BACKGROUND:Trigeminal schwannomas are rare, benign, slow-growing nerve sheath tumors. Endoscopic Transorbital Approach (ETOA) utilization has gained traction in recent years. METHOD:The authors present a surgical video demonstrating the ETOA technique for resection of a Meckel's cave schwannoma with cavernous sinus extension via a superior eyelid incision, with relevant surgical anatomy discussed. CONCLUSION:In carefully selected patients, the ETOA is a safe and effective minimally invasive surgical option that can address lesions involving the Meckel's cave and cavernous sinus.

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

Introduction Deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi) is an established therapy for advanced Parkinson's disease (PD). However, comparative outcome data from the Middle East are limited, and it remains unclear whether target-specific differences reported in randomized trials translate to regional real-world practice. We report outcomes of STN and GPi DBS from a single tertiary center in the United Arab Emirates. Methods We retrospectively reviewed 50 consecutive patients with PD who underwent bilateral STN or GPi DBS between 2020 and 2025 (37 STN, 13 GPi). Demographics, clinical phenotype, levodopa equivalent daily dose (LEDD), Unified Parkinson's Disease Rating Scale part III (UPDRS-III) scores, and adverse events were collected. Outcomes were summarized by target, with exploratory comparisons acknowledging baseline heterogeneity and limited statistical power. Results GPi patients had earlier motor symptom onset and universal dyskinesias, while STN candidates demonstrated more heterogeneous phenotypes. Both targets were associated with substantial LEDD reduction (STN 49.9% ± 32.4; GPi 37.5% ± 22.0). Variability and unequal sample sizes limited definitive target comparisons. Mean OFF-medication to DBS-ON UPDRS-III improvement exceeded 80% for both targets, likely influenced by high levodopa responsiveness, non-blinded assessments, and variable postoperative timing. Conclusions In this first institutional comparative DBS analysis from the UAE, both STN and GPi DBS produced meaningful medication reduction and robust motor improvement, demonstrating that outcomes comparable to landmark trials are achievable within an emerging Middle Eastern neuromodulation program. Methodological limitations preclude conclusions on target superiority and underscore the need for larger prospective regional studies.

Cranial nerves are mechanically irritated by vascular compression in neurovascular compression syndromes. Vagus nerve neuralgia is one of the less prevalent types of Neurovascular Compression Syndromes. It can cause disorders like Hemilaryngopharyngeal Spasm (HeLPS) and Vagus Associated Neurogenic Cough (VANCOUVER syndrome). HeLPS presents with unilateral spasms of the throat and coughing, whereas VANCOUVER syndrome is typified by a chronic cough brought on by vascular encroachment on the rootlet of the vagus nerve. The diseases' clinical manifestations, diagnosis, differential diagnoses, and therapy approaches are discussed, emphasizing the role of microvascular decompression (MVD) in the case of conservative treatment failure. Due to vagus nerve neuralgia's similarities to other diseases, including psychiatric conditions and gastroesophageal reflux disease (GERD), it can be difficult to diagnose and treat. To make the best possible treatment decisions, the effectiveness of both conservative and surgical care modalities including MVD and medication is discussed.

Background: The cranial nerve (CN) V and adjacent neurovascular structures are crucial landmarks in microvascular decompression (MVD). MVD of CN V is the most effective treatment for patients with drug-resistant trigeminal neuralgia (TN) diagnosis. The endoscope-assisted retrosigmoid approach (RSA) provides better exposure and less cerebellar retraction in the corridor towards the cerebellopontine angle (CPA). Methods: Five adult cadaver heads (10 sides) underwent dissection of the MVD in park bench position. MVD was simulated using microsurgical RSA, and the anatomical landmarks were defined. Microsurgical dissections were additionally performed along the endoscopic surgical path. Additionally, we present an illustrative case with TN caused by anterior inferior cerebellar artery (AICA) compression. The CN V and its close relationships were demonstrated. Endoscopic and microscopic three-dimensional pictures were obtained. Results: This study increases the anatomical and surgical orientation for CN V and surrounding structures. The CN V arises from the lateral part of the pons and runs obliquely upward toward the petrous apex. It has motor roots that leave from pons antero-supero-medial direction to the sensory root. The endoscopic instruments provide perfect visualization with minimal cerebellar retraction during MVD. Conclusion: MVD surgically targets the offending vessel(s) leading to TN and aims to create a disconnected area. The combination of preoperative radiographic assessment with and anatomical correlation provides safe and effective application while facilitating selection of the most appropriate approach. The RSA allows satisfactory visualization for CN V. Endoscope-assisted microsurgery through the CPA is a challenge, it should be performed with advanced anatomical knowledge.

