Abstract Background and objectives Giant pituitary adenomas (GPAs) are challenging due to their size and proximity to vital neurovascular structures. While the endoscopic endonasal transsphenoidal approach (EETA) is increasingly used for pituitary adenoma resection, its effectiveness for giant adenomas remains underexplored. This study assesses EETA outcomes for GPA resection at a tertiary care center, focusing on resection extent, complications, and factors affecting surgical outcome. Methods This retrospective study reviewed the clinical data of 50 patients who underwent EETA for giant pituitary adenomas at our institution between 2018 and 2025. Demographic data, tumour characteristics, surgical outcomes, extent of resection, and postoperative complications were analysed. Factors such as tumour size, invasion of surrounding structures, and preoperative visual and endocrine status were evaluated to identify predictors of surgical outcome. Results The study included 50 patients with mean age of 40.92 years with a male preponderance in the cohort of 60%. The mean tumour dimensions were 41 mm(craniocaudal) × 43 mm(mediolateral) × 39(anteroposterior) mm The gross total resection (GTR) rate was achieved in 64% of cases, near total in 32% and subtotal resection in 4%. Postoperative complications were observed in 34% of the patients, with the most common being transient diabetes insipidus in 30%. Improvements in visual function was noted in 62% of patients postoperatively. Conclusion Endoscopic endonasal surgery is a safe and effective approach for GPAs, offering favourable visual and functional outcomes with manageable complication rates.

The surgical management of complex craniovertebral junction (CVJ) anomaly requires decompression of the neurovascular structures. Besides the atlantoaxial dislocation, the spectrum of anomalies noticed at CVJ is myriad. This includes an occipitalised C1 arch, hypoplasia of the C2 pedicle, basilar invagination, a high-riding vertebral artery (VA), a lower origin of the posterior inferior cerebellar artery (PICA), and unilateral or bilateral VA hypoplasia. The aberrant course of the VA has been the most challenging entity to access the C1-C2 joint. The atlantoaxial joint remodelling and reorientation play a vital role in achieving stability in this region. Here, we aim to describe the surgical nuances and share our experience with tailored VA mobilisation for the efficient management of CVJ anomalies. All cases of CVJ anomaly operated between January 2018 and December 2024 were included in this retrospective observational study. The clinical, radiological and operative details were collected from the neurosurgery record-keeping system. The surgical nuances and follow-up recovery of patients with VA anomaly (study group) were compared with those of patients having a normal course of VA (control group). Postoperative clinicoradiological improvement was evaluated at three-month follow-up visits. A total of 32 patients were analysed with a mean age of 47.21 ± 16.20 years. The median pre-operative Nurick’s grade amongst the study population was 4 (IQR: 3,4 and Range: 3–5). Eighteen patients (18/32, 56.3

BACKGROUND:Tuberculum sellae meningioma (TSM) frequently causes significant visual morbidity owing primarily to its proximity to the optic apparatus and associated vasculature. Data on surgical outcome in patients presenting with non-serviceable vision or blindness in the preoperative period remain limited. This study evaluates the postoperative visual recovery in this group of patients and examines the interplay of the potential predictive factors. METHODS:Patients with TSM presenting with severe visual loss or blindness in at least one eye and undergoing first time surgical resection at our center between 2014 and 2024 were analyzed. Clinical, radiological, surgical, and follow-up data were analyzed. Visual outcomes were categorized as improved, unchanged, or deteriorated as per WHO (World Health Organization) criteria. Univariate and multivariate logistic regression analyses were performed. RESULTS:Thirty-seven patients were studied. Immediate postoperative visual improvement was seen in 37.8% patients, increasing to 59.5% at follow-up (mean 47 months). Improvement from non-serviceable to serviceable vision was also observed in a subset of patients. Patients undergoing supraorbital keyhole approach (SOKHA) had predominantly smaller tumors and tumors of meningothelial histology. Interestingly, patients who presented late (> 6 months) had larger tumors and lesser optic canal invasion compared to those presenting early. On the multivariate analysis, a younger patient age (AOR of 0.91, p = 0.049),the SOKHA (AOR = 7.16; p = 0.032), optic canal unroofing (AOR = 19.76; p = 0.030) and a longer duration of preoperative visual symptoms (AOR = 21.323;p = 0.043) correlated with long term postoperative visual improvement. CONCLUSION:Meaningful visual recovery is achievable even in patients with severe preoperative visual impairment. Despite limitations inherent to the nature of the study, our findings testify to the value of timely surgery, role of minimally invasive approach in properly selected patients and optic canal unroofing during surgery as some of the surgeon modifiable factors contributing to a favorable visual outcome in these patients.

