Journal Of Neurosurgery. Pediatrics[JOURNAL]
Sun
200 papers
Myelomeningocele versus myeloschisis: comparison of brain development and need for CSF diversion.
Karuparti S, Lizer A, Narro Garcia F … +7 more , Smith S, Peglar Marsala L, Anadkat J, Bligard KH, Vrecenak J, Mian A, Strahle JM
J Neurosurg Pediatr · 2026 Mar · PMID 41825066 · Publisher ↗
OBJECTIVE: How hydrocephalus rates and brain development differ between myelomeningocele (MMC; with overlying sac) and myeloschisis (without overlying sac) is poorly understood. In this study, the authors compare rates o...
OBJECTIVE: How hydrocephalus rates and brain development differ between myelomeningocele (MMC; with overlying sac) and myeloschisis (without overlying sac) is poorly understood. In this study, the authors compare rates of and age at CSF diversion as well as brain anatomy in patients with MMC and myeloschisis after prenatal and postnatal repair. METHODS: Demographic and clinical data were retrospectively collected from open spinal dysraphism patients who underwent prenatal or postnatal repair between 2015 and 2024 at Washington University in St. Louis. The need for and timing of permanent CSF diversion and brain imaging characteristics on the first postnatal MRI examination were compared by lesion type (myeloschisis vs MMC). The following imaging characteristics were examined: ventricular anatomy; corpus callosum, massa intermedia, tectum, and septum pellucidum morphology; the presence of gray matter heterotopias; hindbrain herniation; and medullary kinking/compression/displacement below foramen magnum. RESULTS: A total of 98 patients (48% female, 88% Caucasian) were included. There were 21 (21%; 9 prenatal repair, 12 postnatal repair) myeloschisis and 77 (79%; 29 prenatal repair, 48 postnatal repair) MMC patients with similar distribution of lesion levels (p = 0.115). After both prenatal (relative risk [RR] 2.17, 95% CI 1.14-5.62) and postnatal (RR 1.33, 95% CI 1.07-1.65) repair, more patients with myeloschisis than MMC required CSF diversion. Those with prenatally repaired MMC (median 94 days, range 15-154 days) underwent CSF diversion earlier than those with myeloschisis (median 210 days, range 13-357 days) (Hodges-Lehmann Δ114, 95% CI 2-226). However, this was no longer significant after adjusting for fetal atrial diameter, the presence of hindbrain herniation, and medullary compression (β = 75 days, 95% CI -78 to 229). There were minimal differences in brain imaging characteristics except for an increased presence of hindbrain herniation (4 [44%] myeloschisis patients vs 6 [21%] MMC patients; Δ23.8, 95% CI -11.9 to 59.4) and a decreased presence of posterior fossa crowding (2 [22%] myeloschisis patients vs 15 [52%] MMC patients; Δ30.3, 95% CI 3.0-62.1) in patients with myeloschisis versus MMC that was repaired prenatally. CONCLUSIONS: Patients with myeloschisis have an increased need for CSF diversion after both prenatal and postnatal repair compared to those with MMC, which may be a consequence of increased rates of hindbrain herniation. The timing of CSF diversion after prenatal repair occurs later in patients with myeloschisis, which may be a consequence of lower rates of medullary compression. These findings suggest that there may be differences in pathophysiology between lesion types and may help with patient counseling.
Epidemiology of ischemic lesions after diffuse low-grade glioma resection: a Scandinavian multicenter study.
Dunås T, Jensdottir M, Solheim O … +18 more , Corell A, Gulati S, Holmgren K, Latini F, Lipatnikova A, Mahesparan R, Milos P, Neimantaite A, Nittby Redebrandt H, Kjelsberg Pedersen L, Sjöberg RL, Sjögren B, Tomasevic G, Thurin E, Tveiten ØV, Zetterling M, Bartek J, Jakola AS
J Neurosurg · 2026 Jul · PMID 41825065 · Publisher ↗
OBJECTIVE: Iatrogenic ischemic injury is believed to be one of the major causes of postoperative neurological deterioration after resection for diffuse low-grade glioma (dLGG). Epidemiological data on ischemic injury fol...
OBJECTIVE: Iatrogenic ischemic injury is believed to be one of the major causes of postoperative neurological deterioration after resection for diffuse low-grade glioma (dLGG). Epidemiological data on ischemic injury following glioma surgery are limited. The aim of this study was to explore the incidence of postoperative ischemia in a population-based cohort and investigate any correlation with postoperative neurological deterioration. METHODS: In this retrospective study, ischemic lesions following dLGG resections, performed at 9 hospitals in Sweden and Norway between 2012 and 2017, were identified on diffusion-weighted MRI and volumetrically segmented. The association between the incidence, size, or type of ischemic lesion (rim lesions, limited to the resection border, or sector lesions, extending further into the brain tissue) and postoperative neurological deficits was analyzed. RESULTS: A total of 286 patients were eligible for study inclusion. A postoperative ischemic lesion was found in 245 (85.7%) cases. In 87 (30.4%) patients, lesions were classified as the rim type; 158 (55.2%) patients had the sector type. Larger ischemic lesions were observed among patients with permanent major deficits (4.2 vs 1.6 cm3, p = 0.022). Sector-shaped ischemic lesions were more often associated with transient neurological deterioration than the rim lesions. The use of advanced imaging, intraoperative monitoring, or other specific neurosurgical techniques and tools did not affect the incidence of ischemic lesions. CONCLUSIONS: The authors found postoperative ischemic lesions to be common after the resection of dLGG. Large and sector-shaped, but not rim-shaped, lesions were associated with measured postoperative neurological deficits. Preventing or limiting the extent of these ischemic injuries is important for improving functional results in dLGG surgery.
