Objective To explore the surgical methods, risk factors and therapeutic effects of standard large trauma craniectomy in the treatment of severe traumatic brain injury at high altitude. Methods The clinical data of 135 patients with severe traumatic brain injury at high altitude who underwent standard large trauma craniectomy (SLTC) were retrospectively analyzed. The patients were followed up for 12 months after surgery, and the therapeutic effect was evaluated using the Glasgow Outcome Scale (GOS). Results Among the 135 patients with severe traumatic brain injury (STBI) at high altitude, 38 cases (28%) achieved good recovery according to GOS, 16 cases (12%) had moderate disability, 15 cases (11%) had severe disability, 3 cases (2.2%) were in a vegetative state, and 63 cases (47%) died. Favourable prognosis group had 54 cases (40%) (GOS 4-5),while 81 cases (60%) were in the poor prognosis group(GOS 1-3). Age, coagulation function, preoperative pupillary changes, and intraoperative blood loss differed significantly between the favourable and poor prognosis groups (P < 0.05) and were associated with patient prognosis. Age over 50 years and preoperative bilateral mydriasis were independent risk factors for poor prognosis (P < 0.05). Conclusion At high altitude, age >50 and preoperative bilateral mydriasis are poor prognostic factors for sTBI. In our single center experience, SLTC was associated with acceptable outcomes in this high-altitude cohort, despite the high overall adverse event rate.
OBJECTIVE:To explore optimized minimally invasive strategies for the treatment of spontaneous intracerebral hemorrhage (sICH) in the basal ganglia, this study describes the technical feasibility and preliminarily experience of the supraorbital keyhole (SOK) approach combined with neuroendoscopic hematoma evacuation in anatomically selected patients. METHODS:This preliminary technical report retrospectively analyzed 5 consecutive patients with basal ganglia sICH who were admitted between September 2025 and February 2026 and met predefined anatomical selection criteria, including a hematoma long axis parallel to the midline. Intraoperatively, neuronavigation was used to plan the surgical trajectory, and hematoma evacuation and hemostasis were performed under direct visualization through a small supraorbital bone window. RESULTS:The results showed that all 5 procedures were completed successfully. The median operative time was 245 min (range, 125-285 min), and the median intraoperative blood loss was 50 mL. The median hematoma evacuation rate was 90% (mean, 74%), with 3 patients (60%) achieving an evacuation rate of ≥90%. No postoperative rebleeding in the operative field or cerebrospinal fluid leakage was observed. One patient with severe ventricular casting developed postoperative intracranial infection and had an unfavorable short-term outcome (Glasgow Outcome Scale score 2). At follow-up, the remaining 4 patients had GOS scores of 3-4. CONCLUSIONS:In this small preliminary series, the SOK approach combined with neuroendoscopic techniques appears technically feasible for anatomically selected basal ganglia sICH. Further validation of its safety and clinical effectiveness in larger retrospective studies is warranted.
OBJECTIVE:To evaluate the feasibility and clinical value of combined lateral spread response (LSR) and Zhong-Lee response (ZLR) monitoring during fully endoscopic microvascular decompression (E-MVD) for hemifacial spasm. METHODS:This case series included 18 consecutive patients with hemifacial spasm who underwent E-MVD with multimodal intraoperative neurophysiological monitoring from September 2024 to March 2026. Monitoring included LSR, ZLR, and brainstem auditory evoked potentials. LSR was recorded from four facial muscles at six predefined stages. ZLR was elicited by direct stimulation of the neurovascular conflict. Outcomes were assessed using the validated hemifacial spasm grading questionnaire. RESULTS:LSR was detected in 83% of patients and disappeared intraoperatively in 93% of those in whom it was detected, with early disappearance in 13%. ZLR was present in all patients before decompression and disappeared in all cases after decompression. ZLR was particularly useful when LSR was absent or disappeared early, and in identifying the true offending vessel in complex neurovascular conflicts. Immediate symptomatic resolution occurred in 78% of patients, and delayed resolution in 22%. The median clinical score improved from 13 (IQR 13-14) preoperatively to 0 (IQR 0-2) at discharge. Mean quality-of-life impairment decreased from 82% to less than 0.2% at 6 months (p < 0.001). CONCLUSIONS:E-MVD combined with LSR and ZLR monitoring was feasible and demonstrated favorable short-term clinical outcomes in this consecutive case series. The two monitoring modalities provided complementary intraoperative electrophysiological information, particularly in patients with absent or inconclusive LSR.
