Journal Of Neurosurgery. Pediatrics[JOURNAL]
Sun
200 papers
Imaging, histological, and molecular characterization of a preclinical, orthotopic model of recurrent glioblastoma following image-guided laser ablation of the primary tumor.
Nagaraja TN, Bartlett S, Cabral G … +16 more , Acharya PC, Morosini N, Datta I, Hasselbach L, Singh J, Parasar P, Ayloo B, Avritt F, Spanick KG, Gowda P, deCarvalho AC, Noushmehr H, Knight RA, Brown SL, Ewing JR, Lee IY
J Neurosurg · 2026 Jun · PMID 42247692 · Publisher ↗
OBJECTIVE: Image-guided laser interstitial thermal therapy (LITT) is a minimally invasive cytoreductive treatment for recurrent gliomas and tumors in eloquent regions. This technique was adapted to develop an image-guide...
OBJECTIVE: Image-guided laser interstitial thermal therapy (LITT) is a minimally invasive cytoreductive treatment for recurrent gliomas and tumors in eloquent regions. This technique was adapted to develop an image-guided glioblastoma (GBM) ablation model of recurrence. The efficacy of imaging biomarkers for evaluating tumor ablation and recurrence was evaluated by comparing the cytopathology and molecular signatures of primary and recurrent tumors. METHODS: Immune-compromised female rats were implanted with U251N tumor cells in 1 brain hemisphere (n = 20). Tumor growth was monitored using MRI and dynamic contrast-enhanced (DCE)-MRI. When tumors reached about 3.5-4.5 mm in diameter at their largest extent, they were ablated using a clinical LITT system (Visualase), guided by diffusion-weighted MRI. Five rats implanted with U251N tumors were used as unablated controls. Postablation DCE-MRI data were acquired at 24 hours and 2 and 4 weeks. Rats were euthanized at 2 and 4 weeks, and brain sections were stained for hematoxylin and eosin (H&E), human major histocompatibility complex (MHC), Ki-67, SOX2, OLIG2, and mesenchymal marker CD44. Additional rats with primary (n = 4) and postablation recurrent (n = 4) U251N tumors were used to compare molecular compositions using RNA sequencing (RNA-Seq). RESULTS: All rats survived the LITT procedure. Sham controls showed increased tumor burden by 2 weeks and were euthanized. In the ablated groups, MRI revealed little tumor tissue at 24 hours after ablation, signs of recurrence at 2 weeks, and significant tumor tissue at 4 weeks. Tumor DCE-MRI parameters showed elevated intratumoral vascular permeability values (i.e., blood-to-tissue forward volumetric transfer constant [Ktrans]) at pre-LITT imaging that shifted to the ablation site periphery at 24 hours after ablation. A progressive decrease in Ktrans was seen until 1 week after LITT. Increasing Ktrans values at 2 weeks and after 4 weeks coincided with histological evidence of tumor recurrence. RNA-Seq showed that cell cycle, cellular movement, and inflammatory disease genes were the most differentially expressed genes (DEGs) in recurrent tumors compared to primary tumors. CONCLUSIONS: These results suggest that DCE-MRI can serve as an efficient imaging biomarker for evaluating glioma cytoablation and for tracking post-LITT recurrence. Functions that influence cell cycle, cell motility, and inflammatory processes were upregulated in the recurrent tumor. This represents a new preclinical, image-guided tumor ablation model of recurrent GBM that can be used to test potential therapies.
Data-driven personalized surgical treatment selection for metopic and sagittal craniosynostosis.
Palmer SK, Elkhill C, Cruz-Guerrero IA … +6 more , Gomez DA, Linguraru MG, Khechoyan DY, Nguyen PD, French B, Porras AR
J Neurosurg Pediatr · 2026 May · PMID 42214106 · Publisher ↗
OBJECTIVE: Although the choice of surgical treatment for craniosynostosis is based on patient age and phenotypic severity, there are no tools to objectively identify optimal treatment approaches. The authors present a qu...
OBJECTIVE: Although the choice of surgical treatment for craniosynostosis is based on patient age and phenotypic severity, there are no tools to objectively identify optimal treatment approaches. The authors present a quantitative study of how age, sex, and phenotypic severity affect the surgical outcomes of patients with midline craniosynostosis to support treatment selection. METHODS: The authors collected pre- and postsurgical 3D photograms of patients with nonsyndromic single sagittal (n = 280) or metopic (n = 69) craniosynostosis, which they grouped into endoscopic strip craniectomy (ESC) or cranial vault remodeling (CVR) cohorts. The authors compared their surgical outcomes using the Head Shape Anomaly (HSA) index, Craniosynostosis Risk Score (CRS), and a novel Craniosynostosis Severity Index (CSI) that provides improved sensitivity to local malformations. Then, the authors quantitatively modeled the effect of age, sex, and presurgical severity on treatment outcomes and used their findings to create a decision tool to support treatment selection. RESULTS: ESC and CVR improved all morphology metrics in patients with sagittal craniosynostosis (p < 0.001). In metopic craniosynostosis, ESC improved the CRS (p < 0.001) and CSI (p = 0.01), CVR improved the CRS (p = < 0.001) but not the CSI (p = 0.15), and neither ESC (p = 0.10) nor CVR (p = 0.83) improved the HSA index. The authors' model showed that ESC outperforms CVR in metopic and sagittal craniosynostosis before 3 and 5 months of age, respectively, as well as in nonsevere phenotypes of sagittal craniosynostosis before 8 months of age. CONCLUSIONS: The authors' quantitative results can support personalized surgical treatment selections for patients with midline craniosynostosis and constitute a needed step to reduce the variability in treatment approaches and outcomes.