-BACKGROUND: Trigeminal schwannoma is an uncom-mon tumor in pediatric patients. Several surgical ap-proaches have been described in the literature. -METHODS: The case of an 11-year-old boy with a giant dumbbell-shaped trigeminal schwannoma removed through a 2-stage approach was presented with an intraoperative video. Using PubMed and Scopus, the literature on tri-geminal schwannoma in pediatric patients was searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. -RESULTS: The search strategy yielded 312 titles, of which 13 were included in the review. Cases of trigeminal schwannoma were described, with a highly variable clinical presentation and anatomical arrangement in cranial fossae. Two-stage approaches were reported, although most studies described single-stage approaches. Common postoperative outcomes were a range of disturbances of cranial nerve V. -CONCLUSIONS: The surgical approach varies based on the tumor conformation. However, a 2-stage pterional sub-temporal and semisitting retrosigmoid approach is a safe, practical, and effective strategy for the removal of dumbbell-shaped trigeminal schwannoma in a pediatric patient.

Movement disorders are an increasing source of disability. Unfortunately, it is under recognized and under treated globally. Deep brain stimulation surgery is a well established modality of management for advanced Parkinson's disease, essential tremor, and dystonia. Establishing a new center of deep brain stimulation, nationally or internationally, has its own challenges. We discuss our challenges and experience.

BACKGROUND: Vestibular schwannoma surgery re-mains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for per-forming the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes.METHODS: In this study, we aimed to establish a stan-dardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization.RESULTS: The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting po-sition, with visual demonstration of the various parts of the procedure through surgical videos. Specific recom-mendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure ofvestibular schwannoma resection in the semi-sitting position.CONCLUSIONS: This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.

Background This study aimed to investigate the occurrence of delayed response following microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and identify potential contributing factors. Additionally, we present two cases with delayed relief observed at our institution. Method Two TN patients with delayed response and clear intra-operative arterial findings are presented in this study. Furthermore, we conducted a systematic review by searching electronic bibliographic databases, including MEDLINE (PubMed), Web of Science, Scopus, and Embase, from inception to 2022. Results We identified a total of 28 full-text articles involving 322 TN patients who experienced delayed pain relief. Out of these, only 11 studies provided sufficient evidence and were included in the final analysis. Among the patients, 73.46% were female. The mean incidence rate of delayed response after MVD treatment for TN was 10.5%, with a range of 0.95 to 57.14% across different studies. The mean age of these patients was 59.86 years. The reported time to pain relief in the existing reports was at least 4 days post-surgery. In 72.88% of the reported cases, right-side dominance was observed. The majority of delayed cases experienced pain relief within 3 months, with a median time of 1 month. Conclusions A thorough examination of the probability of delayed pain relief after MVD for TN and understanding the characteristics of this phenomenon can offer surgeons valuable post-operative guidance and aid in decision-making regarding potential immediate reoperation.

BACKGROUND: In an ample armamentarium in neuro-surgery, the semi-sitting position has produced debate regarding its benefits and risks. Although the position is apparently intuitive, many have abandoned its use since its initial inception, because of reported complexity and po-tential complications, leading to impracticality. However, through standardization, it has been shown not only to be safe but to carry with it many advantages, including less risk of secondary neurovascular injuries and better visu-alization of the surgical field. As with any surgical tech- -ical nuance, the semi-sitting position has advantages and disadvantages that must be weighed before the decision is made to adopt it or not, not only in a case-by-case scenario but also from a departmental standpoint. As we attempt to show, the advantages from a standardized approach for the semi-sitting position in experienced institutions may be more than sufficient to significantly outweigh the disad-vantages, making it the preferable option for most, although not all, posterior fossa surgical interventions. -METHODS: In the present study, we aim to elaborate a straightforward narrative of the steps before incision, in an attempt to simplify the complexity of the position, allevi-ating its disadvantages and exponentially concentrating on its benefits. In nearly 100 steps, we carefully describe the points that culminate with the skin incision, initiating the intraoperative part of the procedure. Each step, therefore, is detailed in full, not in an effort to create a strict manual of the semi-sitting position but rather to facilitate under-standing and put the technique into effect in a real-life scenario, thus simplifying what some depict as complex and time consuming. -CONCLUSIONS: Although several of the steps described are also relevant and integral parts of other surgical positioning, we intend to create a protocol, in a stepwise fashion, to allow facilitated following, to be easily imple-mented in departments with different levels of experience. The steps comprise nursing care through to electrophysi-ologic and anesthesiologic approaches, along with neurosurgical cooperation, making it a team approach, not only to avoid position-related complications but also to optimize preoperative standardization, constructing a safe, efficient, and patient-centered scenario, to set the best possible stage for the next step: the intraoperative part of the intervention.

