Abstract Carotid web (CaW) is a nonatherosclerotic vascular anomaly and an underdiagnosed cause of embolic ischemic stroke, particularly in young patients without traditional vascular risk factors. Its intraluminal position and morphology produce local hemodynamic disturbances that promote thrombus formation and account for the high rate of recurrent distal embolism reported with medical therapy alone. Accurate diagnosis relies on careful evaluation with computed tomography angiography and multiplanar reconstructions, as CaW may be overlooked on conventional imaging. Current evidence indicates that, in symptomatic patients, antithrombotic therapy alone is insufficient to prevent early recurrence, whereas carotid revascularization with endarterectomy or stenting provides excellent safety and efficacy. In contrast, optimal management of asymptomatic CaW remains uncertain and is generally based on clinical and imaging surveillance. This review summarizes the diagnostic features, natural history, and treatment strategies of CaW and presents a practical algorithm to support clinical decision-making in neurovascular practice.
Abstract Idiopathic intracranial hypertension (IIH) is a potentially sight-threatening condition characterized by elevated intracranial pressure without an identifiable cause. This case highlights the importance of appropriate surgical selection in a patient with IIH and progressive visual deterioration. Given the patient's severely compromised optic nerves, ongoing visual loss, and intolerance to medical therapy, urgent intervention was required to decompress the intracranial venous system. The most effective options in such cases include venous sinus stenting or cerebrospinal fluid (CSF) diversion via shunting. In this patient, venous sinus stenting was not a viable option; therefore, CSF diversion through shunt placement was pursued.
Abstract Spine surgery has evolved from manual, highly variable procedures to standardized, reproducible approaches with advancements in robotic-assisted spine surgery (RSS). As these technologies are developed further, procedural complexity may increase along with safety and efficacy profiles. This article provides an updated overview of the landscape of robotic-assisted spine surgery, including clinical applications, technological developments, reported benefits, limitations, and future directions for integration into modern spine practice.
Abstract Metastatic pituitary neuroendocrine tumors (PitNETs), formerly known as pituitary carcinomas, represent a rare subset of pituitary neoplasms, accounting for approximately 0.1% to 0.2% of cases. These tumors typically arise from pre-existing functional macroadenomas and most commonly metastasize to the liver, bone, lungs, and throughout the central nervous system. Given that there are no specific clinical, histopathological, or imaging features that can reliably distinguish metastatic PitNETs from benign or aggressive pituitary adenomas at early stages, timely diagnosis remains challenging. Multidisciplinary management is essential, with therapeutic strategies including repeat surgical resection, radiotherapy, and systemic therapy with temozolomide, either as monotherapy or as part of the Stupp protocol. Emerging therapeutic options, such as peptide receptor radionuclide therapy and immune checkpoint inhibitors, have also shown encouraging results in selected refractory cases. Despite multimodal treatment approaches, sustained responses are uncommon, and the prognosis remains poor, with a mean survival of approximately 2 years following the detection of metastases. Given their rapid progression and unfavorable outcomes, early recognition of metastatic PitNETs is critical. Neurosurgeons should be particularly vigilant in patients with rapidly recurring, hormonally active, and treatment-refractory macroadenomas, as these features may indicate an increased risk of metastatic transformation and warrant closer surveillance. This article reviews the initial clinical presentations, imaging and histopathological characteristics, prognosis, and current management strategies for metastatic PitNETs.
Abstract Noninvasive brain stimulation (NIBS) techniques, including transcranial magnetic stimulation (TMS), transcranial direct and alternating current stimulation (tDCS, tACS), and transcutaneous vagus nerve stimulation (tVNS), represent promising tools for neurorehabilitation and symptom management across neurological and psychiatric conditions. These modalities modulate cortical excitability, foster neuroplasticity, and target maladaptive network activity. Evidence supports applications in stroke, Parkinson disease (PD), Alzheimer disease, chronic pain, and psychiatric disorders, though methodological variability, heterogeneous patient populations, and lack of standardization limit clinical translation. This review synthesizes current knowledge, highlights therapeutic potential, and underscores the need for rigorous trials to establish efficacy and optimize treatment protocols.
Lumbar degenerative disease and stenosis are increasingly prevalent with aging. Modern endoscopic lumbar decompression offers enhanced visualization, reduced tissue disruption, and lower morbidity compared with open surgery, with comparable clinical outcomes. Despite higher costs and a significant learning curve, endoscopy remains a valuable minimally invasive option for treating lumbar spine pathology.