OBJECTIVE:Operating-room exposure in neurosurgical training is unevenly distributed. We developed a patient-specific virtual reality (VR) neurosurgical training platform of 20 patient-derived cases spanning aneurysm, meningioma, and trauma, running standalone on a commercial head-mounted display with cloud-based logging, and report its first independent evaluation. METHODS:A summative usability test of one case-a convexity meningioma-was conducted under IEC 62366-1 by an institutional medical-device testing center. Fifteen neurosurgeons (2 specialists, 13 residents) were recruited and compensated by the center against pre-specified criteria. Independent assessors classified performance on 20 predefined tasks as Correct Use, Use Error, Close Call, or Use Difficulty, and participants completed two 5-point Likert questionnaires. Groups were compared with Fisher's exact and Mann-Whitney U tests. RESULTS:All 15 participants completed the protocol without dropout or deviation. Subjective ratings were high (pooled median 4.0/5.0 on both instruments), highest for display refresh, realism, usefulness, and interface consistency. Specialists had fewer flagged tasks than residents on all three metrics-Use Error 2/20 versus 6/20 (p = 0.235), Close Call 1/20 versus 7/20 (p = 0.044), Use Difficulty 0/20 versus 3/20 (p = 0.231)-but no metric survived correction, and the task-level denominator does not scale with group size. The 'Control' domain was lowest and most variable (trainee median 4.0, range 1-5); errors concentrated in instrument selection and bimanual manipulation. CONCLUSIONS:A patient-specific neurosurgical VR platform running standalone on commercial hardware is feasible and was rated favorably by independently recruited evaluators. This pilot characterizes usability and defines engineering targets-instrument manipulation and user control-rather than testing efficacy.
Background Vestibular schwannoma resection is among the most technically demanding procedures in neurosurgery. Reduced operative exposure during residency has increased the need for realistic and accessible simulation models. Methods A training model was created by combining human placenta with a 3D-printed retrosigmoid craniotomy to simulate vestibular schwannoma resection. Placental and amniotic tissues were configured to reproduce the tumor capsule, facial nerve, lower cranial nerves, cisterna magna, and dura mater. The simulator reproduced dural opening and cerebrospinal fluid drainage, tumor resection, facial nerve preservation, final cavity inspection, and dural closure. Two expert neurosurgeons and two senior residents evaluated the model using a 5-point Likert scale questionnaire. Results The model could be assembled in a mean time of 21 minutes with standard instrumentation. Multiple tumors were obtained from a single placenta, up to a maximum of 9, allowing repeated simulations using the same specimen. The evaluators rated the simulator favorably for perceived microsurgical training value, bimanual coordination, instrument handling, and simulation of a narrow and deep operative corridor. Scores for anatomical realism reflected the inherent technical challenges in replicating the highly intricate cerebellopontine angle anatomy and its vascular structures. Conclusions The described simulator represents the first placenta-based model specifically designed for vestibular schwannoma surgery. Based on these preliminary observations, the model may provide a complementary platform for practicing fundamental microsurgical maneuvers, particularly during the early stages of neurosurgical training.
Cranioplasty is a key reconstructive procedure for restoring cranial integrity, protecting intracranial structures, and enhancing neurological, psychological, and aesthetic outcomes after skull defects. At present, the selection of repair material remains clinically challenging, given that no single material comprehensively fulfills the requirements of mechanical stability, biocompatibility, osseointegration, imaging compatibility, infection resistance, cost-effectiveness, and long-term safety. This review summarizes current advances in cranioplasty materials, encompassing autologous bone, titanium, polymethyl methacrylate, polyether ether ketone, degradable polymers, bioceramics, and bioactive composite scaffolds. Conventional materials remain widely utilized owing to their established clinical performance. However, their applications are limited by several complications. These include bone resorption, infection, implant exposure, mechanical mismatch, and insufficient biological integration. Recent advances have been made in CAD/CAM, three-dimensional printing, surface modification, controlled delivery of bioactive factors, and tissue-engineered scaffolds. These advances have promoted a shift from passive defect coverage toward patient-specific and regenerative reconstruction strategies. However, most emerging strategies are primarily supported by preclinical or heterogeneous clinical evidence. Future studies should prioritize indication-based material selection, standardized outcome assessment, long-term follow-up, and multicenter validation to guide the development of safer and more functional cranioplasty materials.This narrative review was based on a targeted literature search of Google Scholar, PubMed/MEDLINE, Web of Science, Scopus, with an emphasis on recent clinical evidence and emerging translational strategies for materials used in cranial defect repair.
