OBJECTIVE Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. METHODS The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with >= 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score <= 2 or Glasgow Outcome Scale score >= 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. RESULTS The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). CONCLUSIONS This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

Resection has traditionally been the gold standard for treating jugular foramen schwannomas (JFSs). However, given the high risk of neurological deficits associated with surgical intervention, stereotactic radiosurgery (SRS) has emerged as a promising alternative. Despite its growing popularity for other brain tumors, there remains a paucity of data on the outcomes of SRS for JFSs. This study aims to assess the safety and efficacy of SRS as a treatment option for patients with JFSs. We searched Medline, Embase, and Web of Science databases following PRISMA guidelines. Eligible studies included randomized controlled trials and observational studies reporting ≥ 4 JFS patients treated with gamma knife radiosurgery. Comparative analysis with 95

Background:Anterior skull base meningiomas can cause significant symptoms such as mass effect and neuropsychological decline, necessitating surgical resection. The endoscopic extended transnasal approach has emerged as a minimally invasive alternative to craniotomy, offering a means to address these tumors despite challenges due to the proximity of critical neurovascular structures and the high risk of complications such as cerebrospinal fluid (CSF) leaks. This systematic review and meta-analysis evaluate the safety and efficacy of extended transsphenoidal techniques in anterior skull base meningiomas. Methods:This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. A search was performed in Medline, Embase, Cochrane, and Ovid. Eligible studies included those (1) in English, (2) with patients having anterior skull base meningiomas, and (3) who underwent endoscopic surgical management. Endpoints included CSF leak, length of stay, complications, and mortality. Results:The analysis included data from 23 studies involving 573 patients with a median age of 54.77 (range 39.5-67.3) years. Approximately 71% of participants were female. The mean length of stay was 7.50 days (95% confidence interval [CI]: 6.64-8.47). The overall complication rate was 35% (95% CI: 0.22-0.49), with minor complications also occurring in 6% of cases (95% CI: 0.02-0.10). Major complications were reported in 20% of cases (95% CI: 0.10-0.30). The CSF leak rate was 7% (95% CI: 0.04-0.10). Conclusion:In the setting of complex anatomical challenges and inherent risks, the technique showed a moderate complication rate and length of hospital stay. This method demonstrated lower CSF leak and complication rates compared to previously published studies from the past decade.

Sagittal craniosynostosis is the most common form of craniosynostosis. Patients diagnosed with this condition can undergo surgical management using either the conventional open surgery method or the modern approach of minimally invasive endoscope-assisted craniectomy. The present study aimed to compare different outcomes of patients with sagittal craniosynostosis treated with endoscopic procedures versus open surgery. Multiple databases were systematically searched for studies comparing endoscopic and open repair of sagittal craniosynostosis. Outcomes analyzed included estimated blood loss, length of hospital stay, operative time, transfusion rates, complications, reoperations, and cranial indices. Random-effects meta-analyses were performed. Seventeen studies with 2,365 patients were included. Endoscope-assisted surgery showed significantly lower estimated blood loss (mean difference − 118.47 ml), shorter hospital stays (-2.08 days), and reduced operative times (-84.70 min) compared to open surgery. Intraoperative and postoperative transfusion rates were lower with endoscopic treatment (risk ratios 0.22 and 0.30, respectively). Postoperative complications were reduced with endoscopic repair (RR 0.39), without differences in intraoperative complications or reoperations. Preoperative and postoperative cranial indices slightly favored endoscopic approaches. Endoscope-assisted surgery for sagittal craniosynostosis offers perioperative advantages including reduced blood loss, shorter hospitalizations, briefer operative times, lower transfusion needs, and fewer postoperative complications compared to open calvaria remodeling, while achieving comparable cranial reshaping. These findings support an increasing use of minimally invasive endoscopic techniques for repair of sagittal craniosynostosis.

