Neurosurgery[JOURNAL]
Sun
200 papers
Microsurgical Evacuation Efficacy and Functional Outcomes in Spontaneous Intracerebral Hemorrhage by Type of Antithrombotic Therapy.
Ferdowssian K, Aigner A, Raff JH … +7 more , Schubert AJ, König S, Koscielny J, Wasilewski D, Wessels L, Vajkoczy P, Hecht N
Neurosurgery · 2026 Aug · PMID 42398947 · Publisher ↗
BACKGROUND AND OBJECTIVES: Evidence on how different antithrombotic therapies influence microsurgical evacuation efficacy in spontaneous intracerebral hemorrhage (ICH) is limited. Antithrombotic agents may increase hemat...
BACKGROUND AND OBJECTIVES: Evidence on how different antithrombotic therapies influence microsurgical evacuation efficacy in spontaneous intracerebral hemorrhage (ICH) is limited. Antithrombotic agents may increase hematoma volume and impact postoperative outcomes, complicating surgical management. As growing evidence supports surgical ICH evacuation, understanding the role of antithrombotics and emergency reversal strategies is critical. The aim of this study was a comparative overview on how common types of antithrombotic therapy influence radiographic and clinical outcomes in surgically treated ICH. METHODS: In this retrospective study, we included consecutive patients who underwent microsurgical hematoma evacuation for supratentorial ICH between 2008 and 2022. Patient characteristics, antithrombotic therapy, reversal strategies, neuroimaging, and 12-month functional outcome (modified Rankin Scale) were reviewed. Preoperative antiplatelet therapy (APT), vitamin K antagonists, direct oral anticoagulants, and combined antiplatelet/anticoagulant therapy (Comb) was compared with no antithrombotic medication. Multivariable regression models were used to analyze the association between antithrombotic therapy, radiographic, and clinical outcomes. RESULTS: Overall, we included 232 patients with supratentorial ICH (APT: 53, vitamin K antagonists: 29, direct oral anticoagulant: 13, Comb: 17). Patients with any type of antithrombotic therapy presented with larger absolute preoperative hematoma volumes than patients without prior antithrombotic medication. Combined antiplatelet/anticoagulant therapy affected preoperative ICH volume to the greatest extent (volume difference: 14.9 mL; 95% CI: 0.9, 29.0). APT was associated with a 1.4-fold increase in relative postoperative ICH volume (95% CI: 0.9, 2.1), while combined therapy was associated with a 2.1-fold increase (95% CI: 1.1, 4.0). Unfavorable outcome (modified Rankin Scale ≥4) affected 73.5% of patients and was linked to larger preoperative hematomas (63 mL vs 49 mL) and higher relative postoperative hematoma volume (13.7% vs 7.5%). CONCLUSION: Despite preoperative emergency reversal, antithrombotics contributed to higher hematoma volumes, poorer microsurgical evacuation efficacy and worse functional outcome. Particularly for patients receiving APT, the findings underline the importance of optimizing antithrombotic reversal strategies.
Neurosurgeons Are Essential in the Interdisciplinary Care of Patients With Brain Metastasis.
Sheehan J, Kondziolka D
Neurosurgery · 2026 Aug · PMID 42398946 · Publisher ↗
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Performance of Risk Scores in Predicting Intracranial Aneurysm Instability.
Tarkiainen J, Pyysalo L, Frösen J
Neurosurgery · 2026 Jul · PMID 42390970 · Publisher ↗
BACKGROUND AND OBJECTIVES: Several risk scores targeting different end points-rupture, growth, or rupture after growth-are used to guide prophylactic treatment decisions, despite not all being designed to predict aneurys...