Background Pedicled temporoparietal fascial flap (TPFF) onlay has been used as an indirect component of combined revascularization for moyamoya disease (MMD). We describe the technical anatomy and evaluate an extended institutional cohort. Methods We retrospectively studied adults admitted from 2018 to 2024 with angiographically confirmed MMD, Suzuki stage III or IV, and modified Rankin Scale (mRS) score of 3 or less. Fifty-five patients underwent superficial temporal artery-middle cerebral artery bypass with TPFF onlay; 23 who declined surgery received medical management as a self-selected observational comparison. All completed at least 24 months of follow-up. Results Direct bypass patency was 54 of 55 (98%). At 1 week, perfusion-weighted imaging was qualitatively classified as improved in 51 patients (93%) by integrated visual assessment of mean transit time, time to peak, cerebral blood flow, cerebral blood volume, and color maps. On each patient's latest follow-up angiogram, 47 (85%) had Matsushima grade A collateralization after repeat review by 2 senior neurosurgeons. In the nonrandomized comparison, non-surgical management was associated with a higher observed stroke hazard (adjusted hazard ratio, 7.12; 95% confidence interval, 2.61-19.42; P < 0.001). mRS scores improved after surgery. The 12-patient hemorrhagic subgroup was underpowered for equivalence assessment. No perioperative deaths occurred. Conclusions In this selected retrospective cohort, combined bypass and TPFF onlay was associated with high patency, later indirect collateral formation, and favorable functional outcomes. The self-selected comparison does not establish a causal treatment effect, and superiority over other combined techniques was not evaluated.
Pediatric moyamoya disease (MMD) is a progressive steno-occlusive arteriopathy that carries a high risk of recurrent ischemic stroke and neurocognitive decline if left untreated, with a more aggressive course in children under 4 years of age than in older children or adults. This narrative review critically synthesizes original clinical studies published between 2018 and 2026 to provide an evidence-based surgical decision-making framework. A literature search of PubMed/MEDLINE was performed, including only original articles (case series >10 patients, cohort studies) reporting surgical outcomes in children ≤18 years with MMD or moyamoya syndrome. In large contemporary series, indirect revascularization achieves postoperative stroke-free survival rates exceeding 95% and 20-year event-free survival of 97% in young children. Direct or combined bypass provides superior angiographic revascularization but does not significantly lower the long-term stroke rate compared with indirect techniques. Preoperative assessment of cerebrovascular reactivity using BOLD MRI or SPECT with acetazolamide is the strongest predictor of surgical benefit. Preliminary machine learning models using intraoperative arterial blood pressure waveforms can predict postoperative neurological events with an AUROC of 0.738. A four-step surgical algorithm based on age, hemodynamic status and vascular anatomy is proposed. Priorities for future research include an international pediatric registry, validation of AI-based risk stratification tools, and randomized comparisons of direct versus indirect bypass in children aged 4-8 years.
OBJECTIVE:Severe traumatic brain injury (sTBI) creates a substantial burden on neurotrauma systems. While geospatial analyses of TBI have focused on injury location, less is known about how patients' residential environments contribute to regional sTBI burden. This study aimed to identify residence-based spatial clustering of sTBI across Long Island and characterize community-level factors associated with excess incidence. METHODS:We conducted a retrospective cohort study of adults (≥ 18 years) with sTBI (Glasgow Coma Scale ≤ 8) admitted to a Level 1 trauma center (2010-2021). Patient-reported home ZIP codes were mapped to ZIP Code Tabulated Areas (ZCTAs) and linked to U.S. Census American Community Survey data. Spatial autocorrelation was assessed using Global Moran's I and Local Indicators of Spatial Association (LISA). Standardized incidence ratios (SIRs) accounted for population differences. Community-level predictors of elevated SIR were evaluated using beta regression and multivariable models. RESULTS:Among 608 patients, raw sTBI counts demonstrated significant spatial clustering (Moran's I = 0.228, p < 0.05). Population-adjusted analyses identified 28 ZCTAs with significantly elevated SIRs. SIR-based spatial analysis demonstrated significant clustering (Moran's I = 0.321, p < 0.05), with five high-high LISA clusters concentrated in eastern Long Island. Higher proportions of residents aged ≥ 65 and unemployment were associated with increased SIR, while lower proportions of married residents also predicted elevated incidence. CONCLUSION:Residence-based sTBI incidence is spatially clustered independent of population size and associated with specific social vulnerabilities. These findings identify communities disproportionately contributing to neurosurgical trauma burden and inform trauma system planning, prevention, and resource allocation.
