Background:The recent emergence of hybrid operating rooms (H-OR) broadens treatment options for complex intracranial aneurysms. Combining endovascular options enabled by the H-OR with refined microsurgical techniques could provide less arduous treatment alternatives for large, distal, and fusiform MCA aneurysms. Research question:To describe the technical nuances of a hybrid treatment consisting of microcatheter-guided flash fluorescence to enable revascularization bypass and endovascular parent vessel occlusion (PVO) in three different cases of large, distal and fusiform MCA aneurysms. Methods:A technical report of three cases is provided. At a H-OR, after STA harvest and side-appropriate craniotomy, femoral artery access was obtained and a microcatheter was guided in the corresponding aneurysm. Indocyanine green (ICG) was injected throughout the microcatheter while running a videoangiography on the surgical microscope, allowing straight-forward identification of the appropriate vessel recipient for the revascularization bypass. Results:The described hybrid flash-fluorescence technique allowed straight-forward identification of the appropriate vessel recipient for the revascularization bypass in all three cases. After completion of the bypass and verification of its patency by intraoperative angiography, the aneurysms and their parent vessels were occluded endovascularly. Conclusion:This hybrid treatment using modern endovascular and microsurgical techniques obviates the need for a large craniotomy, Sylvian fissure dissection and aneurysm manipulation, while reducing surgical risks and operative time in the treatment of complex fusiform MCA aneurysms. The H-OR room can result in new proficient, creative and safe treatment options of different neurovascular pathologies.

STUDY DESIGN:Prospective multicentre cohort study. OBJECTIVE:This study aimed to compare the holistic improvement of patients with cervical radiculopathy in all health domains (pain, disability, and QOL) following ACDF and TFESI in patients with cervical radiculopathy, identifying patient subgroups that may benefit more from one or both treatments. SUMMARY OF BACKGROUND DATA:Cervical radiculopathy, characterized by neck and arm pain, significantly affects quality of life (QOL) and functional capacity. While anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for persistent symptoms, transforaminal epidural corticosteroid injection (TFESI) offers a less invasive alternative. Limited data exists comparing their effectiveness on disability and QOL. METHODS:This pragmatic multicenter cohort study included patients diagnosed with cervical radiculopathy at 3 Belgian hospitals. Patients received either ACDF (n=34) or TFESI (n=57) based on clinical assessment and patient choice. Pain, disability, and QOL were assessed over an 8-month follow-up using the visual analog scale (VAS), Neck Disability Index (NDI), and EQ-5D, respectively. A hierarchical cluster analysis categorized patients into subgroups for targeted analysis. RESULTS:At 8 months, both treatments improved pain scores (VAS), but ACDF showed significantly greater improvements in NDI (P<0.001) and EQ-5D (P<0.001) compared with TFESI. Cluster analysis revealed that patients with high baseline disability (cluster 3) benefited most from ACDF in terms of both QOL and functional recovery. The probability of a reduction in pain medication use is greater after ACDF. CONCLUSION:ACDF provides superior improvement in disability and QOL for patients with severe cervical radiculopathy compared with TFESI, particularly for patients with severe pretreatment health status (cluster 3). Personalized treatment strategies, guided by patient profiles such as those revealed in this study, may lead to optimized outcomes.

INTRODUCTION:Research on intracranial aneurysm (IAs) emphasizes the role of flow-induced and neuroinflammation-driven vascular remodelling in aneurysm progression and rupture. However, tissue access for histo-molecular analysis remains limited, particularly with the rise of endovascular techniques. This study aims to establish systematic criteria for IA tissue sampling and preservation in clinical practice. METHODS:In this retrospective study, adult patients undergoing IA surgery had systematic sampling of the aneurysmal wall, meninges, middle meningeal artery, and superficial temporal artery. Histological analysis was performed to assess tissue integrity, followed by pre-analysis using housekeeping genes expression to evaluate the feasibility of RT-qPCR analyses. Clinico-radiological data, including sampling-related complications were reviewed. A statistical comparison was made between ruptured and unruptured aneurysm groups. RESULTS:Aneurysms of the middle cerebral artery (MCA) accounted for over 60% in both groups. As expected, in ruptured cases, morbidity and mortality were significantly higher than in unruptured cases (p < 0.001; p = 0.043). No major complications could be directly attributed to sampling. Sampling success rates for the aneurysmal wall reached 97% in both groups, and around 80% for other tissues (STA, MMA, DM). Histopathological analysis of the aneurysmal wall was completed in 85% of unruptured cases and 83% of ruptured cases, indicating a depth limit of >3 mm for aneurysm sampling. Housekeeping gene expression was observed in all samples, without restriction based on aneurysm depth. CONCLUSION:This study proposed criteria for safe and reproducible MCA aneurysm tissue sampling in routine clinical practice. These findings could support the creation of a national French vascular biobank, fostering further translational research.