Utility of ophthalmologic evaluation for papilledema in pediatric emergency department encounters for shunt failure: a single-center retrospective study.
Tora MS, Fofana F, Roach K … +5 more , Johnson P, Romanaggi C, Pua I, McIntyre MK, Winer JL
J Neurosurg Pediatr · 2026 May · PMID 42214105 · Publisher ↗
OBJECTIVE: In shunted pediatric hydrocephalus patients, the potential for shunt failure is a frequent cause of emergency department (ED) presentation. The assessment of papilledema through ophthalmological fundoscopic ex...
OBJECTIVE: In shunted pediatric hydrocephalus patients, the potential for shunt failure is a frequent cause of emergency department (ED) presentation. The assessment of papilledema through ophthalmological fundoscopic examination (OFE) is an often-utilized adjunct evaluation in clinical workup to rule out shunt failure in patients. However, its utility in this setting has not been established in the literature. The objective of the present study was to investigate the association of papilledema with eventual shunt revision in ED encounters to rule out shunt failure. METHODS: The authors conducted a retrospective, single-institution, cohort study of ED encounters with concern for shunt failure prompting neurosurgical evaluation in patients who underwent OFE from January 1, 2014, to December 31, 2021. Chart encounters were reviewed for baseline demographic characteristics, clinical characteristics, presence of papilledema, and interventions. The primary endpoint was need for shunt revision and intraoperative evidence of shunt failure. RESULTS: A total of 594 ED encounters with concern for shunt failure were identified, and 98 encounters were included. Overall, 6 cases of papilledema were identified (6.1%), of whom only 3 were new or worsened (3.1%) compared to prior examinations. Twenty-six (26.5%) encounters resulted in shunt revision, while 72 (73.4%) encounters resulted in no revision. There was no statistically significant difference in baseline patient demographic characteristics, etiology of hydrocephalus, or clinical symptoms between encounters resulting in shunt revision or no revision. No significant difference was identified in the comparison of patients who underwent shunt revision versus those without revision with regard to the presence of papilledema (3 [12%] patients with papilledema vs 3 [4%] without, p = 0.19), performance of shunt tap (6 [23%] vs 9 [12.5%], p = 0.21), or prior shunt revisions (3.2 ± 3.9 vs 2.9 ± 3.3, p = 0.77). CONCLUSIONS: Among pediatric ED encounters with concern for shunt failure, ophthalmological consultation for fundoscopic examination and the presence of papilledema did not demonstrate a significant association with shunt revision. Additional prospective studies are warranted to assess the clinical utility of using OFE as part of the armamentarium of triage in acute shunt failure evaluation.
Sports-related concussion laws in the United States in children and adolescents: an updated cross-sectional review of state statutes.
Shah KH, Vargas-George SA, Roach CS … +2 more , Lu VM, Niazi TN
J Neurosurg Pediatr · 2026 May · PMID 42214103 · Publisher ↗
OBJECTIVE: Despite growing national consensus on the importance of cognitive evaluation and structured, graduated return-to-play protocols in sports-related concussion care in children and adolescents, it remains unclear...
OBJECTIVE: Despite growing national consensus on the importance of cognitive evaluation and structured, graduated return-to-play protocols in sports-related concussion care in children and adolescents, it remains unclear how consistently these practices are reflected in state-level legislation. The authors aimed to evaluate the extent to which current state concussion laws in the United States incorporate evidence-based practices, particularly regarding cognitive testing and specification of qualified medical professionals for return-to-play clearance in these athletes. METHODS: A cross-sectional review of concussion laws across all 50 states and the District of Columbia as of September 2025 was conducted. Statutory texts were abstracted for provisions addressing immediate removal from play, same-day return to play, use of baseline and postinjury cognitive assessments, implementation of graduated return-to-play protocols, and medical clearance requirements with specification of provider type. RESULTS: All 51 jurisdictions have available state-level statutes regarding concussion care in children and adolescents. All require immediate removal of athletes with suspected concussion, with 74.5% basing removal on suspicion and 25.5% requiring signs or symptoms. Fourteen states (27.5%) explicitly prohibit same-day return to play, 2 (3.9%) allow it after concussion is ruled out by sideline evaluation, and the remainder do not address it. Medical clearance is universally required for return to play; however, only 6 states (11.8%) restrict clearance authority to physicians, while most permit broader categories of healthcare providers. Eight states (15.7%) mandate a graduated return-to-play progression, although protocols vary. Only Hawaii requires baseline cognitive testing, and Rhode Island recommends but does not mandate it. CONCLUSIONS: State concussion laws now universally mandate education, removal, and clearance before return, yet variability in coach training, return-to-play protocols, and cognitive testing exists. Aligning legislation with evidence-based standards is needed to ensure consistent protection for young athletes across the country.
Implementing early posthemorrhagic ventricular dilation intervention in preterm neonates: does a standardized pathway improve outcomes?
Keene JC, Ostrander B, Hartman K … +2 more , Franklin Carbaugh S, Kestle JRW
J Neurosurg Pediatr · 2026 May · PMID 42214101 · Publisher ↗
OBJECTIVE: Posthemorrhagic ventricular dilation (PHVD) is a serious complication of intraventricular hemorrhage in extremely preterm infants, associated with high rates of death and neurodevelopmental impairment. Earlier...