Chopsticks mononostril approach with sphenoid sinus cranialization and septal mucosa suturing: a new minimally invasive concept and closure technique for endoscopic endonasal approaches.
Passeri T, Alcântara T, Fava A … +9 more , Watanabe N, Jiang T, Justo J, Vu TH, Bernat AL, Abbritti R, Baussart B, Chainey J, Froelich S
J Neurosurg · 2026 Jul · PMID 41825064 · Publisher ↗
OBJECTIVE: The extended approach and the development of pedicled flaps represented major advancements of the endoscopic endonasal approach (EEA) for skull base lesion removal. However, resection of normal nasal structure...
OBJECTIVE: The extended approach and the development of pedicled flaps represented major advancements of the endoscopic endonasal approach (EEA) for skull base lesion removal. However, resection of normal nasal structures to expand the working corridor and harvesting such flaps can result in significant nasal morbidity, prompting the exploration of less invasive strategies. The authors aimed to evaluate their experience with the minimally invasive chopsticks mononostril technique using sphenoid sinus cranialization with septal mucosa suturing for skull base lesions. Outcomes were compared with those of the traditional extended EEA using the nasoseptal flap (NSF). METHODS: The authors conducted a retrospective cohort study involving 82 consecutive patients who underwent EEA for paraclival and craniovertebral junction lesions. Forty-one consecutive patients were treated using the chopsticks mononostril approach using the sphenoid sinus cranialization technique (SSCT) and septal mucosa suturing and were compared with 41 consecutive patients treated previously using the extended EEA with the NSF technique (NSFT). Surgical outcomes and postoperative results were compared between the groups, with a particular focus on health-related quality of life (HRQOL), assessed using the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q). RESULTS: Demographics of the two groups were broadly similar. Skull base chordoma was the most common indication (70.7% in the SSCT group vs 58.5% in the NSFT group), followed by chondrosarcoma located at the petrosphenoidal suture (14.6% vs 22.0%), craniopharyngioma (4.9% vs 12.2%), and meningioma (7.3% vs 2.4%). The incidence of postoperative CSF leaks (12.2% [n = 5] in the SSCT group vs 9.8% [n = 4] in the NSFT group) was not significantly different between the groups. Gross-total resection or subtotal resection was achieved in 97.6% of SSCT patients compared with 85.4% in the NSFT group (p = 0.11). Importantly, patients who underwent SSCT reported significantly lower EES-Q scores overall (p = 0.004), with better outcomes in both the physical (p < 0.001) and psychological (p = 0.006) domains. CONCLUSIONS: The chopsticks mononostril approach with SSCT and septal mucosa suturing provides a valuable minimally invasive alternative to the traditional extended EEA, which typically relies on a pedicled flap for skull base reconstruction. By using angled endoscopes to navigate around corners rather than removing them, this technique preserves the endonasal anatomy and provides a less invasive option, ultimately contributing to the preservation of the patient's HRQOL.
Surgical neuromodulation: prevalence of Staphylococcus aureus, decolonization, and rates of infection.
Treffy RW, Morris J, Srivastava P … +2 more , Palmer PG, Pahapill PA
J Neurosurg · 2026 Mar · PMID 41825062 · Publisher ↗
OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) are known to colonize various bodily locations and present unique challenges in the prevention and treatment of d...
OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) are known to colonize various bodily locations and present unique challenges in the prevention and treatment of deep surgical site infections (SSIs). The aim of this study was to determine if preoperative colonization testing and decolonization protocols reduce the rate of SSIs in patients undergoing surgical neuromodulation procedures. METHODS: Using a prospectively maintained database, a single-surgeon, single-facility, retrospective study identified 513 spinal cord stimulation (SCS) procedures, 1050 deep brain stimulation (DBS) procedures, and 414 intrathecal baclofen (ITB) pump procedures performed between June 2013 and June 2024. These procedures were performed in 361 patients receiving SCS devices, 375 patients receiving DBS devices, and 308 patients receiving ITB pumps. Preoperative S. aureus nasal swab results, postoperative superficial and deep SSIs requiring device removal, and patient-related comorbidities were analyzed. Patients were monitored for at least 6 months postoperatively for deep SSIs. Different perioperative colonization screening, decolonization, and antibiotic protocols were assessed. RESULTS: Approximately 20% of all patients undergoing implantation of SCS/DBS devices and 25% of patients undergoing implantation of ITB devices had positive results for S. aureus. MSSA colonization was 14 times more common than MRSA colonization in patients who underwent SCS procedures, 9 times more common in those who underwent DBS procedures, and 3 times more common in those who underwent ITB pump procedures. MRSA colonization was 3 times more common in patients who underwent ITB pump procedures than in those who underwent SCS/DBS procedures. There were no deep SSIs in the SCS group. Patients in the ITB pump group had a decrease in infection rate from 8% down to < 2% after implementation of preoperative decolonization protocols. CONCLUSIONS: This study represents the most comprehensive report to date analyzing the prevalence of preoperative MRSA and MSSA colonization in patients undergoing a wide array of surgical neuromodulation procedures. These data support the recommendation that patients receiving neuroimplantable devices, specifically patients undergoing ITB pump procedures, be 1) screened for both MRSA and MSSA, as screening for MRSA alone will not reveal a large fraction of S. aureus colonization; and 2) considered for decolonization protocols prior to surgery. Following these procedures significantly reduced SSIs in patients who underwent ITB pump implantation procedures and might have reduced SSIs for SCS and DBS implantation procedures as well.