BACKGROUND:Single-center series remain useful for benchmarking local practice against the published literature. We report a 21-year experience with cranial and spinal meningiomas at one tertiary center in Türkiye. METHODS:We retrospectively reviewed 108 consecutive patients operated for histopathologically confirmed cranial or spinal meningioma at Zonguldak Bülent Ecevit University, Türkiye, from January 2002 to December 2023. Clinical, histopathological (2021 WHO classification), and surgical (Simpson grade) data were summarized descriptively; recurrence was explored by location and extent of resection using Fisher's exact test. RESULTS:The cohort comprised 76 women and 32 men (mean age 59 years); 86 tumors (80%) were WHO grade 1. Simpson grade I resection was achieved in 68 patients (63%) overall, but in only 4 of 32 skull-base tumors (13%) versus 60 of 72 non-skull-base tumors (83%). The postoperative course was favorable in 86 patients (80%); complications occurred in 14 (13%); in-hospital and 30-day mortality were 2.8% (3/108) and 0.9% (1/108). Over a median follow-up of 83 months in 75 patients, recurrence was documented in 9 (8.3%), more often in skull-base tumors (19% vs 4.2%; odds ratio 5.3, 95% CI 1.2-22.8; p=0.023), but not by extent of resection (odds ratio 2.9, 95% CI 0.5-15.9; p=0.23). CONCLUSIONS:In our hands, complete resection was achieved in most non-skull-base tumors but rarely at the skull base, and mortality was confined to patients presenting with a marked neurological deficit. The clustering of recurrence in skull-base tumors rests on nine events and incomplete follow-up, and describes our experience rather than a generalizable finding.
Objective Clinically nonfunctioning pituitary neuroendocrine tumors (PitNETs) may exhibit lineage-specific radiological and intraoperative features. This study compared the radiological and intraoperative characteristics of T-box pituitary transcription factor (TPIT)-lineage and steroidogenic factor 1 (SF1)-lineage tumors. Methods Transcription factor immunohistochemistry was used to classify 164 clinically nonfunctioning PitNETs, consisting of 46 TPIT-lineage tumors and 118 SF1-lineage tumors. Clinical variables, preoperative neuroradiological findings including multiple microcysts, as well as intraoperative findings including tumor color, consistency, and invasiveness, were evaluated. Results The TPIT-lineage group showed a higher proportion of female patients and a higher frequency of Knosp high-grade tumors than the SF1-lineage group. Magnetic resonance imaging demonstrated that high signal intensity on T2-weighted images and multiple microcysts were more frequently observed in the TPIT-lineage group. Intraoperative findings showed that the TPIT-lineage group more frequently exhibited cavernous sinus invasion, soft aspiratable (SA)-type consistency, dark-red color, sellar dural defects, and sphenoid sinus extension (with local bone defect). Multivariable logistic regression analysis found that female sex, presence of multiple microcysts, and SA-type tumor consistency were independently associated with the TPIT-lineage group. Conclusions Clinically nonfunctioning TPIT-lineage PitNETs, which correspond to silent corticotroph PitNETs, are characterized by radiological and intraoperative features that are readily identifiable. Although TPIT-lineage tumors may show locally invasive growth and frequently lack a distinct pseudocapsule, their soft consistency may facilitate aspiration-assisted endoscopic resection.
OBJECTIVE:Surgery for moderately large pituitary neuroendocrine tumors often identifies the normal pituitary gland on either the left or right side, whereas the layer of the normal pituitary gland becomes thinned or disappears on the opposite side (cavernous sinus side). Conventional extracapsular resection dissects the extra-pseudocapsular layer circumferentially to remove the tumor. However, a more reliable and easier approach is to dissect between the outer pituitary capsule and the medial wall of the cavernous sinus on the cavernous sinus side than the extra-pseudocapsular layer (the layer change technique). METHODS:We retrospectively reviewed 24 consecutive functional pituitary tumors, divided into cases treated with the layer-change procedure (LCP) and other procedures. RESULTS:Extracapsular removal with LCP was used mostly for growth hormone-, thyroid-stimulating hormone-, and prolactin-producing tumors, and medium 10-30 mm size tumors. There were no differences in surgical remission or complications. Postoperative hormone replacement was needed mainly in other procedure group, including patients with Cushing's disease after surgical remission. CONCLUSION:The LCP is a conceptual framework for extracapsular removal. This concept has the potential to improve the accuracy and safety of extracapsular removal for pituitary tumors.