OBJECTIVE: Posthemorrhagic ventricular dilation (PHVD) is a serious complication of intraventricular hemorrhage in extremely preterm infants, associated with high rates of death and neurodevelopmental impairment. Earlier CSF diversion might reduce adverse outcomes, but variability in practice persists. In 2021, a tertiary care center implemented a standardized multidisciplinary PHVD treatment pathway that emphasized standardized ventricular measurements and earlier thresholds for intervention. The aim of this study was to evaluate whether this treatment pathway reduced ventricular dilation and improved developmental outcomes in neonates with PHVD. METHODS: This single-center cohort study analyzed outcomes of neonates born between 2017 and 2023 who underwent PHVD intervention. Patients were dichotomized according to whether they were born before the treatment pathway was implemented (pre-pathway group) or after (post-pathway group). Data were extracted from the Hydrocephalus Clinical Research Network prospective registry and clinical records. Interventions included lumbar puncture (LP), ventricular reservoir placement, and ventriculoperitoneal shunt (VPS) placement. Ventricular dilation was measured using the anterior horn width (AHW) and ventricular index (VI). Developmental outcomes were assessed at ≥ 18 months using standardized development assessments and neurological evaluation. RESULTS: Overall, 104 patients were included; 59 in the pre-pathway group and 45 in the post-pathway group (10 of whom underwent only LP and were included only in an LP subset analysis). Following pathway implementation, high-volume LP was completed in 93% of patients. The median maximum AHW and VI greater than 2 standard deviations above the mean were significantly lower in the post-pathway group (AHW: 32 mm vs 26 mm, p = 0.03; VI: 18 vs 15 mm > 2 standard deviations, p = 0.04). Among 74 infants with 18 months of follow-up, the primary outcome of death or severe cerebral palsy was reduced by 29% after pathway implementation (62% pre-pathway vs 33% post-pathway, p = 0.03). The multivariable analysis of all neonates demonstrated that larger ventricular size at VPS placement and at maximum ventricular dilation independently predicted higher odds of death or severe cerebral palsy, with a 9% increase per 1-mm increase in maximum AHW (adjusted OR 1.09, 95% CI 1.03-1.16, p = 0.006) and 14% increase per 1-mm increase in pre-VPS AHW (adjusted OR 1.14, 95% CI 1.05-1.24, p = 0.002). CONCLUSIONS: This study found potential for improved neurodevelopmental outcomes with pragmatic implementation of a collaborative standardized pathway for PHVD care. Pathway implementation was associated with reduced ventricular size at VPS placement, and smaller maximum ventricular size was a strong independent predictor of improved neurodevelopmental outcomes. These findings support earlier standardized PHVD intervention and highlight the need for larger multicenter studies to validate standardized and pragmatic early intervention approaches for PHVD.
The risk of cerebrospinal fluid rhinorrhea from early resumption of positive pressure ventilation after transsphenoidal surgery with autologous fat graft repair.
Kim LJ, Rennert RC, Couldwell WT
J Neurosurg · 2026 May · PMID 42214100 · Publisher ↗
OBJECTIVE: Multiple closure techniques may prevent CSF leak after transsphenoidal surgery for sellar lesions. In patients with obstructive sleep apnea requiring positive pressure ventilation (PPV), the optimal closure te...
OBJECTIVE: Multiple closure techniques may prevent CSF leak after transsphenoidal surgery for sellar lesions. In patients with obstructive sleep apnea requiring positive pressure ventilation (PPV), the optimal closure technique remains unclear. The authors assessed the efficacy of autologous abdominal fat graft repair for preventing CSF leaks in patients reinitiating PPV early after transsphenoidal surgery. METHODS: A retrospective cohort study was performed to review the records of consecutive patients who underwent microscopic transsphenoidal surgery with autologous fat (with or without fascia) graft repair between January 2018 and December 2024. Rates of CSF leak and other postoperative complications were compared based on the need for postoperative PPV. RESULTS: Among the 609 included patients (84.1% pituitary adenomas, 12.0% Rathke's cleft cysts, 3.1% craniopharyngiomas, 0.8% meningiomas), 73 required PPV at baseline that was reinitiated at discharge (mean postoperative day 3.5 ± 2.9). No significant baseline differences existed between these groups. Twenty patients had persistent CSF leaks requiring postoperative CSF diversion or reoperation (3 PPV patients [4.1%] and 17 non-PPV patients [3.2%]; p = 0.99). Of these, the leak developed after discharge in 1 PPV patient (1.4%) and 6 non-PPV patients (1.1%) (p = 0.837). No difference in relative risk existed for CSF leak in the PPV and non-PPV groups (RR 1.16, 95% CI 0.320-4.198; p = 0.8108). There were no differences in other postoperative complication rates between groups. CONCLUSIONS: Early initiation of PPV after transsphenoidal surgery with autologous abdominal fat (with or without fascia) grafting did not increase the risk of CSF leak, suggesting that it reasonably prevents leaks in patients with sleep apnea after transsphenoidal surgery.
Effect of VEGF coating and intra-arterial injection of mesenchymal stem cells on neointima formation after endovascular stenting in a rabbit model.
Panchendrabose K, Ladak RJ, Muram S … +7 more , Belanger BL, Akbari-Kelachayeh K, Eesa M, Almekhlafi MA, Sen A, Har B, Mitha AP
J Neurosurg · 2026 May · PMID 42214099 · Publisher ↗
OBJECTIVE: The rates of thromboembolic events are highest within the first few days of intracranial stent placement and before complete endothelialization has occurred. Accelerating the rate of neointima formation may be...