Selective dorsal rhizotomy mediating multidimensional improvement in ambulatory children with spastic cerebral palsy: a longitudinal case series.
Budnick H, Young K, Azeemullah A … +4 more , Johnson S, Taylor T, Raskin JS, Angulo-Parker F
J Neurosurg Pediatr · 2026 Mar · PMID 41791119 · Publisher ↗
OBJECTIVE: Selective dorsal rhizotomy (SDR) is a gain-of-function procedure that involves selectively sectioning dorsal rootlets to decrease pathologically active myotatic reflexes mediating spasticity. SDR with physical...
OBJECTIVE: Selective dorsal rhizotomy (SDR) is a gain-of-function procedure that involves selectively sectioning dorsal rootlets to decrease pathologically active myotatic reflexes mediating spasticity. SDR with physical therapy is supported by level I evidence as a treatment for ambulatory children with spastic cerebral palsy (CP). The Gross Motor Function Classification System (GMFCS) is a clinical assessment tool for gross motor function focused on ambulation and mobility, defined by categories graded on a scale from I, most ambulatory, to V, nonambulatory. The GMFCS is intended to provide a general overview of mobility and ambulation. Institutional practice variation in performing SDR coexists with a clinical consensus that ambulatory school-age children with GMFCS levels I through III derive the most benefit from the procedure, with limited evidence supporting SDR in nonambulatory children with CP (GMFCS levels IV and V). While there are several assessment systems to describe the motor functionality of patients with spasticity, they inadequately identify what aspect of motor function or gait improves after SDR. To investigate this, the authors conducted a retrospective study in a single-institution cohort of ambulatory children with spastic CP, comparing tone, gait parameters obtained from gait analysis data, and patient-reported outcomes before and after SDR. METHODS: All consecutive pediatric patients with spastic CP who, between February 2019 and August 2021, underwent both an SDR procedure and pre- and postoperative gait mapping at a single institution were included in the study. The gait parameters of step and stride length for each foot, stride velocity, and toe-in/-out angle were collected. Patient outcomes were determined via chart review. RESULTS: Ten ambulatory patients, 7 of whom were male, had serial gait mapping data and were included in the study. The mean age at surgery was 5.6 years, and the median preoperative GMFCS level was III. There were no major perioperative complications, and the patients were followed up with serial gait mapping for a mean of 2.8 years. The patient- and family-reported outcomes were improved in all patients. The mean ambulation velocity, step length, and stride length all increased, whereas the mean toe-in/-out angle differed in improvement bilaterally. CONCLUSIONS: Children with spastic CP benefit from SDR in multiple dimensions including better patient-reported outcomes, tone control, and improved gait parameters. Improvements in step length, stride length, and velocity are asymmetrical, and the functional impact on gait should be explored in future studies.
Long-term stability of language with remapping in patients with medically refractory epilepsy.
Grant GA, Serafini S, Gramer R … +7 more , Sexton DP, Lu F, Miller KJ, Hodgkinson LM, Andrews E, Madigan D, Ojemann GA
J Neurosurg · 2026 Jun · PMID 41791116 · Publisher ↗
OBJECTIVE: Electrical stimulation mapping is a widely used technique to determine functional localization for medically refractory epilepsy. Sites where stimulation interferes with naming are often focal regions of the f...
OBJECTIVE: Electrical stimulation mapping is a widely used technique to determine functional localization for medically refractory epilepsy. Sites where stimulation interferes with naming are often focal regions of the frontal and temporal cortex. The extent to which these crucial sites remain in the same location over time in an individual adult patient has not yet been established. The aim of this study was to determine whether cortical naming sites identified using stimulation mapping are stable in their anatomical location over time in adult patients with medically refractory epilepsy. METHODS: Twenty-two patients who underwent electrical stimulation mapping for medically refractory epilepsy during surgical interventions separated by more than 1 year between 1967 and 2005 were included. A median of 8.35 years elapsed between mappings. The mean age at the first operation was 27.7 (range 10-39) years. Fourteen patients were female. Mapping occurred under two different conditions: intraoperatively in procedures conducted under local anesthesia or extraoperatively through implanted grid electrodes. A Bayesian hierarchical model of language site locations across repeated interventions was used to assess the stability of locations of stimulation-evoked interference in language naming. RESULTS: Sites where electrical stimulation interferes with language naming were separated by a median of 0.6 cm between the 2 mappings. Eighty-six percent of the mapped sites related to language naming at the second operation were within 1.5 cm of a site identified at the first operation, 61% within 1 cm, and 36% within 0.5 cm. However, in 2 patients, none of the identified language naming sites at the second operation were within 1.5 cm of the sites from the first operation. CONCLUSIONS: This unique, long-term series of neurosurgical mappings reveals that language naming sites in the cortex of adult patients with epilepsy show substantial long-term stability over many years. However, rare relocation of these sites does occur in some patients over many years.