AIM:To examine the potential of transbrachial access (TBA) in carotid artery stenting (CAS). MATERIAL AND METHODS:This systematic review and meta-analysis aimed to comprehensively evaluate the safety and efficacy of TBA for CAS by conducting a thorough search on Medline, Cochrane Library, Embase, and Web of Science databases. Studies reporting TBA for CAS and evaluating primary outcomes such as good neurological results, procedural success, and complications were included. Studies with fewer than 4 patients were excluded. RESULTS:After a meticulous selection of 1837 literature articles, 11 studies were meticulously chosen for the comprehensive examination, involving a total of 273 patients. The analysis of nine studies revealed a consistent 100% procedural success rate with minimal variability (95% CI: 98% to 100%). In the final assessment of neurological status across eight studies, good neurological outcomes were observed in 99% (95% CI: 98% to 100%). Additionally, nineteen complications were identified, leading to a 1% rate (95% CI: 0% to 9%). Among the 223 patients in eight studies, resulting in a pooled estimate of 0% mortality (95% CI: 0% to 1%), indicating a favorable safety profile. CONCLUSION:The results of TBA for CAS demonstrate a highly effective and safe procedure. Despite the limitations, TBA can be an option in patients with no other access available, and further comparative studies are required to establish definitive conclusions.

AIM:To assess the changes of intracranial pressure waveforms (ICPW) acquired noninvasively in a set of acute hydrocephalus patients prior to and posterior to interventions. MATERIAL AND METHODS:Patients with clinical and radiological diagnosis of hydrocephalus were evaluated for alterations in ICPW by means of a system that detects cranial micro expansions just before and immediately after interventions. The system quantified the difference between ICPW peaks (P1 and P2), providing the P2/P1 ratio. RESULTS:Fourteen patients aged from 26 to 73 years old met the inclusion criteria. Hydrocephalus etiologies were normal pressure hydrocephalus, post-traumatic and all patients had an abnormal intracranial compliance waveform, with P2 > P1 before the procedure (5 external ventricular drains (EVD) and 9 ventriculoperitoneal shunts (VPS). Immediately after, 75% of the patients changed to a standard pattern with P1 > P2. CONCLUSION:In this exploratory study using a novel noninvasive technique, rapid cerebrospinal fluid drainage by means of EVD and VPS was effectively assessed and had a positive impact on intracranial compliance.

Background Arteriovenous malformations (AVMs) pose a risk of neurologic deterioration, particularly when located in eloquent areas. While awake surgery is well-established for treating low-grade gliomas near eloquent areas, its efficacy for AVMs is less conclusively reported. Methods This study conducted a systematic review and individual patient data meta-analysis following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Literature searches were performed in PubMed, Embase, and Web of Science. Eligible studies included case reports, case series, retrospective or prospective cohorts, and randomized trials evaluating awake craniotomy (AC) for AVMs. Single proportion analysis with 95% confidence intervals (CIs) was utilized to pool the data. Case series and case reports were put together as a unique cohort. Results An analysis of 20 studies encompassing 287 patients was performed. The individual patient data cohort had 53 patients. The primary outcome pooled analysis indicated an 88% (95% CI: 81%–95%; I2=63%) rate of total resection. Moreover, a rate of nearly 12% (95% CI: 5%–19%; I2=63%) of subtotal resection was observed. Furthermore, the analysis unveiled a 20% (95% CI: 13%–28%; I2=58%) rate of postoperative neurological deficits, alongside a 6% (95% CI: 3%–9%; I2=29%) rate of follow-up neurological deficits. The mean hospital stay was 4.13 (95% CI: 3.61–4.66; I2=73%) days. Conclusions AC for eloquent AVMs showed promising results. A significant rate of postoperative neurological deficits was found, which was reduced at follow-up. A small mean length of hospitalization was also found. These results suggest that AC for AVMs should be considered in eloquent lesion cases.