Intracranial aneurysms can rupture and cause subarachnoid haemorrhage, yet their pathophysiology remains incompletely understood. Bacterial involvement has been proposed, although evidence remains inconsistent. We investigated the presence of bacterial genomic material in aneurysm vessel walls and characterised the oral and rectal microbiome using high-resolution 16 S rRNA amplicon sequencing with DADA2-based amplicon sequence variant (ASV) analysis and PICRUSt2-inferred functional profiling. In this cross-sectional study, 34 neurosurgical patients (16 with intracranial aneurysms, 18 neurosurgical controls) were included. No bacterial genomic material was detected in aneurysm walls or surrounding intracranial tissues. Microbiome profiling of oral (n = 29) and rectal (n = 27) mucosal swabs identified 9,132 ASVs across all samples. Alpha diversity (Shannon entropy, Chao1 richness, Pielou’s evenness, observed ASVs, and Faith’s phylogenetic diversity) did not differ between groups at either site. Beta diversity community composition was similar across Bray–Curtis dissimilarity and weighted and unweighted UniFrac distances (all PERMANOVA p ≥ 0.27, R²<0.05). No genus reached FDR significance after Benjamini–Hochberg correction (178 oral and 201 rectal genera tested). Machine learning classifiers showed no discriminatory ability (Random Forest and XGBoost AUC 0.53–0.60). PICRUSt2-inferred functional profiling of MetaCyc pathways, EC numbers, and KEGG Orthology gene families likewise revealed no FDR-significant differences at either site; nominally elevated pathways in intracranial aneurysm patients included galactitol degradation and NAD biosynthesis II, consistent with trends in Bifidobacterium abundance, but none survived multiple-testing correction. A preliminary OTU-based analysis suggested oral microbiome differences, but these were not reproduced with ASV-level resolution. These findings do not support a distinct mucosal microbiome or functional signature in intracranial aneurysm patients and highlight the importance of high-resolution analytical methods and adequate study power for microbiome research.

BACKGROUND AND OBJECTIVES: Current knowledge on tissue reactions and resorption of hemostatic agents in neurosurgery is mostly derived from animal and non-neurosurgical studies. The limited available data in humans consist of small case series including only a few types of hemostatic agents. This study outlines the histological findings, including inflammatory response, and the degree of resorption observed in hemostatic agents retrieved during cranial and spinal reoperations. METHODS: Histological slides of hemostatic agents and surgical materials retrieved during secondary cranial and spinal procedures performed over a 12-year period were retrospectively evaluated. In a retrospective observational cohort design, the samples were semiquantitatively scored for the microscopic degree of resorption and inflammatory response. Results are summarized using descriptive statistics. Given the sample of convenience, the relationship between the type of agent and the degree of inflammatory response seen on histological examination is assessed in exploratory analysis. RESULTS: Histopathological findings of 160 samples are described, encompassing 14 hemostatic agents and 2 types of surgical materials retrieved during neurosurgical reoperations. Samples were from different types of hemostatic agents (eg, oxidized regenerated cellulose, bone wax, gelatin sponge, fibrin sealant) and materials (eg, neurosurgical patties, polyvinyl alcohol sponge) from cranial (76.3%) and spinal (23.7%) reoperations. Hemostatic agents were found to remain in situ for extended periods, with one case of recognizable remnants at 14.7 years postoperatively, exceeding most manufacturers' reported time frames. Even in the absence of adverse events directly attributable to the hemostatic agent or material, inflammatory reactions and fibrosis were frequently observed across all types of hemostatic agents and materials analyzed. CONCLUSION: This study describes a broad spectrum of inflammatory reactions associated with hemostatic agents and materials used in neurosurgery, even in the absence of clinically attributable symptoms. Several hemostatic agents remain in situ for extended periods, challenging claims made by manufacturers.