Factors affecting cognitive status in patients with intracranial atherosclerosis after surgical revascularization: a post hoc analysis of the ERSIAS-PC phase II trial.
Aguilera-Pena MP, Tusa Lavieri M, Quintero-Consuegra MD … +9 more , Mendoza-Ayus S, Song SS, Schlick K, Harris J, Simpkins AN, Chang D, Nisson PL, Saver JL, Gonzalez NR
J Neurosurg · 2026 Jun · PMID 41791115 · Publisher ↗
OBJECTIVE: Patients experiencing ischemic strokes typically develop substantial cognitive decline. Intracranial atherosclerotic disease (ICAD) is a common stroke etiology that exposes patients to high and prolonged risks...
OBJECTIVE: Patients experiencing ischemic strokes typically develop substantial cognitive decline. Intracranial atherosclerotic disease (ICAD) is a common stroke etiology that exposes patients to high and prolonged risks of recurrence. The ERSIAS-PC (Encephaloduroarteriosynangiosis revascularization for symptomatic intracranial atherosclerotic steno-occlusive performance criterion) phase II trial showed a lower risk of recurrent stroke in patients who underwent encephaloduroarteriosynangiosis (EDAS) plus intensive medical management (IMM). In the current study, the authors evaluate factors contributing to cognitive decline in patients with symptomatic ICAD treated with EDAS revascularization. METHODS: ERSIAS-PC patients without aphasia who had completed at least 1 year of follow-up were included this post hoc analysis. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline and each follow-up and was classified as improved/preserved or worsened. Classification and regression tree (CART) analysis was used to identify factors associated with changes in cognitive function. The factors considered were age, sex, stenosis versus occlusion, baseline modified Rankin Scale score, good collateralization, and compliance with diabetes mellitus (DM), hypertension, and hyperlipidemia (HLD) treatments. RESULTS: Of the 52 ERSIAS-PC patients, 39 were included in this subgroup analysis. The median age was 46 (IQR 37.0-56.0) years, and 27 (69.2%) patients were female. The mean MoCA score was 22.4 ± 4.9 at baseline and 23.9 ± 4.9 at the 1-year follow-up among the 52 patients in the ERSIAS-PC trial population. Among the 39 patients in this subgroup analysis, the MoCA score improved or remained stable in 33 (84.6%) and declined in 6 (15.4%). CART analysis indicated that the most relevant factor for an improved MoCA score after surgery was compliance with DM treatment (94.5% yes vs 74.2% no, p = 0.02). Other factors indicating a nominal though not statistically significant influence were HLD treatment (83.3% yes vs 60.5% no, p = 0.2) and stenosis (99.1% vs 80.9% occlusion, p = 0.6). CONCLUSIONS: Compliance with DM treatment was significantly associated with cognitive preservation in patients with symptomatic ICAD treated with EDAS. The study findings emphasize the importance of the IMM of stroke risk factors in patients with intracranial atherosclerosis, even after surgical revascularization.
The visuo-operative angle: computational 3D assessment of surgical trajectories toward irregular target areas in skull base corridors.
Tariciotti L, Rodas A, Zohdy YM … +11 more , Revuelta Barbero JM, De Andrade EJ, Patel B, Porto E, Maldonado J, Vuncannon JR, Soriano R, Reyes C, Garzon-Muvdi T, Solares CA, Pradilla G
J Neurosurg · 2026 Jun · PMID 41791114 · Publisher ↗
OBJECTIVE: The aim of this study was to introduce the visuo-operative angle (VOA) as a novel neuroanatomical metric for quantifying surgical exposure and visibility in skull base microsurgery. The VOA measures the alignm...