OBJECTIVE: The rates of thromboembolic events are highest within the first few days of intracranial stent placement and before complete endothelialization has occurred. Accelerating the rate of neointima formation may be a strategy to reduce thromboembolic events. This study was performed to evaluate the efficacy of vascular endothelial growth factor (VEGF) embedded in a poly(lactic-co-glycolic acid) (PLGA) coating in conjunction with mesenchymal stem cells (MSCs) to improve neointima formation after stent placement. METHODS: Endovascular stents were coated with VEGF/PLGA or PLGA alone (control 1) or left uncoated (control 2), and protein quantification was performed both before and after a mock endovascular deployment process. A total of 23 New Zealand White rabbits then underwent endovascular implantation of stents coated with VEGF/PLGA, followed by an intra-arterial microcatheter injection of MSCs; stents coated with VEGF/PLGA without MSC injection (vehicle alone); stents coated with PLGA alone without MSC injection (vehicle alone); or uncoated stents without MSC injection (vehicle alone). After stent deployment on day 0 and prior to euthanasia on day 3, animals underwent optical coherence tomography (OCT), so that the degree of neointima formation over the stent struts as well as thrombus formation could be evaluated. Scanning electron microscopy (SEM) was also performed after euthanasia. OCT and SEM images were both scored by observers blinded to treatment group. RESULTS: Stents coated with VEGF/PLGA contained a significantly larger amount of protein than the stents coated with PLGA alone or uncoated stents, and there was no significant loss of protein after the mock delivery process. In vivo, VEGF/PLGA-coated stents with MSC injection demonstrated superior measurements of the neointimal area, neointimal ratio, stent-strut neointimal coverage ratio, and maximum neointimal thickness on OCT compared to those for the uncoated stent at 3 days. VEGF/PLGA-coated stents with MSCs also showed significantly improved scores on SEM and a large, though not statistically significant, reduction in the variability of thrombus formation compared to that with uncoated stents at 3 days (p = 0.06). CONCLUSIONS: This short-term study demonstrates that coating stents with VEGF embedded in PLGA, along with an intra-arterial injection of MSCs, improves neointimal coverage and may reduce thrombus formation. Follow-up studies are required to assess the long-term consequences of VEGF and MSC administration, as well as to elucidate the potential mechanism of their effect.
Impact on pulmonary function from phrenic nerve transfer: a systematic review and meta-analysis.
Emamhadi M, Shoubash L, Haghani Dogahe M … +3 more , Zarei R, Bashiri Aliabadi S, Mahan MA
J Neurosurg · 2026 May · PMID 42214098 · Publisher ↗
OBJECTIVE: The aim of this study was to evaluate the respiratory consequences of phrenic nerve transfer (PNT) by analyzing clinical and paraclinical data across published studies. METHODS: The authors conducted a systema...
OBJECTIVE: The aim of this study was to evaluate the respiratory consequences of phrenic nerve transfer (PNT) by analyzing clinical and paraclinical data across published studies. METHODS: The authors conducted a systematic review and meta-analysis of studies reporting respiratory outcomes after PNT. Only cases with documented postoperative follow-up and perioperative respiratory outcome were included. Data on patient demographics, diaphragm imaging, and pulmonary function test (PFT) values were extracted. Paired analyses were conducted in cases in which pre- and postoperative PFT data were available. RESULTS: Among 617 patients with postoperative follow-up, 4.9% reported respiratory symptoms, and 67.4% of those assessed showed unilateral diaphragm paralysis. A meta-analysis of paired PFT data demonstrated a significant reduction in forced expiratory volume in 1 second and a nonsignificant reduction in forced vital capacity postoperatively. Fifteen (2.4%) of 617 patients reported mild but persistent respiratory symptoms. CONCLUSIONS: Although PNT is effective for motor restoration, postoperative respiratory impairment, although typically mild, was observed in a subset of patients with follow-up data. These findings emphasize the need for long-term monitoring and careful patient selection in PNT, particularly in individuals with reduced pulmonary reserve.
Neuropsychological profile in pediatric patients with brain arteriovenous malformations.
Lima AO, Coelho DS, Wuo-Silva R … +2 more , Silva da Costa MD, Chaddad-Neto F
J Neurosurg Pediatr · 2026 May · PMID 42214097 · Publisher ↗
OBJECTIVE: Brain arteriovenous malformations (bAVMs) are vascular anomalies that can cause significant neurological and cognitive impairments in children and adolescents, even in the absence of hemorrhage. These symptoms...
OBJECTIVE: Brain arteriovenous malformations (bAVMs) are vascular anomalies that can cause significant neurological and cognitive impairments in children and adolescents, even in the absence of hemorrhage. These symptoms, especially the cognitive deficits, can significantly interfere with neurodevelopment and affect social adaptation and quality of life. This study aimed to characterize the neuropsychological profile of pediatric patients with bAVMs and to investigate associations between cognitive performance and malformation characteristics. METHODS: This cross-sectional study included children and adolescents (6-17 years of age) with a confirmed diagnosis of bAVM treated between 2016 and 2023 at the authors' institutions. All information was obtained from medical records. Neuropsychological assessment was performed using the Brief Neuropsychological Assessment Battery infant (6-12 years) and adult (> 12 years) versions. The evaluated domains included orientation, attention, working memory, verbal fluency, memory, language, praxis, perception, and arithmetic ability. Results were compared to age- and education-adjusted normative data. RESULTS: Seventeen patients were included in the study (58.8% female, age range 6-16 years); 10 had ruptured and 7 had unruptured bAVMs. Cognitive impairments were observed in 15 patients (88.2%), most frequently affecting working memory (digit ordering) in 7 patients (41.2%), memory in 5 (29.4%), arithmetic ability in 5 (29.4%), and praxis in 4 (23.5%). In all other domains, at least 1 patient exhibited some degree of impairment. Lesions located in noneloquent areas were associated with lower result performance in the memory domain. No significant associations were found with Spetzler-Martin grade, venous pattern, lesion size, lobe localization, or hemisphere. CONCLUSIONS: Cognitive impairments were common in children and adolescents with both ruptured and unruptured bAVMs, with the most frequent deficits involving executive functions, memory, and arithmetic ability. Lesion location, according to eloquence, was associated with poorer performance in the memory domain. These findings highlight the importance of comprehensive neuropsychological evaluation for guiding treatment planning and ensuring effective long-term follow-up.
