusted p = 0.003), CNBD (r = -0.500, unadjusted p = 0.006), CNFL (r = -0.436, unadjusted p = 0.018), and CTBD (r = -0.393, unadjusted p = 0.035). After false discovery rate correction, the associations with CNFD, CNBD, and CNFL remained statistically significant. In multivariate analysis, CNFD showed the strongest association with ΔBNI (β = -0.498, p = 0.006; R² = 0.258). Twenty-three patients (85.2
Adoptive cellular therapies may expand treatment options for pediatric brain tumors by focusing activity on tumor antigens and limiting off-tumor effects. We systematically reviewed preclinical and clinical evidence for CAR T cells, TCR-engineered T cells, and NK or γδ T-cell platforms directed against HER2, B7-H3 (CD276), EGFR806-reactive EGFR, GD2, IL13Rα2, and EphA2 or EphA3, with attention to delivery route, safety, persistence, and combination strategies. Following PRISMA, we searched PubMed, Embase, and Scopus from inception through September 17, 2025, restricted to English. The search yielded 324 records; 103 duplicates were removed; 221 titles and abstracts were screened; 180 full texts were reviewed; and 34 studies were extracted by two independent reviewers. We captured design, tumor and molecular features, product engineering, route and schedule, lymphodepletion, toxicities including cytokine release syndrome, immune effector cell associated neurotoxicity, and tumor inflammation associated neurotoxicity, radiographic or clinical response, survival, and correlatives such as persistence or trafficking in blood, cerebrospinal fluid, or tumor tissue, cytokines, and antigen dynamics. In vivo studies showed reproducible antitumor activity for HER2 in medulloblastoma, GD2 in diffuse midline glioma, and multi-antigen constructs incorporating IL13Rα2 and EphA2 in medulloblastoma and ependymoma, with significant survival advantages compared with controls. γδ T cells targeting the EphA axis selectively killed medulloblastoma with neural sparing; GD2 CAR NK-92 inhibited diffuse intrinsic pontine glioma growth. In early clinical programs, route shaped safety and pharmacodynamics. For GD2, low-dose intravenous induction followed by repeated intraventricular dosing produced objective radiographic regressions and manageable tumor inflammation associated neurotoxicity, while dose-limiting cytokine release syndrome was confined to higher intravenous doses. Intraventricular B7-H3 CAR T cells, given without lymphodepletion, enabled multi-cycle dosing with mainly grade 1 to 2 events and cerebrospinal fluid localized persistence. Weekly intracranial EGFR806 CAR T cells were feasible and well tolerated, with stable disease as the best response in a small cohort. Across trials, persistence and immune activation were most evident in cerebrospinal fluid, supporting cerebrospinal fluid centered pharmacodynamic monitoring. Mechanism-based combinations, including IGF-axis inhibition in diffuse midline glioma and epigenetic priming of GD2 with an integrated safety switch in medulloblastoma, enhanced activity. The evidence supports pediatric-centric antigen selection and a CNS-first, locoregional dosing approach to increase on-tumor exposure and reduce systemic toxicity. Priorities include multi-antigen strategies to prevent escape, incorporation of safety switches, earlier deployment when tumor burden is low, and prospective cerebrospinal fluid pharmacodynamics in multisite phase II studies.