BACKGROUND AND OBJECTIVES:Insular glioma (IG) resection is technically demanding and carries a high risk of postoperative neurological deficits, primarily due to ischemic injury to the middle cerebral artery (MCA) perforators. Understanding pre- and postoperative lenticulostriate artery (LSA) anatomy may clarify the tumor-perforator relationship and its clinical impact. METHODS:This prospective single-center study analyzed pre- and postoperative three-dimensional time-of-flight magnetic resonance angiography (3D-TOF MRA) to assess IG-LSA relationships. The extent of resection (EOR) and complications were correlated with LSA involvement patterns and postoperative reduction in the number of visible LSAs. RESULTS:LSA involvement patterns included "displaced" (28%), "contact" (56%), and "engulfed" (16%) types. Postoperatively, mean LSA count declined from 3.76 to 3.0 (p = 0.007). Reduction occurred in all patients with engulfed LSAs and in 30% with contact type. Giant IGs were more frequent in contact and engulfed patterns (p = 0.008). Tumors with reduced LSAs were more often oligodendroglioma or glioblastoma than grade 2 astrocytoma (p = 0.004). LSA loss was unrelated to surgical approach but correlated with radical resection (p = 0.019) and neurological deficits (p = 0.001). CONCLUSION:IGs with LSA engulfment should undergo subtotal resection, whereas contact-type lesions require intraoperative judgment regarding EOR. Radical resection in giant IGs with unsafe tumor-LSA relationships, especially in aggressive histologies, increases the risk of permanent deficits. Not all single-LSA injuries result in lasting impairment. Routine preoperative 3D-TOF MRA is recommended for evaluating IG resectability and minimizing ischemic complications.

Background Thalamic neoplasms contribute to approximately 1 to 5% of all brain tumors. These are more commonly found in the pediatric age group. The different aspects of thalamic gliomas (TG) have occasionally been reported.Objectives This article aims to assess the clinico-radiological profile, management, and postoperative follow-up; to compare differences between the adult and pediatric populations and between biopsy and resection groups; and to explore poor prognostic factors. Methods This retrospective analysis included 41 patients with TG over 5 years. Various study parameters were taken into consideration. Appropriate statistical tests were applied ( p < 0.05-significant). Results Our study included 10 patients in the pediatric age group and 31 adult patients. Out of these, 25(61%) were males and 16(31%) were females. Most patients (70.7%) presented with Karnofsky performance status <80. The most common symptom was headache (80.5%), followed by motor deficits. Only one tumor had bilateral involvement. Only 10 patients had tumors confined to the thalamus, while others had extensions to adjacent structures. Contrast enhancement was seen in most, with less than half showing cystic degeneration. Thirteen patients (31.7) had glioblastoma. More than half (22 patients) died due to TG, which included only two pediatric patients. The mean overall survival was 24.5 +/- 4.3 months, and the median was 8 +/- 3.1 months. Conclusion We found a higher occurrence of TG in adults and a male predilection in the pediatric group. Our study forms one of the largest studies on TG reported in contemporary times. The comparative analysis between pediatric and adult TG presented here is a valuable contribution to the literature.

Paraclinoid aneurysms, arising from the internal carotid artery between the proximal dural ring and the posterior communicating artery, pose significant microsurgical challenges due to their proximity to critical neurovascular structures. Despite advances in endovascular techniques, surgical clipping offers definitive exclusion with lower recurrence. This study evaluates surgical outcomes and operative nuances in clipping paraclinoid aneurysms over a 12-year period. A retrospective review was conducted of 116 patients with paraclinoid aneurysms who underwent surgical clipping at a tertiary centre between 2011 and 2023. Data on demographics, clinical presentation, aneurysm morphology, surgical strategy, and outcomes were analysed. The outcome was assessed using the modified Rankin Scale (mRS), with a favourable outcome defined as mRS 0–2. A p-value < 0.05 was considered significant. Informed consent was obtained from all the patients. Among 116 patients median age at presentation was 48 (38.25–59.75) years, 80.2