Rediscovering the origins of Kocher's point.
Kanter M, D'Amico A, Patel J … +3 more , Heilman CB, Kryzanski J, Riesenburger R
J Neurosurg · 2026 May · PMID 42214096 · Publisher ↗
Kocher's point serves as the most common entry site for accessing the ventricles of the brain. Named after Nobel laureate Theodor Kocher, a prominent Swiss surgeon of the late 19th and early 20th centuries, the discovery...
Kocher's point serves as the most common entry site for accessing the ventricles of the brain. Named after Nobel laureate Theodor Kocher, a prominent Swiss surgeon of the late 19th and early 20th centuries, the discovery of the anatomical landmark highlights the power of progressive refinement and collaboration across generations. Utilizing his well-acclaimed craniometer, Kocher described a safe trajectory to the lateral ventricle, navigating around eloquent regions of the brain and resolving the issue of ventricular collapse, a concern during his time with the use of Keen's point. To perform ventricular drainage, Theodor Kocher employed an approach resembling the modern craniotomy with bone flap replacement, which he deemed provided greater visibility of the target region anterior to the precentral gyrus. Despite achieving excellent ventricular drainage through his point, the open approach failed to address the risk of blood loss and infection and the requirement for high levels of anesthesia. Were it not for the forgotten contributions of Theodor's son, Albert Kocher, the present method of external ventricular drainage would have remained far more complicated. Albert simplified the approach, using cocaine for local anesthesia and directly drilling through the skin and bone at Kocher's point followed by insertion of a syringe.
Assessment system for short-term lower cranial nerve dysfunction following medulla oblongata glioma surgery: risk stratification and optimal surgical strategy.
Zhang M, Xiao X, Jia H … +8 more , Liu Y, Jiang W, Xie L, Pan C, Wu Z, Zhang J, Zhang L, Zhang P
J Neurosurg · 2026 May · PMID 42214095 · Publisher ↗
OBJECTIVE: Medullary gliomas pose significant surgical risks, particularly the risk of postoperative lower cranial nerve (LCN) dysfunction, which profoundly affects quality of life. The lack of standardized risk assessme...
OBJECTIVE: Medullary gliomas pose significant surgical risks, particularly the risk of postoperative lower cranial nerve (LCN) dysfunction, which profoundly affects quality of life. The lack of standardized risk assessment hinders optimal surgical planning. The aim of this study was to develop and validate an individualized predictive model for short-term postoperative LCN impairment integrating clinical and imaging data and to estimate individual risk across a range of resection extent to optimize surgical planning. METHODS: A retrospective cohort (n = 111, January 2020-February 2023) was used for model development, with prospective validation (n = 45, February 2023-December 2024). The primary outcome was postoperative LCN dysfunction (inability to be extubated within 14 days or requiring tracheotomy with persistent ventilation). Predictive modeling was performed using logistic regression, incorporating multistage feature selection, hyperparameter optimization, and bootstrapped validation. Model performance was evaluated using metrics such as area under the curve (AUC), Brier score, calibration, and decision curve analysis (DCA) in the prospective validation set. Shapley Additive Explanations (SHAP) analysis was used to interpret feature contributions, and a nomogram was constructed for clinical implementation. Optimal extent of resection (EOR) thresholds were explored to balance functional preservation and tumor clearance. RESULTS: Four independent predictors of LCN dysfunction were identified: EOR (OR 1.84, 95% CI 1.07-3.16), infiltrative growth (OR 10.46 [95% CI 2.70-40.52]), preoperative LCN impairment (OR 6.79 [95% CI 2.54-18.16]), and cervical cord involvement (OR 4.64 [95% CI 1.55-13.91]). The model demonstrated strong discrimination (training AUC 0.85 [95% CI 0.76-0.92], testing AUC 0.89 [95% CI 0.79-0.97]) and good calibration (Brier score 0.12). High-risk patients, defined as those with a model predicted risk probability > 0.471 based on Youden's index, had significantly higher rates of pneumonia, tracheostomy, and prolonged mechanical ventilation. Stratified resection plans showed that low-risk patients benefited from gross-total resection (EOR 88.4%, [95% CI 75.7%-100.0%]), while high-risk patients achieved optimal functional outcomes with limited resection (EOR 40.8%, [95% CI 38.2%-50.5%]). SHAP and nomogram analyses provided transparent, patient-specific information for risk consultations. CONCLUSIONS: This study presents the first predictive model tailored to short-term postoperative LCN outcomes following medullary glioma surgery, proposing a dynamic resection paradigm based on individualized risk stratification. By guiding surgical planning and intraoperative decision-making, this model facilitates a balance between maximal tumor control and functional preservation.
Risk stratification in pediatric dysembryoplastic neuroepithelial tumors: impact of molecular alterations, age, and extent of surgery.
Yaşar AH, Tanrıkulu B, Erşen-Danyeli A … +1 more , Özek MM
J Neurosurg Pediatr · 2026 May · PMID 42214094 · Publisher ↗
OBJECTIVE: Dysembryoplastic neuroepithelial tumors (DNETs) are usually described as benign, but long-term data clearly show that progression is not rare. Molecular diagnostic techniques have revealed that FGFR1 alteratio...