PURPOSE: Moyamoya vasculopathy is a progressive cerebrovascular disease characterized by stenosis of the intracranial internal carotid arteries, leading to chronic cerebral ischemia. Indirect revascularization techniques, such as multiple burr hole surgery, aim to promote collateral vessel formation and improve cerebral perfusion. This study evaluates the clinical and radiological outcomes of multiple burr hole surgery in a diverse Belgian patient population with Moyamoya vasculopathy. METHODS: A retrospective single-center cohort study was conducted, including 15 patients (22 hemispheres) who underwent multiple burr hole surgery between 2007 and 2024. Clinical outcomes, stroke recurrence, and magnetic resonance (MR) perfusion parameters—relative cerebral blood volume (rCBV) and relative time to peak (rTTP)—were analyzed pre- and postoperatively in five predefined brain regions. Of the 22 hemispheres, raw MR perfusion data were available in 11 (50%), limiting subgroup analyses and statistical power. RESULTS: Postoperative MR perfusion imaging demonstrated significant improvements in rCBV and rTTP in the frontal, parietal, and occipital lobes of surgically treated hemispheres (p < 0.05) after a median follow-up of 21 months. No significant changes were observed in deep brain structures (thalamus and basal ganglia) or the contralateral hemisphere. Clinically, one patient experienced a recurrent ischemic stroke during follow-up. One patient developed transient postoperative paresthesia, and one patient suffered fatal cerebral edema. CONCLUSION: Multiple burr hole surgery has the potential to be an effective technique for enhancing cerebral perfusion in selected patients with Moyamoya vasculopathy. The observed improvements in superficial cortical perfusion support its role as an alternative to direct revascularization in selected cases. Future long-term follow-up studies are essential to assess sustained benefits and refine patient selection criteria for indirect revascularization.

DNA methylation profiling is an integral diagnostic tool in the classification of central nervous system (CNS) tumors. While the Heidelberg CNS Tumor Methylation Classifier is widely used to support CNS tumor diagnostics, new classifiers such as CrossNN are emerging. However, their clinical performance and added value within routine diagnostic workflows remain insufficiently explored. In this study, we evaluated the diagnostic performance of the CrossNN classifier in a real-world CNS tumor cohort and compared it with the established Heidelberg classifier to assess its potential as both a non-inferior alternative and a complementary tool to improve diagnostic accuracy. A retrospective cohort of CNS tumors profiled using Illumina Human Methylation 930k EPIC v2 BeadChip arrays was analyzed. Classifier outputs were compared with integrated WHO CNS5 (2021) diagnoses. In addition, CrossNN and Heidelberg outputs were harmonized to WHO CNS5 (2021) tumor type levels and evaluated both individually and within sequential and parallel diagnostic workflows. The proposed workflows were subsequently assessed in an independent prospective validation cohort. Among 205 samples, CrossNN correctly classified 88.8% of cases and demonstrated 86.8% concordance with the Heidelberg classifier. CrossNN demonstrated non-inferior classification performance compared with the Heidelberg classifier. Combining both classifiers increased the number of clinically informative and correct classifications by nearly 10%. This finding was confirmed in an independent validation cohort of 41 samples. In conclusion, these results demonstrate the complementary strength of the CrossNN and Heidelberg classifiers as a dual-classifier strategy to improve diagnostic confidence and accuracy in routine CNS tumor diagnostics.