Gliomas represent the tumors of the central nervous system that originate from glial cells. Overall survival predictions and treatment regimen selection are based on accurate tumor diagnosis and grading. However, the diagnosis of glioma remains critically dependent on either invasive biopsies or advanced imaging. This exploratory study aims to assess the diagnostic potential of urine specimens for discriminating gliomas from controls and identify the dysregulated pathways in a North Indian cohort. Urine is an ideal non-invasive candidate, requires no prior preparation, and considerably increases patient compliance. Urine samples from 50 glioma patients were analysed with 1H NMR (Nuclear Magnetic Resonance) spectroscopy and compared with those of healthy controls. Statistical analysis was performed in MetaboAnalyst 6.0 to identify significantly perturbed metabolites. Diagnostic performance was assessed using the Receiver Operating Characteristic (ROC) curve, and the Random Forest model was used to evaluate classification accuracy. Pathway enrichment and topology analysis based on the KEGG (Kyoto Encyclopedia of Genes and Genomes) database were performed to identify dysregulated pathways. 1H NMR metabolic analysis of urine samples revealed seven statistically significant (p < 0.05) metabolites namely acetate, pyruvate, creatinine, dimethylamine, glutamine, alanine and carnitine. This panel of metabolites displayed excellent diagnostic capability with an Area Under the Curve of 0.90 as measured by a multivariate ROC curve. The random forest model efficiently differentiated glioma from control samples using significant metabolites. Disruption in the primary energy pathways of the body and in the metabolism of major amino acids was observed in the pathway analysis. Integration of these urinary signatures into current clinical practice can serve as an additional diagnostic tool and a non-invasive screening method for populations at risk. They can also be monitored in real time, thus aiding in adaptive treatment strategies and therapy assessment.

Postoperative meningitis remains an important complication following pediatric posterior fossa tumor (PPFT) surgery and is associated with increased morbidity, prolonged hospitalization, and delays in adjuvant therapy. However, data regarding its incidence and perioperative risk factors in children remain limited. To determine the incidence, risk factors, microbiological profile, and cerebrospinal fluid (CSF) characteristics of postoperative meningitis in PPFTs. A retrospective analysis of 116 PPFT cases was performed. Patients with postoperative meningitis were compared with those without meningitis to identify potential risk factors. Meningitis cases were further classified into culture-positive and culture-negative groups, and CSF biochemical and cytological parameters were analyzed. Statistical analysis was performed with significance set at p < 0.05. Among 116 patients (age = 9 ± 4 years; male:female::2.2:1), postoperative meningitis occurred in 19 (16.4

The authors present a video showing the technical aspects of trapping and superficial temporal artery-middle cerebral artery (STA-MCA) bypass for fusiform M2 aneurysm for complete exclusion of the aneurysm from the cerebral circulation. The importance of cerebral angiography cannot be stressed enough for such fusiform aneurysms to decide on the morphology of the aneurysm and, hence, plan out the surgical approach. Traditional direct clipping techniques and clip reconstruction techniques may be impractical for fusiform aneurysms. Trapping the aneurysm and bypassing it from the circulation either through high flow or low flow bypass is the way forward. Branching vessels and underlying perforators must be sought out enthusiastically before planning out the trapping of the aneurysm. In such cases, extracranial-intracranial low flow bypass using a superficial temporal artery as the donor gives adequate distal flow in the MCA territory. Care should be taken to consider aneurysmectomy to relieve the patient of the symptoms attributable to the mass effect of the aneurysm. In this video, we describe one such fusiform M2 aneurysm, which was trapped and bypassed using a superficial temporal artery for a patient who presented with subarachnoid hemorrhage.

Cerebellopontine angle epidermoids (CPAE) are known to present irritative symptoms due to the adjacent tumour or compressive symptoms due to direct contact and compression by the tumour. Presentation due to contralateral structural involvement has not yet been highlighted in these cases. Our aims & objectives are to evaluate patients of CPAE presenting with contralateral symptoms and to compare this subset with patients presenting with ipsilateral symptoms. This study is a retrospective analysis of patients who underwent surgery over the last 22 years for CPAE. Several parameters were taken into consideration for assessment of above objectives. Appropriate statistical tests were applied and ap-value of less than 0.05 was considered statistically significant. A total of 105 patients were included, out of which 27 patients (25.7 %) presented with symptoms of contralateral structural involvement. The most common CN with bilateral involvement were the lower cranial nerves (n = 7, 25.9 %) and most common contralateral CN involved was CN VII (n = 6, 22.2 %). On comparison with the cohort of ipsilateral structural involvement (n = 78, 74.3 %), a comparatively lower incidence of contra-/bilateral LCN involvement (p-value 0.026), ipsi-/bilateral motor deficit (p-value < 0.00001) and contra-/bilateral brainstem structures involvement (p-value < 0.00001) was observed. It isn't uncommon for CPAE to present with contralateral symptomatology as nearly one-fourth cases of our series exhibited the same. Our research adds to the small pool of studies describing contralateral symptomatology in CPAE and is the first to describe various deficits (other than trigeminal neuralgia) with a comparative analysis.