OBJECTIVE: Dysembryoplastic neuroepithelial tumors (DNETs) are usually described as benign, but long-term data clearly show that progression is not rare. Molecular diagnostic techniques have revealed that FGFR1 alterations sit at the core of DNET biology. Importantly, FGFR1 point mutations are known to drive more aggressive behavior in several pediatric gliomas. Likewise, younger children often demonstrate poorer tumor control across multiple low-grade glioma subtypes. These parallels raise the question of whether similar risk patterns exist within DNETs. The aim of this study was to identify reliable predictors of progression in pediatric DNETs by analyzing FGFR1 alteration subtypes, patient age, and extent of resection in order to refine risk stratification. METHODS: This retrospective study examined 37 pediatric DNET cases that were confirmed according to the 2021 WHO classification. FGFR1 and BRAF alterations were assessed using droplet digital PCR (ddPCR), and methylation profiling was applied in selected cases. RESULTS: FGFR1 alterations were found in nearly 70% of tumors. The most striking finding was the markedly poor prognosis of FGFR1 point mutant cases, with progression rates exceeding 70%, whereas FGFR1 tandem duplications showed a much more indolent course. Age also emerged as a key factor: 45% of patients aged ≤ 10 years progressed, compared with only 5.9% of older children. Gross-total resection remained the strongest surgical determinant of long-term tumor control. CONCLUSIONS: DNETs are biologically heterogeneous. Subtotal resection, FGFR1 point mutations, and younger age clearly identify a higher risk subgroup with shorter progression-free survival. Considering the molecular profile, age, and surgical extent together provides a more accurate framework for clinical decision-making and follow-up planning.
Temporal relationship between hematoma resolution and functional recovery after middle meningeal artery embolization for chronic subdural hematoma.
DeMessie B, Essibayi MA, Salim HA … +83 more , Karandish A, Park J, Khatri D, Haranhalli N, Baker A, Zampolin R, Brook AL, Lee SK, Adeeb N, Li YL, Simonato D, Ortega DA, Cancelliere N, Diestro JD, Carnevale JA, Schreiber C, Orscelik A, Abecassis Z, Raub S, Sioutas GS, Salsano G, Abo Kasem R, Kvint S, Falzon A, Cantrell V, Holliday B, Abaricia JO, Maleknia PD, Cruz-Criollo L, Schimmel S, Musmar B, Alexander MD, Rios Zermeno J, Koul P, Aljuboori A, Vollherbst DF, Gajski D, Cooper J, Alwakaa O, Ogilvy CS, Al-Mufti F, Kalousek V, Möhlenbruch MA, Scarcia L, Schirmer CM, Huynh T, Tawk RG, Settecase F, Tjoumakaris S, Jabbour P, Vakharia K, Zanaty M, Ortega-Gutierrez S, Jones JG, Colasurdo M, Nasser HH, Sundararajan SH, Mosimann PJ, Nossek E, Raz E, Al Kasab S, Spiotta AM, Castellan L, Del Sette B, Michelozzi C, Saraceno D, Panni P, Srinivasan VM, Burkhardt JK, Marnat G, Santini PM, Levitt MR, Lanzino G, Brinjikji W, Knopman J, Kass-Hout T, Spears J, Marotta T, Mendes Pereira V, Fuschi M, Dmytriw AA, Altschul DJ, MESH collaborators
J Neurosurg · 2026 May · PMID 42172679 · Publisher ↗
OBJECTIVE: The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal patte...
OBJECTIVE: The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal pattern of cSDH resolution, and identify factors associated with favorable outcomes. METHODS: This real-world multicenter retrospective study included cSDH patients treated with MMAE at 24 centers between 2019 and 2024. Hematoma thickness was measured at baseline and at follow-up intervals (1-4 weeks, 1-3 months, 3-6 months, 6-12 months, and > 12 months after embolization). Resolution patterns were modeled using exponential decay functions. Modified Rankin Scale (mRS) scores assessed functional outcomes. Good functional outcome was defined as mRS score ≤ 2. Resolution patterns were modeled using exponential decay functions to estimate time to 50% and 80% reduction. Patients were categorized as complete resolution (≥ 99%) or by quartile of the remaining distribution (substantial [73%-98%], moderate [53%-73%], partial [27%-53%], minimal [< 27%]). The primary outcome was good functional status (mRS score ≤ 2). RESULTS: The authors analyzed a total of 1781 patients with 2295 cSDHs who underwent MMAE. The mean ± SD age was 72.8 ± 12.4 years and 68.1% of patients were male. The initial mean hematoma thickness was 15.31 ± 6.53 mm, decreasing to 5.24 ± 5.91 mm at final follow-up (mean reduction 64.3% ± 42.1%). Resolution followed an exponential decay pattern, with an estimated time to 50% reduction of 1.8 months and to 80% reduction of 8.9 months. Complete resolution occurred in 1031 of 2224 patients (46.4%) with complete follow-up. The median (IQR) mRS score improved from 1 (0-3) at baseline to 0 (0-2) at > 12 months. Good functional outcomes were more common in patients with complete versus minimal resolution (68.9% vs 35.0%, p < 0.001). Achieving ≥ 73% resolution within 90 days was associated with better outcomes (good outcome in 76.9% of those with ≥ 73% resolution vs 67.3% in those without, p < 0.001). Neurological deterioration was the strongest predictor of lack of good outcome (23.7% in patients with neurological deterioration vs 82.4% without, p < 0.001). CONCLUSIONS: After MMAE for cSDH, reduction in hematoma thickness follows a predictable exponential decay pattern. Greater extent (≥ 80%) and faster timing (within 90 days) of resolution are valuable prognostic indicators. Functional outcomes improve progressively through 6-12 months after the procedure. The relationship between resolution extent and functional outcomes provides quantitative benchmarks for evaluating treatment response.