Background: Ependymomas account for 6% to 10% of childhood central nervous system tumors. This study aimed to evaluate the safety and efficacy of proton radiotherapy in intracranial ependymoma patients. Methods: We performed a systematic review and single-arm meta-analysis. We searched Medline, Embase, Cochrane, and Web of Science for eligible trials. Random-effects model was used to calculate the risk ratios (RRs), with 95% confidence intervals (CIs). Statistical analyses were performed using RStudio version 4.2.3. Results: Ten cohorts comprising 908 patients with ependymoma were included. The patient population had an average age of 3.5 years, and 53.4 % were male. In terms of proportion, nine outcomes were analyzed: 3-year Progression-Free Survival (PFS; Proportion = 0.63; 95 % CI [0.40-0.87]; I2 = 95 %), 5-year Local Control (LC; Proportion = 0.79; 95 % CI [0.69-0.90]; I2 = 85 %), 5-year Event-Free Survival (EFS; Proportion = 0.65; 95 % CI [0.52-0.78]; I2 = 95 %), 5-year Overall Survival (OS; Proportion = 0.83; 95 % CI [0.77-0.90]; I2 = 82 %), 2-year OS (Proportion = 0.91; 95 % CI [0.88-0.94]; I2 = 0 %), 3-year OS (Proportion = 0.92; 95 % CI [0.89;0.95]; I2 = 43 %). Additionally, neurological (Proportion = 0.17; 95 % CI [0.07-0.27]; I2 = 97 %), dermatological (Proportion = 0.20; 95 % CI [0.00-0.44]; I2 = 82 %), and brainstem complications (Proportion = 0.03; 95 % CI [0.01-0.04]; I2 = 31 %) were investigated. Conclusion: While proton radiotherapy appears safe and effective based on current data, these results should be approached cautiously, as broad confidence intervals in some adverse event rates suggest variability in outcomes.

BackgroundEndovascular treatment (EVT) of intracranial aneurysms (IAs) has improved significantly with the integration of virtual simulation software (VSS) in surgical planning and device selection. Despite promising outcomes, discrepancies remain between physician and VSS recommendations. This review synthesizes evidence on (1) comparisons between VSS-chosen and physician-chosen dimensions; (2) VSS-chosen and postoperative measured dimensions; and (3) the success rate of VSS-guided device deployment.MethodsA systematic search adhering to PRISMA guidelines was conducted in Medline, Embase, Web of Science, and Cochrane databases up to January 2024. Eligible studies included case series, cohort studies, and randomized trials assessing VSS for stent selection in IAs treatment. Mean difference (MD) and single-arm meta-analysis with 95% confidence intervals (CIs) under a random-effects model were performed for continuous and binary outcomes. Subanalyses were conducted for Sim&Size and PreSize software.ResultsTen studies comprising 658 IAs were included. Pipeline Embolization Device was most commonly used. Findings demonstrated (1) high accuracy of VSS when comparing simulated and postoperative lengths (MD -1.7 mm; 95% CI -4.37 to 0.98 mm); (2) physician-chosen lengths overestimated compared to VSS (MD -2.11 mm; -3.43 to -0.79 mm); (3) no significant difference in physician- versus VSS-chosen diameters (MD -0.04 mm; -0.13 to 0.06 mm); and (4) high VSS-guided deployment success (96%; 93-99%) with low complications (4%). Subanalyses showed 95% and 92% deployment success rates for Sim&Size and PreSize, respectively.ConclusionVSS effectively estimates device length and achieves high deployment success, with low complication rates, supporting its utility in EVT planning.

BACKGROUND:Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial.OBSERVATIONS:A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement.LESSONS:In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient’s quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47

BACKGROUND:Stellate ganglion block (SGB) may have protective effects in patients at risk of vasospasm following subarachnoid hemorrhage (SAH) due to reduced sympathetic activity. However, the safety and clinical outcomes of SGB in this scenario are not definitively known. The objective was to evaluate the safety, clinical outcomes, and cerebral blood flow velocity in patients submitted to SGB or cervical sympathectomy with SAH. METHODS:Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and meta-analysis of studies investigating SGB or cervical sympathectomy use in SAH were conducted. PubMed, Cochrane Library, and Embase were evaluated. Patients with mRS from 0 to 2, GOS from 4 to 5, or symptom resolution were considered favorable clinical outcomes. Related mortality was defined as death by vasospasm or delayed cerebral ischemia. RESULTS:The analysis included 8 studies comprising 182 patients. Only 2 studies employed SGB prophylactically. The results revealed favorable outcomes in 52% of patients (95% CI: 37%-65%). The overall incidence of complications was 2% (95% CI: 0% -26%). The mortality rate was 13% (95% CI: 7%-21%), with a vasospasm-related mortality rate of 11% (95% CI: 2%-20%). A decrease of cerebral blood flow velocity was reported in 4 studies. CONCLUSIONS:The notable reduction in cerebral blood flow velocity following SGB, alongside positive outcomes and a low occurrence of mortality and complications, highlights its significance as a therapeutic intervention for vasospasm following SAH. While the number of studies evaluating SGB as a preventive measure is limited, the promising results emphasize the importance of future research.