OBJECTIVE: The aim of this study was to introduce the visuo-operative angle (VOA) as a novel neuroanatomical metric for quantifying surgical exposure and visibility in skull base microsurgery. The VOA measures the alignment between surgical trajectories and target exposure areas in 3D space. Additionally, the authors explored its implementation in 3D photogrammetry of cadaveric models and 3D-segmented presurgical imaging models to assess the feasibility of VOA in experimental and clinical settings. METHODS: Five latex-injected human cadaveric specimens were used to evaluate various endoscopic and microscopic approaches. The VOA was calculated as the angle formed by the surgical trajectory line and the plane of the target exposure area. Photogrammetry was used to generate high-resolution 3D models of the dissected regions and replicate the measurement virtually. Finally, a clinical exploratory trial was conducted in a patient undergoing an endoscopic endonasal approach for a pituitary neuroendocrine tumor (PitNET) with clival erosion. Three-dimensional-rendered preoperative imaging was used to define and measure the target clival region and its VOA, and intraoperative neuronavigation validated the measurement. RESULTS: VOA showed excellent interrater agreement across 36 target areas (bias ≤ 1°, within-subject coefficient of variation 1%-6%). Endoscopic and microscopic findings were consistent with prior literature using different exposure metrics and expert opinion while adding surgically relevant detail on trajectory visibility and instrument direction toward deep targets (e.g., an endoscopic transorbital approach [ETOA] vs a transmaxillary approach to Meckel's cave and the anterolateral triangle; subtemporal vs translabyrinthine/retrosigmoid approaches to the internal acoustic canal; frontotemporal-orbitozygomatic approach vs ETOA at the clinoid triangle). Photogrammetry yielded measurements highly concordant with cadaveric data. Presurgical estimates (VOA approximately 52.7°) aligned with intraoperative values (53.5°), supporting the feasibility of the VOA as an analytical tool for approach analysis and modeling. CONCLUSIONS: The VOA is a simple, reproducible geometrical metric (in degrees) that relates the surgeon's line of sight and instrument path to the target plane, adding directional detail not captured by conventional metrics. Integrated with photogrammetry and 3D-segmented imaging, the VOA enables the quantitative comparison of corridors and approach variants, as well as supporting regional anatomy modeling. Early results are promising, but larger cadaveric series and multicase clinical studies are needed to establish the accuracy, robustness, and applicability of this metric across anatomical research, surgical planning, and intraoperative calculations.
Does extrinsic versus intrinsic venous sinus stenosis represent distinct clinical entities in patients with intracranial hypertension?
Schartz D, Bender MT
J Neurosurg · 2026 Mar · PMID 41791113 · Publisher ↗
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Dermal sinus in children: epidemiology, diagnosis, and management of a retrospective cohort.
Zou Z, Kang S, Chen K
J Neurosurg Pediatr · 2026 Mar · PMID 41791107 · Publisher ↗
OBJECTIVE: Dermal sinus (DS) is a rare congenital disorder characterized by an epithelium-lined tract extending inward from the skin, potentially causing severe neurological complications. The current literature is limit...
OBJECTIVE: Dermal sinus (DS) is a rare congenital disorder characterized by an epithelium-lined tract extending inward from the skin, potentially causing severe neurological complications. The current literature is limited by small sample sizes and insufficient analytical depth, hindering clear diagnostic and management guidelines. This is the largest study to comprehensively analyze epidemiological, diagnostic, and management outcomes in order to enhance clinical guidance for pediatric DS. METHODS: The medical records of 107 DS patients (60 males and 46 females; mean ± SD age 2.99 ± 2.67 years) admitted to Beijing Children's Hospital over a 15.62-year period were retrospectively reviewed, with a focus on patient demographic characteristics, clinical presentations, imaging findings, and treatment interventions. Factors associated with clinical outcomes were analyzed using the 2-sided Fisher's exact test (p < 0.05). RESULTS: The mean ± SD prehospital delay was 236 ± 474 days. Infection prevalence was high (80%), primarily meningitis (55%) and myelitis (42%). Neurological deficits were present in 76% of cases. MRI sensitivity was high (94%) for DS tract detection but limited for assessing intradural terminations and inclusion cyst types. The complete resection rate (76%) improved significantly when patients achieved preoperative normalization of body temperature and had sufficient posttherapy waiting periods (> 7 days). Preoperative complications were associated with less favorable outcomes, with 77% of symptomatic patients fully recovering. Recurrence (6%) exclusively followed incomplete resection and was significantly associated with abscesses, hydrocephalus, and shorter posttherapy waiting periods. CONCLUSIONS: Early sign recognition, complementary imaging modalities, careful preoperative management to reduce inflammation, and timely individualized surgical planning balancing neural preservation and recurrence risk are essential for optimizing outcomes in DS.
Therapeutic management of intracranial internal carotid artery blowout syndrome: an institutional case series and individual participant data meta-analysis.
Singh R, Terry F, Mateti N … +25 more , Li J, Sequeiros J, Zubedi F, Buddhiraju K, Bheemarasetty P, Rodriguez-Calienes A, Lopez-Calle J, Saal-Zapata G, Quispe-Vicuña C, Levy AS, Diaz-Llanes B, Zullo K, Fitzgerald E, Porwal M, Meyer M, Cullen L, Jamshidi AM, Patel R, Enriquez-Marulanda A, Elijovich L, Moses ZB, Taussky P, Jeong S, Starke RM, Luther E
J Neurosurg · 2026 Jul · PMID 41791106 · Publisher ↗
OBJECTIVE: Carotid blowout syndrome is a constellation of clinical presentations involving injury to the extracranial carotid system. It is frequently secondary to postradiation effects or direct invasion from head and n...