Tumor-induced osteomalacia (TIO) is a rare syndrome caused by phosphaturic mesenchymal tumors that secrete substances, like FGF23, leading to phosphorus loss and osteomalacia. These tumors are often small and challenging to locate. Surgical excision is the primary treatment and usually results in symptomatic improvement. This report presents seven cases of skull base origin of these tumors to add to the existing literature. This retrospective study reviewed patients with phosphaturic mesenchymal tumors (PMT) who underwent surgical excision at a tertiary care institute from 2015 to 2023, focusing solely on tumors confined to the anterior or lateral skull base. The analysis included demographics, clinical features, biochemical and radiologic findings, tumor location, surgical details, and follow-up. The study included 7 patients (6 males, 1 female) with ages ranging from 40 to 65 years (mean age: 52 years). Common symptoms included lower back pain (70

Introduction: Pathologies involving the central skull base and upper posterior fossa are often multicompartmental and difficult to access without endangering important neurovascular structures. A combined transcavernous (described by Dolenc) and anterior transpetrous approach (described by Kawase) provides an excellent anterolateral visualization of this area, complimenting advantages of each of these classical approaches. In this article, the surgical technique and results of this approach in 14 patients is reported. We wish to highlight a two surgeon "tag team" technique and our novel technique for CSF release during extradural phase of surgery.

Endoscopic minimally invasive skull base surgery using the transorbital neuroendoscopic technique for cavernous sinus epidermoid serves as a pivotal link to open transcranial surgeries. This method involves a minimally invasive transorbital approach, including lateral orbitotomy and drilling the greater sphenoid wing, followed by cutting the orbitomeningeal band, peeling the dura mater, and exposing the tumor. This approach is technically demanding and requires thorough knowledge of anatomy and familiarity with endoscopic instruments. The favorable clinical, cosmetic, and radiological outcomes underscore the effectiveness of this technique, highlighting the role of endoscopy in minimally invasive skull base paramedian pathologies. The video can be found here: https://stream.cadmore.media/r10.3171/2025.1.FOCVID24188.

Spetzler–Martin (SM) grade III arteriovenous malformations lie at the borderline between low- and high-risk lesions, so their ideal management strategy is still debated. We aim to examine functional, angiographic and seizure outcomes after modern microsurgical treatment of SM grade III arteriovenous malformations (AVMs) and to assess prognostic factors within Lawton sub-groups. We retrospectively reviewed 45 consecutive SM grade III AVMs resected between January 2014 and December 2023. Demographics, nidus morphology, use of pre-operative embolization, surgical obliteration, complications, modified Rankin Scale (mRS) and modified Engel seizure class were recorded at discharge, 6 months and 1 year. Multivariate logistic regression identified predictors of unfavourable outcome (mRS > 2). Mean age was 26 years. 64