AIM:To evaluate the usage and the effectiveness of LVIS Jr device technology in managing wide-neck intracranial aneurysms. MATERIAL AND METHODS:PubMed, Embase, and Web of Science databases, comprising studies with outcomes related to LVIS Jr use in wide-neck intracranial aneurysms were searched systematically. Data was extracted from the selected articles and subjected to statistical analysis. RESULTS:Among 886 initially identified articles, 20 studies met our inclusion criteria, comprising a total of 557 patients. Our analysis revealed a 96% final occlusion rate under common effects and 93% under random effects, with substantial heterogeneity (I² = 69%). Good clinical outcomes were observed in 99% of cases with low heterogeneity (I² = 27%). Mortality rates were extremely low, with only one reported death out of 499 patients across 18 studies, resulting in a 0% mortality rate for common and random effects and no heterogeneity (I² = 0). Complications occurred in 44 of 482 patients, yielding a 6% rate in the common effect model and 6% in the random effects model, with nonsignificant heterogeneity (I² = 25%). CONCLUSION:LVIS Jr observed a favorable rate of final occlusion and good clinical outcomes, and the low mortality and complication rates highlight its safety in the treatment of wide-neck aneurysms.

Introduction: Intracranial mycotic or infectious aneurysms result from the infection of arterial walls, most caused by bacterial or fungal organisms. These infections can weaken the arterial wall, leading to the formation of an aneurysm, a localized dilation, or a bulge. The management can be conservative mainly based on antibiotics or invasive methods such as clipping or endovascular treatment. Purpose: We performed a systematic review and meta-analysis of the current literature on endovascular treatment of mycotic aneurysms, analyzing the safety and efficacy associated with this procedure. Methods: We systematically searched on PUBMED, Cochrane Library, Embase, and Web of Science databases. Our search strategy was carefully crafted to conduct a thorough investigation of the topic, utilizing a comprehensive combination of relevant keywords. This meta-analysis included all studies that reported endovascular treatment of mycotic aneurysms. To minimize the risk of bias, studies with fewer than four patients, studies where the main outcome was not found, and studies with no clear differentiation between microsurgical and endovascular treatment were excluded. Results: In a comprehensive analysis of 134 patients, it was observed that all except one patient received anti-biotics as part of their treatment. Among the patients, 56% (a total of 51 out of 90 patients) underwent cardiac surgery. Additionally, three patients required a craniotomy following endovascular treatment. 12 patients experienced morbidity related to the procedures performed, indicating complications arising from the in-terventions. Furthermore, four aneurysms experienced rebleeding while treatment. A pooled analysis of the endovascular treatment of the mycotic aneurysm revealed a good level of technical success, achieving a 100% success rate in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as illustrated in Fig. 2. Similarly, the aneurysm occlusion rate demonstrated a notable efficacy, with a success rate of 97% observed in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as depicted in Fig. 3.Conclusion: The results strongly support the efficacy of endovascular treatment in achieving technical success, complete aneurysm occlusion, and favorable neurological outcomes. Additionally, the notably low incidence of complications and procedure-related mortality reaffirms the safety and benefits associated with this intervention.

Bypass revascularization helps prevent complications in Moyamoya Disease (MMD). To systematically review complications associated with combined direct and indirect (CB) bypass in MMD and analyze differences between the adult and pediatric populations. A systematic literature review was conducted per PRISMA guidelines. PUBMED, Cochrane Library, Web of Science, and CINAHL, were queried from January 1980 to March 2022. Complications were defined as any event in the immediate post-surgical period of a minimum 3 months follow-up. Exclusion criteria included lack of surgical complication reports, non-English articles, and CB unspecified or reported separately. 18 final studies were included of 1580 procured. 1151 patients (per study range = 10—150, mean = 63.9) were analyzed. 9 (50.0%) studies included pediatric patients. There were 32 total hemorrhagic, 74 total ischemic and 16 total seizure complications, resulting in a rate of 0.04 (95% CI 0.03, 0.06), 0.7 (95% CI 0.04, 0.10) and 0.03 (95% CI 0.02, 0.05), respectively. The rate of hemorrhagic complications in the pediatric showed no significant difference from the adult subgroup (0.03 (95% CI 0.01—0.08) vs. 0.06 (95% CI 0.04—0.10, p = 0.19), such as the rate of ischemic complications (0.12 (95% CI 0.07—0.23) vs. 0.09 (95% CI 0.05—0.14, p = 0.40). Ischemia is the most common complication in CB for MMD. Pediatric patients had similar hemorrhagic and ischemic complication rates compared to adults.