Endovascular treatment, with its ever-expanding applications, is mainstay of treating posterior circulation aneurysms. Superior cerebellar aneurysms are unique because multiple studies show that comparable outcome can be achieved by a microsurgical approach as well. We describe a 49-year-old woman who was diagnosed with an unruptured multilobulated anterior communicating artery aneurysm and a broad-based left superior cerebellar artery aneurysm while getting evaluated for headache. After discussing treatment options, including observation, endovascular treatment, and microsurgery, the patient opted for definitive microsurgical clipping.(1) An eyebrow incision and subfrontal approach was chosen.(2-4) Type-B superior cerebellar artery aneurysms are traditionally approached ipsilaterally, and posterior clinoidectomy is often warranted to improve the access. Whereas, a contralateral approach with more medial and oblique angle obviate the need for drilling the posterior clinoid(5) provided that the basilar tip is not high riding. Choosing a contralateral subfrontal craniotomy, the aneurysm can be approached from the nondominant side. An inverted aneurysm clip was used for better visualization.(6,7) An endoscope improved visualization of the oculomotor nerve, the relationship of the aneurysm to the parent artery, and excluded residual neck.(8-10) Indocyanine green angiography confirmed exclusion of aneurysm and patency of normal arteries. Subsequently, the bilobed anterior communicating artery aneurysm was approached through the same corridor and was clipped uneventfully. The patient recovered well from surgery and was discharged without any neurological deficit. After careful assessment of individual skull base anatomy, superior cerebellar artery aneurysms can be approached safely from the contralateral nondominant side by sub frontal craniotomy. The patient consented to the procedure and publication of her images. Image at 1:39 reprinted from Patra et al,(5) Copyright 2016, with permission from Elsevier. Images at 2:26 and 6:22 reprinted from Krammer and Lumenta,(7) Copyright 2010, with permission from the Congress of Neurological Surgeons.

Resection of large vestibular schwannomas (VS) in semisitting position is one of the most challenging neurosurgical procedure,(1) with only few neurosurgical centers performing this surgery with minimal morbidity. In this surgical video, we describe various tumor dissection principles for successful resection. A 42-year-old female patient presented with loss of serviceable hearing, gait imbalance, intermittent hemifacial spasm, and early hydrocephalus. Imaging revealed a VS Hannover grade 4B on the right side. Indication for microsurgical resection was due to brainstem compression with mild hydrocephalus. A retrosigmoid approach in the semisitting position has the advantage of working in a bloodless surgical field applying a bimanual dissection technique supported by gravity, significantly reducing operative timing.(2,3) All patients undergo preoperative echocardiogram bubble study to rule out a patent foramen ovale. Intraoperative transoesophageal echocardiography, 2 central lines, and extensive neuromonitoring including facial electromyography and moto evoked potential are essential parts of the procedure. After retrosigmoid craniotomy, drilling of internal auditory canal with progressively reducing size of a diamond burr(4-6) is followed by continuous irrigation with a suction irrigation device with body warm ringer solution after dural opening. Avoiding bipolar cautery, using "underwater" techniques, bimanual dissection of arachnoid from tumor, repeated use of Cavitron ultrasonic surgical aspirator within safe zone, and repeated papaverine irrigations, are essential steps of surgery. Anatomic preservation of the cochlear nerve should be attempted even in cases for optional second-stage cochlear implant placement. All participants and any identifiable individuals consented to publication of his/her image.