BACKGROUND AND OBJECTIVES: Several risk scores targeting different end points-rupture, growth, or rupture after growth-are used to guide prophylactic treatment decisions, despite not all being designed to predict aneurysm rupture directly. We evaluated how population, hypertension, age, size, earlier subarachnoid hemorrhage, site (PHASES), earlier subarachnoid hemorrhage, location, age, population, size, shape (ELAPSS), triple-S, and Juvela scores perform in identifying rupture-prone aneurysms and predicting instability in intracranial aneurysms deemed to have low enough rupture risk to justify conservative treatment. METHODS: This retrospective study included all patients with ruptured or conservatively managed unruptured intracranial aneurysms diagnosed from 2005 to 2020 in Tampere University Hospital. Risk scores were calculated from clinical and imaging data at diagnosis. For ruptured aneurysms, score distributions were analyzed to assess sensitivity. For conservatively managed unruptured aneurysms with radiological follow-up of ≥3 months, discrimination for composite instability end point (rupture or growth of ≥1.0 mm) was evaluated using receiver operating characteristic curves, calibration plots, and decision-curve analysis. RESULTS: A total of 2258 aneurysms were analyzed: 1180 ruptured and 1078 unruptured. Among conservatively managed unruptured intracranial aneurysms, 29 ruptured (3%), including 7 fatal cases identified through a nationwide cause-of-death search. Of the 519 unruptured intracranial aneurysms (48%) with radiological follow-up (median, 3.4 years; total, 2256 aneurysm-years), 71 (14%) demonstrated instability (52 growth, 19 rupture). In the ruptured cohort, PHASES demonstrated the highest sensitivity. ELAPSS and triple-S achieved the best discrimination for instability (area under the curve, 0.78 [95% CI, 0.71-0.85] and 0.79 [0.72-0.85]). Decision curve analysis indicated that ELAPSS and triple-S provided the highest net benefit within clinically relevant thresholds (6%-20%). CONCLUSION: In the ruptured aneurysm cohort, PHASES showed the highest sensitivity for identifying rupture-prone aneurysms. In the conservatively managed cohort, ELAPSS and triple-S best discriminated instability, and all models except Juvela showed high sensitivity for rupture. All models had low positive predictive value and limited specificity, indicating that current risk scores alone are insufficient for treatment selection and require further refinement.
Electric-Scooters: An Emerging Source of High-Severity Pediatric Head Trauma.
Petitet P, Musarra A, de Laurentis C … +6 more , Beuriat PA, Szathmari A, Vinchon M, Guernouche S, Javouhey E, Di Rocco F
Neurosurgery · 2026 Jul · PMID 42390229 · Publisher ↗
BACKGROUND AND OBJECTIVES: Electric scooters (ES) have become increasingly popular among children and adolescents in France. To date, very little is known about their impact on the incidence and severity of pediatric hea...
BACKGROUND AND OBJECTIVES: Electric scooters (ES) have become increasingly popular among children and adolescents in France. To date, very little is known about their impact on the incidence and severity of pediatric head trauma (HT). METHODS: We conducted a retrospective single-center study of patients aged 2 to 18 years admitted to a pediatric neurosurgery ward between 2021 and 2025 for HT related to ES, nonmotorized two-wheeled vehicles (bicycles, kick-scooters; NMTV), or motorbikes. Demographics, accident characteristics, helmet use, clinical and radiological severity, neurosurgical management, hospital course, and need for rehabilitation were collected. Injury severity was assessed using a multivariate model combining neurological, radiological, and in-hospital outcomes. A follow-up phone interview was conducted in a subset of ES patients to assess long-term functional outcome and postinjury behavior regarding mobility habits. RESULTS: ES-related HT rose from 1 case in 2021 to 25 in 2025, whereas the number of HT related to NMTV and motorbikes remained stable. Nearly half of injured ES riders were below the legal age, and helmet use was rare. The severity profile of ES-related HT was greater than that of bicycle and kick-scooter accidents, and comparable to that of motorbike accidents. Five ES patients required surgical intervention, most commonly for epidural hematoma evacuation. At follow-up, most patients had favorable functional outcomes, but nearly one-third experienced persistent disability, and helmet adoption after injury remained limited. CONCLUSION: ES have emerged as a high-severity mechanism of pediatric HT, comparable to motorbikes. Enhanced prevention strategies, including helmet enforcement, and age regulation, are urgently needed.
Survival After Surgery for Spinal Osteosarcoma and the Role of Chemotherapy and Treatment Sequencing: A National Cohort Multivariable Analysis.