Neurosurgery is an intensely competitive field. With the USMLE Step 1 transitioning to a pass/fail system, research has become a crucial component of the neurosurgery residency application process. This emphasis on research is particularly critical for international medical graduates (IMGs), who often face greater challenges compared to their U.S. counterparts. IMGs typically need more publications and higher H-indices to stand out. However, accessing quality research opportunities is significantly more difficult for those from low- and middle-income countries. This mini-review aims to provide a new perspective for IMGs, demonstrating that publishing in prestigious neurosurgical journals is possible even with limited resources. We searched Scopus and reviewed Brazilian publications from 2014 to 2023 in Neurosurgery and the Journal of Neurosurgery. We extracted the methodological designs of the studies and the graduation status of the first authors. In 2023–2024, four Brazilian medical students published systematic reviews in major neurosurgical journals as first authors, marking a revolutionary change in the Brazilian neurosurgical landscape not seen in the past decade. These achievements illustrate that high-impact publications are attainable without geographical proximity, substantial financial support, or access to extensive institutional databases. Letters to the editor also represented a considerable Brazilian contribution. Literature reviews and letters to the editor are accessible methods for IMGs to engage in impactful research. IMGs can maximize their abilities and significantly contribute to neurosurgery by embracing literature reviews and meta-analyses. These approaches can open doors for those without other avenues to begin their research careers.

The treatment for peripheral nerve sheath tumors (PNSTs) is based on surgical excision and the primary goal is to improve symptoms whilst preserving neurological function. In order to improve this technique, surgeons may use sodium fluorescein (SF) to help visualize the neoplasm and, consequently, facilitate its removal. Aiming to assess the efficacy of this emerging surgical strategy, we conducted a systematic review and single-arm meta-analysis. We conducted a systematic search on the PubMed, Embase, and Web of Science databases, following the PRISMA guidelines. Studies without outcomes of interest, case series with less than four patients, letters, comments, technical notes, editorials, reviews, and basic research papers were excluded. The outcomes considered for this study were: the number of tumors that achieved total resection, subtotal resection, or near total resection, the approach/technique utilized by the surgeon, SF-related complications, and total complications. Five studies, with a total of 175 individuals, were included in our survey. Notably, 70

Background Von Hippel-Lindau (VHL) disease is a rare autosomal dominant disorder that predisposes patients to develop multiple cysts and tumors, such as hemangioblastomas (HBs) and clear cell renal cell carcinoma (ccRCC), due to mutations in the VHL tumor suppressor gene. While treatment of HBs varies based on their characteristics and has improved patient survival, it still involves high morbidity and mortality, leading to ongoing debates and studies to refine therapy strategies. Recent developments include the emergence of Belzutifan, a novel inhibitor targeting hypoxia-inducible factor 2α (HIF-2α), which has shown promising results in ongoing trials, particularly for patients not immediately requiring surgery. Methods This systematic review and meta-analysis aimed to comprehensively evaluate the efficacy and safety of Belzutifan for treating HBs associated with VHL disease. Search was conducted across Medline, Embase, Cochrane, and Web of Science databases. Statistical Analysis was performed, with proportions and 95 % confidence intervals. Statistical analyses were carried out using R Studio. Results Ten studies were selected, comprising 553 patients. The population mean age was 40 (24–65), and 50 % of the population was formed by males. In terms of proportion, 6 analyses were performed: Disease Stability of 31 % [95 %CI:14 %–47 %; I2 = 2 %]; Disease Progression of 2 %[95 %CI:0 %–9 %; I2 = 0 %]; Partial Response of 75 % [95 %CI:54 %–96 %; I2 = 58 %]. Complete response of 1 % [95 %CI:0 %–7 %; I2 = 0 %];and Side effects, anemia 81 % rate [95 % CI:54 %–100 %; I2 = 94 %], and fatigue rate of 79 % [95 % CI:54 %–100 %;I2 = 94 %]. Conclusion Results indicate that Belzutifan effectively stabilizes disease, reduces tumor progression, and achieves significant therapeutic responses, although side effects like anemia and fatigue were noted.