OBJECTIVE: Carotid blowout syndrome is a constellation of clinical presentations involving injury to the extracranial carotid system. It is frequently secondary to postradiation effects or direct invasion from head and neck cancers and is often managed via endovascular therapy (EVT). However, intracranial internal carotid artery blowout syndrome (ICABS) is a less described entity, has no predefined management algorithms, and can be difficult to manage due to the inherent anatomical limitations of the intracranial carotid. The aim of this study was to perform an individual participant data meta-analysis and present an institutional case series to describe the clinical course of ICABS, as well as to provide a treatment algorithm for this rare syndrome. METHODS: A search for all reported ICABS cases was performed using PubMed, Embase, Scopus, Web of Science, and Google Scholar until June 30, 2024. Additional cases from our institution were added. The primary outcomes were hemorrhagic control, postoperative complications, and all-cause mortality. RESULTS: The database search yielded 31 studies, and with the addition of 8 patients from the study institution, 80 patients (median age was 55 years) with ICABS were analyzed. The most common injury type was acute blowout (53.8%) and the most commonly affected segment was the petrous internal carotid artery (43.8%). The most frequent underlying diagnosis was head and neck cancer (52.5%). Radiation therapy (37.5%) and surgery (37.4%) were the most common preceding interventions. Overall bleeding control after individualized therapy was attained in 81.2% of patients, with most requiring parent vessel sacrifice (41.2%). The overall postoperative complication rate was 35%. The overall mortality rate was 27.5%, with mortality occurring predominantly in the conservative treatment group (60%) compared with the EVT (27.6%) and surgery (17.6%) groups. CONCLUSIONS: ICABS is rare and often fatal. It frequently occurs after radiation therapy for head and neck cancer or iatrogenically during transsphenoidal surgery. First-line treatment for acute ICABS is often EVT, as it offers a rapid means of halting further hemorrhage. Emerging technologies have allowed for more vessel-preserving strategies and warrant further investigation. Herein, an evidence-based algorithm is provided to help guide management. Systematic review registration no.: CRD42022385494 (www.crd.york.ac.uk/prospero/).
Letter to the Editor. Responsible integration of AI in microsurgical training.
Riaz M, Grassia F
J Neurosurg · 2026 Mar · PMID 41791102 · Publisher ↗
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Editorial. Hydrocephalus, pulsatility, and the windkessel effect.
Rocque BG, Limbrick DD
J Neurosurg Pediatr · 2026 Mar · PMID 41791100 · Publisher ↗
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A model of hydrocephalus due to windkessel impairment caused by subarachnoid space obstruction.
Egnor M, Shirdel Abdolmaleki N, Ravishankar A … +4 more , Mani R, Wang Y, Fiore S, Djurić PM
J Neurosurg Pediatr · 2026 Mar · PMID 41791099 · Publisher ↗
OBJECTIVE: The traditional view that hydrocephalus due to obstruction in the subarachnoid space (SAS) is caused by malabsorption of CSF does not account for many experimental and clinical aspects of the disorder. Flow MR...
OBJECTIVE: The traditional view that hydrocephalus due to obstruction in the subarachnoid space (SAS) is caused by malabsorption of CSF does not account for many experimental and clinical aspects of the disorder. Flow MRI reveals that nearly all CSF motion is pulsatile, and that hydrocephalus is linked to significant redistribution of pulsatility within the CSF pathways. Pulsatility in the cranium is governed by the cerebral windkessel system that buffers the energy of arterial pulsations via CSF to ensure smooth capillary blood flow. This study proposes a new model of intracranial thermodynamics based on the theory that high impedance to pulsatile energy flow through the CSF pathways causes hydrocephalus. METHODS: The authors used a simple current-divider electrical circuit model of the cerebral windkessel system with input voltage derived from arterial blood pressure tracings from 12 normal dogs. SAS obstruction in the model was simulated using CSF flow values corresponding to published data from flow MRI studies of patients with hydrocephalus. RESULTS: Modeling of hydrocephalus due to subarachnoid obstruction shows windkessel impairment and redistribution of CSF pulsatility caused by high damping of pulsatility in the SAS. Modeling of ventricular dilation as an active physiological adaptation shows improved windkessel function. Modeling of shunting shows windkessel restoration. The model produces the salient features of hydrocephalus due to obstruction in the SAS without invoking CSF malabsorption. CONCLUSIONS: The authors propose that hydrocephalus due to SAS obstruction is impairment of the cerebral windkessel system due to high impedance to pulsatility in the subarachnoid CSF path that redistributes arterial pulsatile energy to the capillaries and jeopardizes capillary integrity. Windkessel theory introduces several new perspectives on hydrocephalus: 1) adaptive ventricular dilation is an active physiological response to windkessel impairment and lowers CSF path impedance to pulsations; 2) increased intracranial pressure (ICP) results from pressure energy accumulation due to windkessel dysfunction; 3) shunting is an accessory windkessel and reduces ICP by draining energy; 4) windkessel theory offers a new taxonomy of hydrocephalus, linking hydrocephalus due to SAS obstruction and hydrocephalus caused by aqueductal obstruction, normal pressure hydrocephalus, and low pressure hydrocephalus as related but distinct disorders of CSF path impedance; and 5) windkessel theory provides an explanation for hydrocephalus without invoking CSF malabsorption. Windkessel theory provides a new understanding of hydrocephalus and indicates new approaches to treatment.
Mapping physiological high-frequency oscillation rates of the cerebral cortex for improved epileptogenic zone delineation in stereoelectroencephalography.