Introduction: The management of neurovascular pathologies has changed globally over the last few decades. Endovascular treatments are increasing, and fewer surgical procedures are performed. Research question: Evaluate the evolution of vascular neurosurgery in Belgium over the last 30 years and compare with other countries. Material and methods: Belgian nationwide data was obtained from 1991 to 2021 via the National Institute for Health and Disability Insurance (INAMI-RIZIV). Cost of surgical and endovascular implants used in 2022 was obtained. Results: Over a 30-year period a total of 37,504 procedures were performed in Belgium, consisting of 13,767 (36.7%) surgeries and 23,737 (63.3%) endovascular treatments (EVT).Adjusted to population per 100000, surgical management peaked at 6.02 in 1996 and gradually dropped below 3.0 in 2019. EVT increased from 1.06 in 1991 to 10.5 in 2021.Important regional differences are seen in terms of total number of procedures as well as ratio of surgery to endovascular surgery.The total cost of surgical implants in 2022 was the equivalent of 1% of the total cost of endovascular implants. Discussion and conclusions: This data confirms a similar trend to other regions in the world: a reduction in surgical management and increase in endovascular management for CNS vascular pathologies.Important regional differences are noted in terms of volume and ratio of endovascular to surgery.A nationwide registry based on patient data and outcomes can help decide whether there should be centralization to manage vascular pathologies.

Hemostatic agents and other foreign materials are frequently encountered in neuropathology samples. Recognizing these materials is crucial for accurate diagnosis and in the context of adverse events. This article provides an overview of macroscopic and microscopic characteristics of commonly used hemostatic agents and materials in neurosurgery. Samples of sterile hemostatic agents and retrospectively collected pathology slides were examined. Routine histopathological processing, special stains, and polarized light microscopy were utilized to document the appearance of these materials. A total of 22 hemostatic agents and 9 artifacts and foreign bodies were analyzed. Distinct macroscopic and microscopic properties, as well as effects of tissue processing, were documented. Recognizing hemostatic agents and materials is largely dependent on their main constituents. A constituent-based approach for identification of these materials is presented for the practicing neuropathologist.

Introduction: Exogenous and endogenous sex hormones, especially Progesterone agonists, may be causally linked to meningioma progression. Cessation of treatment leads to stabilization or regression of Progestin-induced meningioma. In many cases, avoiding sex hormone therapy may be possible in the context of meningioma treatment. However, hormonal treatment is not always easily replaceable and concise real-world recommendations regarding sex hormones and meningioma are lacking. Material and methods: A combined effort was initiated between Neurosurgical, Gynaecological and Endocrinological societies of Belgium to gather relevant information regarding sex hormone therapies and meningioma. After complete literature review, consensual recommendations were established. Results: Collegial recommendations regarding sex hormones therapies and meningioma in the context of oral contraceptives, menopause hormonal treatment, fertility treatment, pregnancy and gender-affirming therapies are emitted and nuanced. Discussion and conclusion: Withdrawal and monitoring of sex hormone therapies are discussed in detail.A decision tree regarding Meningioma and Combined contraception, Progestin Contraception, Menopause Hormonal treatment, Progestin and Gender-affirming therapy is suggested.

INTRODUCTION:Intracranial aneurysm (IA) rupture accounts for 3% of strokes and is associated with a concerning mortality rate. Subarachnoid hemorrhage with cerebral hematoma (CSAH) often results in a higher mortality rate; however, the optimal treatment approach remains unclear. This study aims to identify factors predicting poor outcomes and mortality in cases of CSAH due to ruptured aneurysms in the anterior cerebral circulation. METHODS:This study retrospectively included 102 patients with anterior circulation aneurysm ruptures, treated between 2017 and 2019. A multidisciplinary team determined the treatment strategies. Statistical analyses were performed to assess outcomes. RESULTS:In the bivariate analysis of CSAH related to anterior circulation aneurysm rupture, significant factors associated with morbidity (mRS >2 at one year follow-up) and mortality were: WFNS score severity, mydriasis, Tako-Tsubo, and the presence of hydrocephalus. In the multivariate analysis, significant factors for mortality were hydrocephalus (p < 0.01) and Tako-Tsubo (p < 0.001), while significant factors for morbidity were hydrocephalus (p < 0.01) and hematoma volume (p = 0.012). CONCLUSION:Our study analyzed a series of cases involving CSAH from anterior circulation aneurysms. We emphasize the importance of prompt treatment for hydrocephalus and suggest that the diagnosis of Tako-Tsubo should delay but not prevent treatment. Depending on local ethical standards, treatment abstention could be considered in patients with severe WFNS scores, the presence of mydriasis, hematoma >45 mL, and hydrocephalus. Our findings indicate that life-threatening hematomas are best managed surgically, while smaller, non-life-threatening cases may benefit from endovascular treatment, though further randomized trials are needed for validation.