Objectives In this systematic review and meta-analysis, we review the literature regarding patients with Cushing's disease (CD) with negative or inconclusive magnetic resonance imaging (MRI). Methods A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), EMBASE, and Cochrane electronic bibliographic databases. Results 28 articles described surgical management of inconclusive MRI or MRI-negative CD. A total of 858 patients underwent surgery for their Cushing adenoma. Different types of surgery, including endoscopic endonasal transsphenoidal surgery (EETS) (190 cases) and microscopic endonasal transsphenoidal surgery (METS) (488 cases), were performed on patients with MRI-negative CD. 7 studies, which included 164 patients, did not describe any surgery. EETS and METS are conducted to achieve selective adenomectomy (231 cases), partial adenomectomy (80 cases), total adenomectomy (13 cases), hemihypophysectomy (15 cases), or enlarged adenomectomy (48 cases). Based on available data on these studies, the remission rate, persistence rate, and recurrence rate after different types of surgeries on patients with MRI-negative CD were 72.97%, 27.03%, and 12.05%, respectively. There was no statistically significant difference between EETS and METS in the subanalysis regarding recurrence rate, remission rate, and persistence rate. However, the recurrence rate in the METS group is almost 3 times higher than in the EETS group. Conclusions Surgery has a good prognosis in patients with MRI-negative CD in terms of remission, and EETS has a lower rate of disease recurrence than METS; therefore, EETS seems to be the potential recommended treatment technique, while to confirm the therapeutic method of choice, further investigations should be done.

Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied (Fig. 1A and B). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed (Fig. 2A). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem (Fig. 2B, C). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance (Fig. 2D). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches (Fig. 1C and D). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) (Fig. 1C and D).The link to the video can be found at: https://youtu.be/9eACAJVwQBs.

Background: Lumbar compartment syndrome is a recognized clinical phenomenon, despite receiving less attention as a clinical entity. Given its rarity, the definitive presentation, diagnosis, and management strategies are not completely agreed upon. Materials and Methods: A literature search on PubMed of all case reports of lumbar paraspinal compartment syndromes was conducted. All case reports and reviews were analyzed for patient demographic data, presentation, diagnostic evaluation, treatment, and clinical follow-up. Results: A total of 37 cases of lumbar compartment syndrome were identified. Overall, 91.9% occurred in men with an average age of 30.9 years. Weightlifting (n=18, 48.6%) and physical exertion (n=7, 18.9%) accounted for the majority of presentations. In all, 37.8% of cases occurred unilaterally. Creatinine kinase, aspartate aminotransferase, and alanine aminotransferase were notably elevated. Compartment pressure was elevated with an average of 91.8 mm Hg (SD: 44.8 mm Hg). Twenty-two cases were treated operatively (59.5%) and 15 (40.5%) were treated nonoperatively. In total, 19/20 (95.0%) of cases treated operatively reported either resolution of pain or return to baseline activities without limitation, compared with 1/11 (9.1%) treated nonoperatively. This difference between the operative and nonoperative cohort was statistically significant (P<0.0001). Conclusions: Lumbar paraspinal compartment syndrome is a rare, but well-documented clinical entity. In all, 67.5% of cases occurred after weightlifting or physical exertion. Overall, 40.5% of cases in the literature were treated nonoperatively. Per our analysis, there is a clinically and statistically significant difference in cases treated operatively versus nonoperatively (95.0% vs. 9.1%, P<0.0001).

We present the microsurgical management of a giant partially thrombosed right middle cerebral artery (MCA) aneurysm.(1,2) The patient underwent a right frontotemporal craniotomy with a plan to perform a temporary superficial temporal artery (STA)-MCA bypass to minimize the risk of ischemia during the anticipated period of prolonged temporary aneurysm trapping required to complete the aneurysm thrombectomy and clip reconstruction. Baseline blood flow measurements were recorded in the M1 artery as well as the frontal and temporal M2 branches. A frontal STA bypass to a cortical frontal MCA branch was performed. The aneurysm was temporarily trap occluded, and the intrasaccular thrombus removed. The aneurysm was then clipped by stacking multiple right-angled clips applied from both the frontal and temporal sides of the aneurysm. Blood flow was remeasured, and the temporal M2 artery was found to be occluded. The decision was made to perform a second bypass to temporal MCA branch using the parietal branch of the STA. The aneurysm was subsequently permanently trap occluded by placing permanent clips on the M1, frontal M2, and temporal M2 arteries. Intraoperative blood flow measurements and indocyanine green angiography confirmed patency of the double barrel STA to MCA bypass. The patient had an uneventful postoperative course.The patient has consented to the procedure and to the publication of her image and surgical video. All relevant patient identifiers have been removed from the video and accompanying radiology slides.