Khalilullah T, Shah S, Vattipally VN … +8 more , Shah K, Hersh AM, Dardick J, Azad TD, Xia Y, Theodore N, Meyer C, Lubelski D
Neurosurgery · 2026 Jul · PMID 42384028 · Publisher ↗
BACKGROUND AND OBJECTIVES: Primary spinal osteosarcoma is a rare, morbid malignancy, frequently involving critical neurovascular structures and causing neurological compromise. Evidence guiding management is limited, and...
BACKGROUND AND OBJECTIVES: Primary spinal osteosarcoma is a rare, morbid malignancy, frequently involving critical neurovascular structures and causing neurological compromise. Evidence guiding management is limited, and the benefit of surgery and perioperative chemotherapy is largely extrapolated from extremity disease. This study evaluates overall survival (OS) among surgically treated spinal osteosarcoma patients, examines the influence of chemotherapy and treatment sequence, and identifies predictors of chemotherapy administration. METHODS: Using the National Cancer Database (2004-2023), we identified patients with histologically confirmed spinal osteosarcoma who underwent surgery. Baseline characteristics were compared between surgery-only and surgery and chemotherapy cohorts. OS was assessed using Kaplan-Meier analysis, with interaction testing for grade and treatment effects. Multivariable Cox models were performed. A logistic regression model evaluated predictors of chemotherapy utilization. RESULTS: A total of 899 surgically treated patients were analyzed; 685 (76%) received chemotherapy. Before matching, the combination of surgery and chemotherapy was associated with superior 30-, 90-day, and 1-year survival (all P < .001). Kaplan-Meier curves demonstrated improved OS at both 1 and 5 years for surgery and chemotherapy, with the greatest impact observed in high-grade disease. In multivariable analysis, surgery and chemotherapy in low-grade osteosarcomas was associated with lower mortality (hazard ratio 0.51, P = .025 [0.28, 0.92]). No survival difference was observed between neoadjuvant, adjuvant, or combined sequencing. CONCLUSION: Among patients undergoing resection for spinal osteosarcoma, perioperative chemotherapy was associated with improved early and unadjusted OS, with the greatest impact observed in high-grade tumors. However, this survival advantage was attenuated in adjusted analysis. These findings suggest that although chemotherapy remains critical in high-grade spinal osteosarcoma, its role in low-grade disease where toxicity may outweigh the benefit warrants further investigation.
Safety and Efficacy of 3-Month Versus 6-Month Duration of Dual Antiplatelet Therapy in Pipeline Embolization Treatment of Intracranial Aneurysms.
Cuoco JA, Ritchey N, Constable M … +6 more , Wang AC, Kim JE, Schunemann V, Youssef PP, Powers CJ, Nimjee SM
Neurosurgery · 2026 Jul · PMID 42384009 · Publisher ↗
BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is considered the standard medication regimen after Pipeline Embolization Device (PED) treatment of intracranial aneurysms. However, the optimal duration of DAP...
BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is considered the standard medication regimen after Pipeline Embolization Device (PED) treatment of intracranial aneurysms. However, the optimal duration of DAPT after PED remains uncertain. We compared the safety and efficacy of 3 months vs 6 months or more of DAPT in the PED treatment of intracranial aneurysms. METHODS: We performed a retrospective cohort comparison study of 257 consecutive patients with intracranial aneurysms treated with PED who were either prescribed a 3-month (early termination) or ≥6-month course (standard duration) of DAPT. All patients had clinical follow-up of at least 3 months after discontinuation of DAPT. Baseline demographics, aneurysm characteristics, periprocedural data, complications before and after discontinuation of DAPT, and aneurysm occlusion rates on follow-up angiography were compared between cohorts. RESULTS: The study cohort consisted of 257 patients, including 155 patients in the early termination group and 102 patients in the standard duration group. Total complications after DAPT discontinuation were significantly lower in the early termination cohort (1.3% vs 9.8%, P = .002). There were no significant differences in total major complications between groups after DAPT cessation, nor were there differences in any specific major complication. Minor thromboembolic complications were significantly lower in the early termination cohort (1.3% vs 8.8%, P = .008) after DAPT discontinuation without a significant difference in any specific event. The rate of complete aneurysm occlusion on 6-month follow-up angiography was significantly higher in the early termination cohort (82.6% vs 70.6%, P = .024). CONCLUSION: In this study, we found that early termination of DAPT at 3 months after PED treatment has overall similar safety and efficacy outcomes as compared with the current standard 6-month regimen. These preliminary data encourage prospective studies to determine optimal DAPT durations in the PED treatment of intracranial aneurysms.