Parasuram H, Pillai A, Gopinath S … +4 more , Rajeshkannan R, Ravindran S, Raman A, Anandakuttan A
J Neurosurg · 2026 Jun · PMID 41759173 · Publisher ↗
OBJECTIVE: Given the challenges of interpreting preictal- and ictal-phase stereoelectroencephalography (SEEG), a complementary approach of examining interictal activity could be of value. High-frequency oscillations (HFO...
OBJECTIVE: Given the challenges of interpreting preictal- and ictal-phase stereoelectroencephalography (SEEG), a complementary approach of examining interictal activity could be of value. High-frequency oscillations (HFOs), recorded at frequencies greater than 80 Hz in SEEG, are often pronounced in but not unique to the epileptogenic zone (EZ) compared with normal cortex. The aim of this study was to assess a novel HFO rate ratio to identify the EZ using region-specific interictal HFO rates, and to estimate the optimal threshold for the HFO rate ratio for both ripples and fast ripples to localize the EZ. METHODS: Patients with epilepsy who underwent resective surgery following SEEG at a single institution (January 2017-December 2022) and had available postoperative MRI with at least 12 months of follow-up were included. A region-specific normative HFO database was retrospectively constructed using interictal physiological HFO detected from nonresected brain areas of 37 patients who remained seizure free after epilepsy surgery. The optimal HFO rate ratio was estimated by finding the ratio that best matched the resection volume that defines the EZ in seizure-free patients. Then an optimal HFO rate ratio was used to detect region-specific pathological HFOs. RESULTS: Sixty-three patients (32 female, mean age 25 years) with 7512 bipolar SEEG recordings who underwent surgery for epilepsy were analyzed. The HFO rate ratio method accurately localized the EZ in 92% of patients with seizure freedom and identified pathological HFO rates in 80% of patients with persistent seizures, both within (19%) and outside (35%) the resected areas. The optimal threshold for the ripple HFO rate ratio to accurately localize the EZ was 5.8 times the normative value and 2.7 times that of fast ripples, with sensitivity and specificity greater than 85%. CONCLUSIONS: These findings provide evidence that differentiating physiological and pathological interictal HFO rates are helpful in localizing the EZ, with potential utility in patient-specific surgical planning. Further prospective validation of this methodology is warranted.
The pattern and outcome of infants and neonates undergoing endoscopic third ventriculostomy in Tanzania: an observational cohort study.
Shayo CS, Ikwuegbuenyi CA, Sabas RR … +3 more , Tosi U, Hoffman C, Shabani HK
J Neurosurg Pediatr · 2026 Feb · PMID 41759095 · Publisher ↗
OBJECTIVE: Hydrocephalus in infants is a substantial public health burden in East Africa. In sub-Saharan Africa, hydrocephalus is estimated to affect more than 100,000 new infants annually. Endoscopic third ventriculosto...
OBJECTIVE: Hydrocephalus in infants is a substantial public health burden in East Africa. In sub-Saharan Africa, hydrocephalus is estimated to affect more than 100,000 new infants annually. Endoscopic third ventriculostomy (ETV) is considered a safe procedure and is a method of choice for the treatment of obstructive hydrocephalus. ETV outcomes in children older than 2 years are abundant; however, minimal outcomes data for infants and neonates younger than 2 months are available in the literature. The authors therefore sought to evaluate the patterns of presentation, endoscopic anatomy, and clinical outcomes in a cohort of infants younger than 6 months who underwent ETV at a major East African center. METHODS: A retrospective cohort study was conducted using prospectively collected data from all patients with hydrocephalus who were younger than 6 months and underwent ETV or ETV with choroid plexus cauterization (CPC) at Muhimbili Orthopaedic Institute from June 2012 to December 2020. Demographic and clinical data were collected and included age, presentation, etiology, endoscopic anatomy, type of treatment, and clinical outcome. The primary outcomes were 1) ETV success and 2) ETV failure. Predictors of each outcome were assessed through univariate/multivariate logistic regression. RESULTS: Of the 325 infants treated for hydrocephalus, 62% were male, with a median age of 86 days; 69% of the infants presented with congenital hydrocephalus, 37% underwent ETV, and 48% underwent ETV/CPC. The ETV success rate at 4 weeks postoperatively was statistically significantly lower among infants aged 2 months or older compared with those younger than 2 months (0.88 vs 0.95, p = 0.022). No difference was seen 26 weeks postoperatively (0.63 vs 0.73, p = 0.116). At the 52nd week, the failure rates were 0.60 for infants aged 2 months or older versus 0.62 for those younger than 2 months, with no significant difference (p = 0.770). CONCLUSIONS: Despite prior findings that younger age has poor reliability in ETV, the use of ETV and combined ETV/CPC have shown better clinical outcomes than that with ventriculoperitoneal shunting in treating hydrocephalus in this study among African neonates.
Surgical skill is not a virtue.
Church EW
J Neurosurg · 2026 Feb · PMID 41759094 · Publisher ↗
Abstract loading — click title to view on PubMed.
Letter to the Editor. Are traumatic brain injury biomarkers lesion-specific?