Lumbar spinal fusion surgeries are increasingly being performed in spinal degenerative disease, often accompanied by perioperative opioid prescriptions. The aim of this study is to analyze prolonged postoperative opioid use following a standardized opioid prescription after single-level lumbar spinal fusion surgery in a Belgian population. This prospective, multicentric observational study included patients undergoing single-level lumbar fusion surgery for degenerative disease. A standardized postoperative opioid protocol (Targinact 2 × 10 mg/5 mg, Paracetamol 4 × 1 g and Ibuprofen 3 × 600 mg) was applied uniformly. Prolonged opioid use was defined as continued opioid use six months after surgery. Patient data were collected using the Back-App®. Among 198 participants, 32.8

OBJECTIVE:This article describes the results of the first-in-human prospective clinical trial of a hemostatic hydrogel of the self-assembling peptide IEIK13 for hemostasis in intracranial surgery. Both safety and efficacy of IEIK13 for intraoperative hemostasis of oozing bleeding were evaluated in this multicenter trial. METHODS:A total of 80 participants underwent a surgical intervention, during which 203 intradural bleeding sites were treated with IEIK13. Hemostasis was evaluated at 30 seconds and again at 1, 2, 3, and 6 minutes after application. A performance goal of >70% of bleeding sites reaching hemostasis within 3 minutes after application of IEIK13 was used to demonstrate noninferiority in statistical analysis. Clinical safety evaluation was performed postoperatively, at hospital discharge, and at 1 and 3 months after surgery. This included follow-up radiological imaging within the first 72 hours postoperatively and at 3 months. RESULTS:Hemostasis was achieved within 3 minutes in 94.1% of bleeding sites, and within 6 minutes in 95.6% of bleeding sites. Subanalysis revealed that hemostasis occurred within the first minute in 89.2% of cases. There were no intraoperative device deficiencies. Results of the safety assessment did not raise any specific concerns. The nature and rate of adverse events did not significantly differ from what is typically expected in neurosurgical practice. CONCLUSIONS:IEIK13 is effective and safe for hemostasis of oozing bleeding during intracranial neurosurgery. Based on this trial, the transparent IEIK13 hydrogel is a useful addition to the neurosurgical hemostasis toolbox.

To report the rate of diameter reduction of intracranial arteries during aneurysm clipping. Also, in the subset of ruptured aneurysm (RA) the relationship between diameter reduction and symptomatic vasospasm (SVS) Is investigated. A retrospective dataset containing demographics, aneurysm characteristics, vessel dynamics and SVS in adults with surgically clipped intracranial aneurysms was analyzed. The vessel diameters were recorded intraoperatively, both pre- and postclipping. SVS was assessed by transcranial doppler ultrasound or CT-angiogram in the presence of neurological deterioration. Backward multivariable logistic regression models were applied to define variables associated with SVS. A total of 117 surgically clipped adults with intracranial aneurysms were included of which 49 (42%) presented with subarachnoid hemorrhage due to a RA. Intraoperatively measured vessel diameters were smaller in the RA group compared to the non-RA group. The vessel diameter changes before and after placement of the surgical clip are comparable in all groups, with a mean reduction of 15% (RA, non-RA, SVS and no-SVS). Incidence of SVS was 57.1% (in RA group), mean age 53 years and 73.5% were women. Female sex was independently associated with the occurrence of SVS (p = .024). Surgical aneurysm manipulation leads to a consistent reduction of 15% in intracranial artery diameters. Although vessel diameters are smaller in patients with RA compared to non-RA, there is no difference in intraoperative vessel diameter dynamics for both groups. We found no association between the degree of vessel diameter reduction and the occurrence of symptomatic vasospasm in the RA group.