Risk Factors of Revision Surgery After Acute Proximal Junctional Fracture Following Adult Spinal Deformity Surgery.
Shin TS, Park JS, Kang DH … +2 more , Lee CS, Park SJ
Neurosurgery · 2026 Jul · PMID 42378085 · Publisher ↗
BACKGROUND AND OBJECTIVES: Acute proximal junctional fracture (APJFx) is a severe form of proximal junctional kyphosis after adult spinal deformity surgery and is often associated with revision surgery. However, the clin...
BACKGROUND AND OBJECTIVES: Acute proximal junctional fracture (APJFx) is a severe form of proximal junctional kyphosis after adult spinal deformity surgery and is often associated with revision surgery. However, the clinical course of APJFx is heterogeneous, and not all patients require revision. The aim of this study was to identify independent risk factors of revision surgery after APJFx to guide the timing and necessity of revision surgery. METHODS: This retrospective study included patients who developed APJFx within 6 months after undergoing multilevel (≥5 levels) fusion surgery. Demographic, surgical, and radiographic variables were analyzed. Initial postoperative alignment was evaluated using the sagittal age-adjusted score and the Global Alignment Proportion score. Radiographic parameters at the time of APJFx detection were also assessed. Revision-free survival was analyzed using Kaplan-Meier analysis. Independent predictors of revision surgery were identified through multivariate logistic regression, and optimal cutoff values were determined using receiver operating characteristic analysis. Patients were stratified into 4 subgroups based on identified risk factors. RESULTS: Eighty patients met the inclusion criteria, and 35 patients (43.8%) underwent revision surgery during a mean follow-up of 24.6 months. Most revision surgeries (82.9%) were performed within 24 months after APJFx detection. Multivariate analysis identified 2 independent predictors of revision surgery: a higher sagittal age-adjusted score pelvic incidence minus lumbar lordosis (PI-LL) modifier score (odds ratio = 1.76; cutoff = 0.5 point, indicating PI-LL overcorrection) and a greater proximal junctional angle at APJFx detection (odds ratio = 1.10, cutoff = 22.5°). Patients with both risk factors exhibited the highest revision rate (71.4%), whereas those with neither risk factor had the lowest rate (17.6%). CONCLUSION: Revision surgery after APJFx is common, particularly in patients with PI-LL overcorrection and increased proximal junctional angle at fracture detection. Risk-based stratification using these parameters may aid in guiding early surgical decision making and surveillance strategies.
Sensorimotor Network Alterations and Compensation in Cervical Spondylotic Myelopathy: A 7 T Task-Based and Resting-State Functional MRI Study.
Shima K, Oishi N, Okada T … +8 more , Duy Thuy DH, Fujibayashi S, Shimizu T, Murata K, Sono T, Otsuki B, Matsuda S, Isa T
Neurosurgery · 2026 Jun · PMID 42377928 · Publisher ↗
BACKGROUND AND OBJECTIVES: Cervical spondylotic myelopathy (CSM) is a leading cause of spinal cord dysfunction, yet the central neural mechanisms underlying motor impairment and recovery remain unclear. METHODS: This stu...