Headache disorders are common worldwide and associated with frequent emergency department visits, prolonged hospital admissions, and patient disability. Careful attention should be made in diagnosing a headache disorder accurately, as this has important implications for management. While a vast array of pharmacologic and noninvasive treatment options are available, surgical intervention can be considered in refractory cases of headache, depending on the underlying disorder. The purpose of this narrative review is to summarize the current evidence for surgical management of common primary and secondary headache disorders.
Acromegaly is caused by hypersecretion of growth hormone (GH), primarily from GH-secreting pituitary adenomas. High GH results in excess insulin-like growth factor 1 (IGF-1) production, leading to a multi-system disease characterized by somatic overgrowth, physical disfigurement, multiple comorbid conditions, and premature mortality. Early diagnosis and treatment are essential to mitigate excess mortality associated with acromegaly. Diagnosis is made by elevated IGF-1 and lack of suppression of GH after glucose administration. Transsphenoidal pituitary surgery is the first-line therapy in acromegaly. Medical therapy is a second-line option in patients with persistent disease after surgery. Radiation therapy is usually a third-line option if medical therapy fails.
Chronic subdural hematoma (cSDH) is one of the most prevalent neurosurgical conditions in the aging population and is believed to involve a self-perpetuating inflammatory cycle that leads to neo-membrane formation and leaky neovascularization. Traditional treatment via surgical drainage effectively evacuates the hematoma but often fails to prevent recurrence due to unresolved underlying inflammation. Recently, middle meningeal artery embolization (MMAE) has emerged as a minimally invasive technique that targets the membranes to reduce recurrence. Early studies and meta-analyses suggest that MMAE significantly lowers recurrence rates and the need for reoperation compared with surgery alone. Recent and ongoing clinical trials, including EMBOLISE, STEM, and MAGIC, have reported preliminary favorable outcomes; thus, MMAE may be poised to become the standard of care for adjuvant management following surgical drainage of cSDH.
Intracranial aneurysms (IAs) demonstrate significant risks due to their potential to rupture, leading to subarachnoid hemorrhage and high mortality rates. Accurate detection, diagnosis, and treatment of IAs are of great importance. These processes typically rely on imaging tools such as computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography. However, these tools are subject to human mistakes and variability in interpretation. Artificial intelligence (AI), including machine learning and deep learning, is being investigated more and more to improve IA management by enhancing its accuracy and efficiency. AI methods, such as convolutional neural networks, have demonstrated potential in the detection and characterization of aneurysms with high accuracy. Additionally, AI models can predict aneurysm rupture risk and guide treatment decisions, improving patient outcomes through individualized therapeutic regimens. Future developments in AI algorithms are expected to further integrate AI into clinical practice, improving the detection, diagnosis, and treatment of IAs.
The stroke awareness mnemonic FAST was expanded to BEFAST (adding B for balance and E for eye symptoms) to inform medical professionals and the public that sudden visual acuity or visual field loss, diplopia, and oscillopsia are symptoms that require prompt recognition and management as acute stroke syndromes. A high index of suspicion and an organized approach to triage are needed when facing these presentations in pre-hospital or hospital settings. The multidisciplinary collaboration between emergency providers, ophthalmologists, vascular neurologists, and vascular neurosurgeons is mandated for a prompt and accurate diagnosis, targeted evaluation and management, and optimized outcomes.
Patients who present with intracranial hemorrhage (ICH) require prompt diagnosis and emergent treatment. Anticoagulants are an independent predictor of poor outcomes in patients with acute ICH patients. Therefore, discontinuation of the offending medication and anticoagulation reversal, along with aggressive blood pressure management, is of utmost importance. This article provides a review of anticoagulation-associated ICH, including common anticoagulant medications and reversal agents. Evidence-based guidelines are applied to explain the current medical management paradigm as well as emerging therapies to improve patient outcomes.
Acromegaly is caused by hypersecretion of growth hormone (GH), primarily from GH-secreting pituitary adenomas. High GH results in excess insulin-like growth factor 1 (IGF-1) production, leading to a multi-system disease characterized by somatic overgrowth, physical disfigurement, multiple comorbid conditions, and premature mortality. Early diagnosis and treatment are essential to mitigate excess mortality associated with acromegaly. Diagnosis is made by elevated IGF-1 and lack of suppression of GH after glucose administration. Transsphenoidal pituitary surgery is the first-line therapy in acromegaly. Medical therapy is a second-line option in patients with persistent disease after surgery. Radiation therapy is usually a third-line option if medical therapy fails.