BACKGROUND:The gold standard for the diagnosis and detailed evaluation of spinal dural arteriovenous fistula (SDAVF) is a digital subtraction angiography (DSA). However, this procedure is time-consuming and effortful. A time-resolved contrast enhanced 4D magnetic resonance angiography (4D-MRA) can be used to increase the diagnostic accuracy of spinal magnetic resonance imaging for the detection and localization of a SDAVF. The goal of this study is to assess the diagnostic accuracy of 4D-MRA for the detection and localization of a SDAVF in comparison to DSA based on a systematic review of the literature. METHODS:We performed a systematic review and meta-analysis on the diagnostic accuracy of 4D-MRA compared to DSA. Literature was reviewed from the PubMed, Cochrane, and EMBASE databases. RESULTS:In comparison with DSA, the pooled sensitivity of MRA was 98.2% (95% confidence interval [CI] 91.5%-99.6%), with a pooled specificity of 88.2% (95% CI 57.5%-97.6%) for the diagnosis of SDAVFs. The side and level of the SDAVFs were correct in 91% (95% CI: 86%-94%) and 76% (95% CI: 71%-80%), respectively. CONCLUSIONS:Current literature indicates that 4D-MRA has a high sensitivity and specificity for the detection and localization of a SDAVF. It can serve to guide DSA to shorten the procedural time, reduce the risk of complications, and decrease patient discomfort.

Extracranial-intracranial (EIC) bypasses are used to treat Moya-Moya syndrome and complex aneurysms. Evaluating bypass patency is vital. Current methods include intraoperative techniques like indocyanine angiography, micro-doppler probes, and postoperative non-invasive imaging. However, adjudicating the frequent discordant imaging results is done via conventional digital subtraction angiography (DSA) despite its associated risks. Our study aims to quantitatively evaluate bypass patency by introducing a novel biomarker, the virtual cut-flow index (VCFI) derived from 4D-PACK MRI imaging. We prospectively reviewed consecutive adult patients who underwent bypass surgery at our institution between January and October 2023. MR angiography was performed, employing 4D-PACK (four-dimensional pseudo-continuous arterial spin labeling (4D-pCASL)-based angiography using CENTRA-keyhole and view sharing) imaging. We measured arterial signal intensity using regions of interest (ROIs) placed on the superficial temporal artery (STA) and a branch of the middle cerebral artery (MCA) post-bypass. We modeled signal evolution using linear regression and extracted slope α coefficients and then calculated the virtual cut-flow index (VCFI) using the equation VCFI = αMCA/αSTA. We included 18 patients corresponding to 19 bypasses. The median VCI was significantly higher in patients with a patent bypass compared to those with an occluded bypass (87.33 vs. 19.87%; p < 0.05). The median αMCA coefficient was significantly higher in patients with a patent bypass compared to those with an occluded bypass (69.21 vs. 11.34; p < 0.05). The median αSTA coefficient was significantly higher in patients with a patent bypass compared to those with an occluded bypass (102.74 vs. 44.74; p < 0.05). We introduced a novel noninvasive biomarker, the virtual cut-flow index, as a new means to assess bypass patency. While DSA remains the gold standard, VCFI offers a promising avenue for quantitative evaluation, potentially enhancing postoperative monitoring and influencing surgical planning.

Background: Microsurgery is essential in various surgical specialties, but learning these skills is challenging due to work hour limitations, patient safety concerns, documentation time, and ethical objections to practicing on live animals. This randomized controlled trial compares 2 microsurgical training models: the smartphone model and the microscope model. Methods: Thirty students without prior microsurgery experience were randomized into 3 groups: control (CG), smartphone (SG), and microscope (MG). Participants performed microsurgical skill tests and a chicken femoral artery anastomosis before and after 10 hours of standardized training according to their assigned models. The CG performed the test twice without training. Performance was assessed by time to complete the anastomosis, University of Western Ontario Microsurgery Skills Assessment scale, anastomosis patency, and time to complete the round-the-clock test. Results: No significant differences were observed among groups at baseline. Significant improvement in anastomosis time was achieved in the MG (27.4 minutes, P = 0.005) and SG (27.0 minutes, P = 0.005), but not in the CG (13.1 minutes, P = 0.161). On the University of Western Ontario scale, the MG improved by 6.0 points (P = 0.002), the SG by 5.1 points (P = 0.006), and the CG by 2.4 points (P = 0.009). Patency rate significantly improved in the MG and SG (P = 0.002) but not the CG (P = 0.264). Round-the-clock time improved in all groups (P < 0.001). Conclusions: Basic microsurgical skills can be effectively learned using the smartphone training model, with performance improvements comparable to the microscope model. Its main limitation is the lack of stereoscopy.