Advocacy efforts by the American Society of Pediatric Neurosurgeons: evolving priorities, ongoing initiatives, and future directions.
Hersh DS, Martin JE, Rocque BG … +12 more , Albert GW, Akbari SHA, Blount JP, Bristol RE, Durham SR, Duhaime AC, Kulkarni AV, Tomei KL, Weiner HL, Wellons JC, Weprin BE, Robinson S
J Neurosurg Pediatr · 2026 May · PMID 42172678 · Publisher ↗
Abstract loading — click title to view on PubMed.
Impact of intracranial pressure monitoring on 30-day mortality in severe traumatic brain injury: a retrospective cohort study in Kenya.
Ongas T, Chikophe I, Mavuti J … +4 more , Olunya DLO, Qureshi M, Cheserem B, Mogere E
J Neurosurg · 2026 May · PMID 42172674 · Publisher ↗
OBJECTIVE: The objective of this study was to evaluate 15-year trends in epidemiology, baseline severity, management, and outcomes of severe traumatic brain injury (sTBI) at a Kenyan tertiary center, and to determine the...
OBJECTIVE: The objective of this study was to evaluate 15-year trends in epidemiology, baseline severity, management, and outcomes of severe traumatic brain injury (sTBI) at a Kenyan tertiary center, and to determine the impact of invasive intracranial pressure (ICP) monitoring on 30-day mortality in a low- and middle-income country (LMIC) context. METHODS: A retrospective quasi-experimental cohort analysis of consecutive sTBI admissions (postresuscitation Glasgow Coma Scale [GCS] score ≤ 8, age ≥ 13 years) from January 1, 2010, to December 31, 2024, was conducted. This time period was divided into two eras: era 1 (2010-2014), premonitoring, and era 2 (2015-2024), routine monitoring. Patient demographics, injury severity (Injury Severity Score [ISS], pupillary response, and Marshall CT class), physiology, therapies utilized (hyperosmolar agents, CSF drainage, barbiturates, and decompressive craniectomy [DC]) and outcomes were collected. Propensity score analysis with 1:1 nearest-neighbor matching for age, sex, ISS, GCS score, pupillary response, hypotension, hypoxemia, time to admission, and Marshall CT class was applied. The primary outcome was 30-day mortality. RESULTS: Among 126 sTBI patients (median age 32 years, 80% male), 52 (41%) received ICP monitoring (56% parenchymal, 44% external ventricular drain). In the unmatched analysis, the mortality rate was 27% with monitoring versus 54% without (risk ratio [RR] 0.50, p = 0.002). In the matched analysis (41 pairs), the mortality rate was 29% with monitoring versus 51% without (RR 0.57, OR 0.39, p = 0.043). Era 2 showed a higher use of hypertonic saline (62% vs 35%, p = 0.003), CSF drainage (37% vs 1.4%, p < 0.001), and DC (22% vs 2.4%, p = 0.011). Complication rates from use of the monitoring device were low (infection 7.7%, hemorrhage 7.7%). CONCLUSIONS: Over the 15-year period, sTBI admissions rose while early mortality declined following the adoption of ICP monitoring and protocol-based care. In this LMIC setting, ICP monitoring was independently associated with lower 30-day mortality, supporting the use of guideline-concordant neuromonitoring and scalable multimodality bundles.
Letter to the Editor. ICP amplitude: physiological context, limitations, and integration with waveform analysis.
de Oliveira Manduca Palmiero H, Figueiredo EG
J Neurosurg · 2026 May · PMID 42172673 · Publisher ↗
Abstract loading — click title to view on PubMed.
Communication in the OR: what we could learn from Starbucks and The Bear.
Amin-Hanjani S
J Neurosurg · 2026 May · PMID 42172666 · Publisher ↗
Abstract loading — click title to view on PubMed.
Hippocampal volume for prediction of working memory performance in patients with infantile hydrocephalus.
Ragguett RM, Meng L, Adil D … +2 more , Eagleson R, de Ribaupierre S
J Neurosurg Pediatr · 2026 May · PMID 42172665 · Publisher ↗
OBJECTIVE: Infantile hydrocephalus is a common condition that requires surgery. However, cognitive outcomes following treatment are poorly understood, limiting the ability to prognosticate cognitive functioning or target...
OBJECTIVE: Infantile hydrocephalus is a common condition that requires surgery. However, cognitive outcomes following treatment are poorly understood, limiting the ability to prognosticate cognitive functioning or target cognitive therapies. Some studies have shown that children with infantile hydrocephalus often experience memory difficulties. Given the role of the hippocampus in memory, the aim of this study was to assess hippocampal volume in children with infantile hydrocephalus compared with controls and to further evaluate the relationship between hippocampal volume and working memory. METHODS: Children with infantile hydrocephalus and healthy control children were recruited between 2015 and 2024 for comparison. All participants underwent a neuroimaging protocol that included T1-weighted structural MRI. Hippocampal volumes were extracted, verified, and corrected for total intracranial volume. Participants also completed a neurocognitive battery using a digital version of the multicolored Mr. Peanut task for assessing working memory. A multiple regression model was used to examine the impact of hippocampal volume on working memory performance. RESULTS: Overall, 54 participants were included in the study; 37 healthy controls (19 male, mean age 9.15 ± 2.16 years) and 17 children with infantile hydrocephalus (9 male, mean age 9.49 ± 1.55 years). There was no significant difference in age or sex between groups. Total hippocampal volume and working memory performance were significantly decreased for patients with infantile hydrocephalus compared with healthy controls (both p < 0.005). Furthermore, the multiple regression model showed that total hippocampal volume was a positive predictor of working memory performance (p < 0.01). Sex and lateral ventricle volume were not significant predictors. CONCLUSIONS: Children with infantile hydrocephalus had worse working memory performance and a smaller mean hippocampal volume compared with healthy controls. Similar to studies in healthy control children, hippocampal volume was a positive predictor of memory performance in the current study. These findings add to the scant existing literature characterizing cognitive deficits in infantile hydrocephalus. Additional studies with larger sample sizes and further consideration of factors that can impact working memory are needed.