Cushing’s disease (CD) is an endocrine disorder characterized by increased adrenocorticotropic hormone production by the pituitary that was initially described and treated by Harvey Cushing. Since its discovery, advancements have been made in its diagnostic criteria and treatment modalities. Here, we provide an updated review of CD along with important advancements of surgical and medical treatment.
The jugular foramen (JF) is a complex region, and tumors affecting this area can extend toward both intra and extracranial spaces. Intracranially, tumors can project over posterior fossa and to middle ear structures, and can cause venous outflow disturbances, either by venous structures invasion or compression. Extracranially, they can involve the emerging segments of CN VII-XII, as well be close to important neurovascular structures as the carotid or vertebral arteries. The most common tumor of JF is paraganglioma, however a common subset of lesions comprises lower cranial nerves schwannomas. These lesions usually enlarge the foramen and compress surrounding structures, presenting with mass effect symptoms upon diagnosis due to a usually a slow-growing pattern, and microsurgical resection is most of the times the treatment of choice. Extensive laboratory training is essential to handle surgical approaches to JF properly.
This article reviews current scientific understanding and clinical management practices for small unruptured intracranial aneurysms (sUIAs). The management of sUIAs has been a longstanding controversial issue due to the lack of consensus on whether these aneurysms require treatment. Traditionally, these aneurysms have been conservatively managed and monitored. However, as understanding of aneurysm natural history has grown and treatment methods have improved, the field of sUIA management has shifted toward microsurgical and endovascular approaches. Therefore, it is important for neurosurgeons to have an updated review of current management practices of sUIAs to improve their care for this patient population. From this activity, neurosurgeons will gain a comprehensive understanding of sUIA management by reviewing risk factors for sUIA growth and rupture, screening recommendations, decision-making heuristics, and updated treatment methods. Key takeaways from this activity include: (1) appreciating the unique features of sUIAs, which make these lesions controversial to manage; (2) identifying specific risk factors for sUIA growth and rupture; (3) understanding screening guidelines and treatment methods for these aneurysms; and (4) acknowledging remaining gaps in knowledge of sUIA decision-making and management.
Vertebral artery dissections (VADs) are an important potential cause of ischemic stroke and subarachnoid hemorrhage. The pathophysiology of VAD involves an intimal tear, leading to intramural hematoma and luminal stenosis, which can subsequently lead to occlusion or rupture of the vessel. Diagnostic challenges stem from the often subtle clinical presentation, typically involving unilateral head and neck pain. Management ranges from antithrombotic therapy to endovascular and surgical interventions, depending on severity. Despite advances in diagnostic imaging and treatment, outcomes vary, underscoring the need for prompt diagnosis and tailored therapeutic approaches.
Multiple options are available for sellar reconstruction after endoscopic endonasal resection of pituitary masses. Neurosurgeons and otolaryngologists must be adept at assessing sellar defects and choosing appropriate repair techniques to minimize the risk of CSF leaks and complications. This activity addresses essential competencies, including evaluating the extent of CSF leaks, selecting optimal grafts, and applying multilayered reconstruction techniques for complex defects. Key takeaways include the importance of tailoring reconstruction to the severity of CSF leaks, the effectiveness of nasoseptal flaps for high-grade leaks, and the potential for minimalistic reconstructions in cases without intraoperative leaks. Understanding the historical evolution and current best practices in sellar repair enhances patient outcomes and reduces postoperative morbidity.
Superior semicircular canal dehiscence syndrome (SSCDS) is a condition in which the temporal bone covering the superior semicircular canal becomes progressively thinner until it eventually erodes, creating an inner ear “third window” with the intracranial cavity. The result of this dehiscence is a constellation of symptoms, including sound- and pressure-induced vertigo, autophony, hyperacusis for internal bodily sounds, and low-frequency conductive hearing loss (CHL). By using imaging, audiologic evaluation, and vestibular testing, audiologists and otolaryngologists can differentially diagnose SSCDS and determine course of treatment. Management options involve observation or surgery. In patients with minimal symptoms, observation is safe. In patients with severe symptoms, surgery via a transmastoid approach or middle fossa approach to plug or resurface the superior canal defect may be performed.
Lesions of the anterior cranial fossa (ACF) are challenging to treat. Historically, to obviate retraction on the frontal lobes and access the entire lesion, extensive craniofacial and skull base approaches were employed, often leading to significant cosmetic defects and morbidity. With the advent of expanded endonasal approaches, select lesions involving the ACF are treated with endoscopic endonasal approaches (EEAs). Consequently, for the contemporary skull base neurosurgeon, understanding the anatomy of EEAs to ACF lesions is vital. Thus, in this article we detail the surgical anatomy of EEAs to the ACF.