Hearing outcomes of two cases of growing sporadic vestibular schwannoma, resected via a translabyrinthine approach with simultaneous cochlear implantation are reported. After gross total resection and anatomical preservation of the facial and cochlear nerve, the integrity of the cochlear nerve-on an electrophysiological level-was evaluated using the intracochlear test electrode of the Auditory Nerve Test System. After confirming electrically -evoked auditory brainstem recordings, cochlear implantation and hearing rehabilitation were performed as per the single -sided deafness protocol. This report describes the audiological outcome with respect to speech understanding in quiet and noise, localization of sounds as well as phoneme discrimination up to one year after surgery.

Background: Dural arteriovenous fistulas (DAVF) within the anterior cranial fossa (ACF) are of particular concern due to their higher hemorrhage rates. Surgical intervention is typically the most effective treatment for ACF DAVFs, although recent advancements suggest increasing use of endovascular techniques. It has consistently shown effectiveness, with minimal thromboembolic risks. Case description: We present two cases of ACF DAVF graded Cognard type IV. A successful pterional and frontotemporal approach was performed, respectively. Postoperative angiography confirmed complete DAVF occlusions, and the patients had an uneventful recovery. Conclusion: ACF DAVFs can be exposed through direct or indirect approaches, with advantages and drawbacks for each method. The anterior interhemispheric approach is widely recognized for its safety and efficacy. Limited studies have advocated for the use of the pterional approach, showing feasibility and potential benefits such as avoiding frontal sinus reconstruction and providing an excellent view of the fistula. Furthermore, pterional approach offers sufficient exposure and favorable cosmetic outcomes, making it a viable option for ACF DAVFs. The presented cases exemplify the efficacious surgical management of ACVF DAVFs through distinct approaches, underscoring the significance of personalized treatment strategies and the effectiveness of surgical interventions in accomplishing total obliteration of the fistulas.

INTRODUCTION:Dorsal root ganglion stimulation (DRGS) has emerged as a promising treatment for chronic neuropathic pain. However, its safety and complications are not fully understood, with existing literature primarily based on case reports, observational studies, and data base analyses. This systematic review and meta-analysis aims to assess the prevalence of noninfectious complications associated with DRGS, focusing on the trial phase, postimplantation period, and revisions, while identifying risk factors for these outcomes. MATERIALS AND METHODS:This systematic review adhered to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and was registered in the International Prospective Register of Systematic Reviews database. A comprehensive search was conducted across multiple data bases in June 2023. Studies included randomized and nonrandomized trials, and cohort studies involving ≥20 patients with DRGS. The exclusion criteria were studies that did not differentiate DRGS-specific complications, focused solely on infections, lacked sufficient data for prevalence estimation, or presented only subanalyses from larger studies. A meta-analysis of proportions was performed to estimate the overall prevalence of complications. RESULTS:Thirteen studies with 634 participants were included. The pooled prevalence of all complications was 37% (95% CI: 19%-57%), with device-related complications being the most common at 27% (95% CI: 15%-42%). Lead fractures and migrations were the most frequently reported device-related complications with, respectively, 6% (95% CI: 2%-12%) and 6% (95% CI: 2%-10%). Procedure-related complications had a pooled prevalence of 1% (95% CI: 0%-5%), with dural puncture being the most common. The prevalence of DRGS explantations was 12%, primarily due to insufficient pain relief. CONCLUSIONS:DRGS shows a safety profile comparable to that of spinal cord stimulation, with similar rates of lead migrations and fractures. Improvements in surgical techniques, technology, and clinician expertise are expected to reduce complications. Future research should standardize reporting practices and detail implantation techniques to better understand and refine best practices in DRGS implantation.