From Velasco to NAUTILUS: an evolution of centromedian nucleus targeting in epilepsy.
Neudorfer C, Nanda P, Sisterson ND … +6 more , Kammen A, Rapalino O, Jaimes C, Patra S, Ghatan S, Richardson RM
J Neurosurg · 2026 May · PMID 42139739 · Publisher ↗
OBJECTIVE: The field of neuromodulation for idiopathic generalized epilepsy is rapidly evolving. The recently completed NAUTILUS trial, an industry-sponsored multicenter, randomized, sham-controlled study evaluating cent...
OBJECTIVE: The field of neuromodulation for idiopathic generalized epilepsy is rapidly evolving. The recently completed NAUTILUS trial, an industry-sponsored multicenter, randomized, sham-controlled study evaluating centromedian nucleus (CM) stimulation, represents a landmark effort to rigorously assess this approach. Although trial results are not yet available, the need to understand and standardize the anatomical targeting of the CM remains critical. The precision of electrode placement fundamentally determines whether stimulation engages the intended thalamocortical circuits, shaping both efficacy and reproducibility across centers. METHODS: The authors present a comprehensive review of the evolution of CM targeting in epilepsy, tracing its development from early stereotactic approaches to current imaging-based strategies. The authors detail the surgical targeting workflow used across NAUTILUS trial sites, which incorporates advanced MRI sequences and atlas-informed refinements. This review also offers practical resources and tools enabling clinicians to implement the described methodology in clinical and research settings. RESULTS: Modern CM targeting strategies reflect a transition from indirect, coordinate-based techniques to individualized, image-guided planning. These methods have been successfully implemented across centers participating in the NAUTILUS trial, enabling accurate electrode placement even in patients with complex anatomy. The workflow accommodates both direct visualization and atlas-based alternatives when imaging quality is suboptimal. CONCLUSIONS: This review outlines the evolution of CM neuromodulation-from Velasco's early targeting approaches to modern image-guided surgery-and provides a reproducible framework for clinicians. As neuromodulation moves toward broader clinical adoption, anatomically precise targeting will be key to optimizing outcomes. The surgical approach recommended in the NAUTILUS trial offers an implantation framework intended to support future location-based outcome analysis.
Impact of fetal myelomeningocele repair on the clivus-supraocciput angle and third ventricle anatomy: evaluation of the outcome of endoscopic third ventriculostomy and choroid plexus cauterization.
Azouz H, Guerrero RA, Schreck MR … +3 more , Vlastos EJ, Greves CD, Elbabaa SK
J Neurosurg Pediatr · 2026 May · PMID 42139738 · Publisher ↗
OBJECTIVE: Fetal myelomeningocele repair (FMMR) has shown significant promise in decreasing the incidence of myelomeningocele (MMC)-associated hydrocephalus. In this study, the authors report on the reversal of hindbrain...
OBJECTIVE: Fetal myelomeningocele repair (FMMR) has shown significant promise in decreasing the incidence of myelomeningocele (MMC)-associated hydrocephalus. In this study, the authors report on the reversal of hindbrain herniation via FMMR. They also describe biometric changes in third ventricle anatomy, which influences the outcome of endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC). METHODS: At the Arnold Palmer Hospital for Children and Winnie Palmer Hospital for Women & Babies, the maternal and fetal inclusion and exclusion criteria developed by the Management of Myelomeningocele Study (MOMS) were applied to determine eligibility for prenatal MMC repair. Patient charts, prenatal fetal MRI, ultrasonography studies, and postnatal brain MRI for the first 50 FMMRs performed between 2019 and 2024 were retrospectively reviewed for this study. Ventricle size was measured prior to fetal surgery, as was the clivus-supraocciput angle (CSO) on fetal and postnatal images. Neonates were stratified into hydrocephalic and nonhydrocephalic groups for comparative analysis. The hydrocephalic group included patients who had undergone ETV/CPC or insertion of a ventriculoperitoneal shunt (VPS). RESULTS: A total of 50 women underwent FMMR. One woman did not consent to inclusion in the study, 8 patients remained in utero at the time of analysis, and 3 patients died. Of the 38 patients included in the analysis, 21 (55%) underwent treatment for their symptomatic hydrocephalus; 4 received a VPS, and 17 underwent ETV/CPC. Four ETV/CPC cases did not respond to the treatment and were scheduled for VPS insertion, resulting in an overall ETV/CPC success rate of 70.6% (12/17) in the study. A statistically significant difference in the mean prenatal ventricle size was observed between the nonhydrocephalic (9.61 mm) and hydrocephalic (12.1 mm, p = 0.023) groups. Additionally, a significant difference in the CSO angle in the first month after birth was noted between the groups (67.2° vs 76.7°, p = 0.01). CONCLUSIONS: There is strong evidence that FMMR decreases MMC-related hydrocephalus by reversing hindbrain herniation and altering the developmental anatomy of the third ventricle. This makes ETV/CPC a safe alternative to CSF shunting because of the newly altered anatomy of the third ventricle and posterior fossa. Larger studies are recommended to further evaluate fetal brain development after FMMR.
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