OBJECTIVE:This study aimed to analyze the comparative tumor resection rates and complication profiles of the transsylvian (TS) and transcortical (TC) approaches to the insular glioma (IG) and emphasize the concept of onco-microneurosurgery as a key to surgical success in these difficult areas. METHODS:A retrospective analysis of a single surgeon's prospectively maintained data of surgically resected, newly diagnosed IGs in adult patients (≥ 18 years old) was conducted. Propensity score matching was performed with a tolerance limit of 0.05 for comparison of the TS and TC cohorts. The extent of resection (EOR) was categorized with 90% resection as a cutoff. Neurological complications persisting beyond 3 months were considered permanent complications. These two variables were combined to derive a Composite Postoperative Outcome Index (CPOI) and graded as 0, 1a, 1b, or 2. RESULTS:Fifty-two patients (male-to-female ratio of 2.25:1) were studied, with 26 patients in each group. Radical tumor resection (≥ 90%) was obtained in 77% patients (n = 40), with transient and permanent neurological complication rates of 46.2% (n = 24) and 15.4% (n = 8), respectively. A significantly higher rate of maximal safe resection (CPOI grade 0) was obtained using a TS approach for the entire TS cohort (p = 0.008), as well as subgroups of non-giant segmental IGs (p = 0.011) and those with specific Berger-Sanai zone II involvement (p = 0.01). The TC approach was found to be significantly safer in giant IGs when a subtotal resection was performed (p = 0.03). Permanent neurological complications with ≥ 90% EOR (CPOI grade 1b) were significantly higher in the TC group (p = 0.009), including non-giant segmental IGs (p = 0.001) and those specifically involving Berger-Sanai zone II (p = 0.01) of the insula. Long-term functional status and disease progression were similar in both groups. CONCLUSIONS:These results suggest the continued role of the TS approach in IG resection in the contemporary era. Irrespective of the approach, the key variable appears to be a meticulous microsurgical technique, supplemented by the available adjuncts, in the preservation of perforator arteries and subcortical circuitry. Thus, an optimally designed, individual institution-tailored hybrid onco-microneurosurgical approach is the most pragmatic approach to IGs.

Parent Artery Occlusion (PAO) is a valid treatment choice in giant internal carotid artery (ICA) aneurysms of the cavernous segment when the preoperative balloon test occlusion (BTO) demonstrates an adequate cross circulation from the contralateral side. A high flow arterial bypass is, however, mandatory if the result suggests otherwise or is indeterminate. We present here a case of a 72-year lady where the BTO results were inconclusive. Rather than proceeding for the ICA ligation and a high flow bypass straight away, we replicated the BTO in the operation theatre, using intraoperative electrophysiologic neuromonitoring under the general anaesthesia. A temporary clip was applied on the ICA followed by gradual reduction of the blood pressure up to 30% from the baseline and sustained for 30 min. The motor evoked potential (MEP) and somatosensory evoked potential (SSEP) monitoring did not show ipsilateral hemispheric ischemia. Assured by this electrophysiologic evidence, we proceeded with ligation of the cervical ICA. The patient recovered from surgery without any neurological deficits and remains functionally intact at 4-years follow-up. Based on this case, this novel method can be considered a further refinement of the conventional BTO, allowing clarification of the inconclusive results that may sometimes be encountered.

Among the rare distal anterior cerebral artery (DACA) aneurysms, those lying below the genu of the corpus callosum are considered even rarer. While the conventional interhemispheric approach provides inadequate exposure to these aneurysms, the more popular basal approaches lead to frontal sinus violation with attendant risks. In addition, both these standard approaches are maximally invasive to the skin, bone and brain. Three patients with sub-callosal DACA aneurysms were treated. A2 segment aneurysm was treated using a supra-orbital keyhole craniotomy, while the other two (distal, involving proximal A3 segment) were dealt with using pre-coronal unilateral keyhole parasagittal craniotomy and an anterior interhemispheric approach. The procedures were completed uneventfully. The clinical, radiological features and surgical videos were reviewed. The mean age was 47.3 years (37–53 years) with two females and one male. Two patients had acutely ruptured aneurysms, and all were in good clinical grades. One patient had an A2 segment aneurysm close to the anterior communicating artery, while the other two patients had a proximal A3 aneurysm, just beneath the genu of the corpus callosum. The aneurysm was completely occluded in all 3 patients. At follow-up (mean: 16.4 months), all 3 patients are functionally independent. Subcallosal DACA aneurysms may be amenable to the keyhole approaches that spare the frontal sinus and the bridging veins. Case selection and experience with the traditional approaches are however, mandatory.

Reaching parenchymal segments of the lateral lenticulostriate artery (LSA) perforators, which represent the medial resection limit in insular gliomas (IG), remains a challenge. The currently described methods are indirect and sometimes, imprecise. We report an antegrade direct skeletonization technique to identify these tiny arteries at the medial end of IGs with an illustrative case of grade 2 astrocytoma. The patient recovered uneventfully following a near total tumor resection without any postoperative radiological ischemia in the LSA territory. Our microsurgical technique of antegrade LSA skeletonization may be useful in insular gliomas with a sharp medial border.