Lampros M, Alexiou G, Voulgaris S
J Neurosurg · 2026 Feb · PMID 41759090 · Publisher ↗
Abstract loading — click title to view on PubMed.
Virtual telementoring to instruct selective dorsal rhizotomy technique in a resident cadaver laboratory at Philippine General Hospital.
Del Rosario SD, Shao B, Oldam J … +8 more , Alexander M, Barkley A, Clerkin P, Seng KS, Hong MA, Legaspi GD, Baticulon RE, Aldana PR
J Neurosurg Pediatr · 2026 Feb · PMID 41759086 · Publisher ↗
OBJECTIVE: To address unmet neurosurgery needs in the Philippines, particularly in remote areas of the archipelago, workforce development requires increased trainee learning opportunities and modalities for mentorship wi...
OBJECTIVE: To address unmet neurosurgery needs in the Philippines, particularly in remote areas of the archipelago, workforce development requires increased trainee learning opportunities and modalities for mentorship with existing surgeons. Telementoring adjuncts could facilitate these in an accessible, active, and continuing manner. Therefore, the aim of this study was to assess the feasibility and efficacy of telementoring to instruct a cadaveric selective dorsal rhizotomy dissection laboratory for neurosurgery residents in the Philippines. METHODS: Junior neurosurgical residents at Philippine General Hospital participated in a virtual lecture, which was followed by telementored cadaver dissections using an operative microscope guided by an overseas faculty neurosurgeon during a live audio/video exchange. Usability metrics and survey responses were recorded. Postlaboratory unproctored dissections were completed by each participant, and surgical skills as demonstrated on the video recordings were evaluated by two blinded adjudicators via the Objective Structured Assessment of Technical Skills (OSATS) tool. RESULTS: Four rhizotomy-naive junior residents participated. During each 1-on-1 telementored dissection session, a mean of 30 question-answer or mentor-mentee redirection exchanges transpired. Internet connection problems were frequent, with a mean of 5 connectivity issues requiring reconnection per session. All residents reported improved confidence in performing selective dorsal rhizotomy. In postlaboratory assessments, all participants successfully completed the main components of the procedure, with the OSATS evaluations demonstrating basic proficiency in all surgical domains. CONCLUSIONS: A telementored cadaver laboratory session was conducted by a live remote surgical instructor to junior neurosurgery residents in a middle-income country setting. The study demonstrated the feasibility of teaching operative skills using this method, with evaluation and feedback via OSATS scoring. It is recommended that a reliable internet connection be ensured before telementoring is trialed in a live clinical setting.
Endoscopic endonasal surgery for infradiaphragmatic craniopharyngiomas: the impact of diaphragma sellae resection.
Wu J, Ye Z, Xu C … +6 more , Gao Z, Wu B, Wu X, Tang B, Xie S, Hong T
J Neurosurg · 2026 May · PMID 41719552 · Publisher ↗
OBJECTIVE: Infradiaphragmatic craniopharyngiomas (ICs) are anatomically distinct lesions bounded by an elevated diaphragma sellae (DS). While endoscopic endonasal surgery (EES) has emerged as their primary treatment, ach...
OBJECTIVE: Infradiaphragmatic craniopharyngiomas (ICs) are anatomically distinct lesions bounded by an elevated diaphragma sellae (DS). While endoscopic endonasal surgery (EES) has emerged as their primary treatment, achieving complete resection remains challenging due to frequent tumor-DS adhesions, potentially contributing to higher recurrence rates. Authors of this retrospective study evaluated the efficacy and safety of DS resection (DSR) during EES for IC. METHODS: The data for patients with ICs treated with EES between March 2011 and December 2024 were retrospectively reviewed. According to their intraoperative DSR status, patients were classified into the DSR group or non-DSR group. Comprehensive analyses were performed to compare demographics, clinical characteristics, and surgical and long-term outcomes between the resection groups, with additional comparison to contemporary published series. RESULTS: Forty-six patients with IC were included in the final cohort, with 29 in the DSR group and 17 in the non-DSR group. The DSR group tended to have larger tumor volumes (p = 0.050) and a significantly higher proportion had endocrine dysfunction (p = 0.022) and preoperative hypothalamic involvement (p = 0.002). Forty-three patients (93.5%) underwent complete tumor resection. There was no significant difference in the extent of resection (p = 0.628), endocrine outcomes, visual outcomes, and postoperative hypothalamic involvement (p = 0.258) between the 2 groups, whereas DSR increased the rate of pituitary stalk transection (p = 0.001) and operation times (p < 0.001). DSR did not significantly increase the risk of CSF leakage (p = 0.451), electrolyte imbalance (p = 0.108), or intracranial infections (p = 0.524). During a median 60.5 months of follow-up (IQR 27.8-90.3 months), the recurrence rate and hypothalamic syndrome rate were 4.3% and 6.5%, respectively, for the whole cohort, and they were not significantly different between the 2 resection groups. CONCLUSIONS: As the first dedicated analysis of DSR in the EES era, this study demonstrates that intentional DSR facilitates optimal tumor removal without substantially increasing complication risks. These findings support selective DSR use for ICs demonstrating significant DS adhesion, potentially improving long-term disease control while maintaining an acceptable safety profile.
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