BACKGROUND AND OBJECTIVES: Cervical spondylotic myelopathy (CSM) is a leading cause of spinal cord dysfunction, yet the central neural mechanisms underlying motor impairment and recovery remain unclear. METHODS: This study used the first 7 T functional MRI (fMRI) study in patients with CSM to investigate sensorimotor network alterations. Sixteen patients with CSM and age-matched healthy controls underwent task-based fMRI during hand grasping and resting-state fMRI. Ten patients completed 3-month postoperative follow-up imaging. Clinical severity was assessed using Japanese Orthopaedic Association (JOA) scores. RESULTS: Task-based fMRI during hand movements revealed compensatory bilateral recruitment in patients with CSM compared with controls, with significantly increased activation in the ipsilateral primary motor cortex (M1; peak: 45, -21, 56; T = 7.93, P < .001) and contralateral cerebellum (peak: -21, -52, -28; T = 7.23, P < .001). Cerebellar hyperactivation correlated negatively with JOA total scores (peak: -26, -56, -24; T = 10.74, P < .001) and dexterity subscales (T = 9.05, P < .001), indicating severity-dependent compensation. Resting-state analysis revealed widespread increases in sensorimotor network connectivity. The strongest alterations were observed in bilateral M1 connectivity (T = 14.65, P < .001), bilateral primary sensory cortex connectivity (T = 14.53, P < .001), and M1-supplementary motor area (SMA) connections (right M1 to left SMA: T = 13.21, P < .001; bilateral SMA: T = 13.89, P < .001). Intracerebellar networks showed marked hyperconnectivity (bilateral cerebellar lobule VI: T = 15.35, P < .001; bilateral cerebellar lobule IV-V: T = 14.25, P < .001). Resting-state connectivity strength was negatively correlated with both JOA total scores and dexterity subscales. CONCLUSION: This 7T fMRI study reveals that CSM induces compensatory reorganization involving the contralateral cerebellum and ipsilateral motor cortex, with severity-dependent hyperconnectivity. These findings clarify mechanisms of motor compensation and suggest cerebellar-focused rehabilitation as a potential therapeutic strategy.
Hyperselective Peripheral Neurectomy Versus Medical Therapy for Refractory Poststroke Spasticity: A Randomized Controlled Trial.
Bajaj J, Banawal LK, Jain A … +12 more , Khandelwal N, Kumar A, Patidar J, Lemos CL, Dhurwe R, Singh M, Sinha M, Sharma M, Ratre S, Parihar VS, Swamy NM, Yadav YR
Neurosurgery · 2026 Jun · PMID 42377927 · Publisher ↗
BACKGROUND AND OBJECTIVES: Poststroke spasticity is a common and debilitating condition that limits functions, is associated with pain, and impairs independence. Medications are often costly, temporary or insufficient to...
BACKGROUND AND OBJECTIVES: Poststroke spasticity is a common and debilitating condition that limits functions, is associated with pain, and impairs independence. Medications are often costly, temporary or insufficient to manage this condition. We aimed to compare the efficacy and safety of hyperselective peripheral neurectomy with best medical therapy in patients of poststroke spasticity. METHODS: This trial was a prospective, randomized controlled study performed on adults with poststroke spasticity [modified Ashworth scale (MAS) score of 3-4] refractory to maximal tolerated baclofen. Patients were randomized (1:1) to undergo surgery plus rehabilitation or to continue medical therapy with rehabilitation. The primary outcome was change in MAS score at 12 months from baseline. RESULTS: Fifty patients were randomized equally into the 2 groups. At 12 months, the surgical group had significantly greater reduction in spasticity with a between-group difference of 1.36 points (95% CI 0.97-1.74; P < .001). The surgical group also had clinically meaningful ≥1-grade improvement in MAS score in 96% of patients compared with only 8% in the medical group (number needed to treat 1.14). Functional independence improved only within the surgical group, with no significant between-group difference. No differences were observed in power or sensory outcomes. Transient neuropathic pain was observed in 5 patients in the surgical group (resolved with medicines in 2-3 months). CONCLUSION: The hyperselective peripheral neurectomy is associated with substantial and sustained reduction in spasticity in carefully selected patients. TRIAL REGISTRATION NUMBER: CTRI/2023/11/060191.
Letter: Interhospital Variation in Operative Intervention for Firearm-Related Penetrating Traumatic Brain Injury and Associations With Inpatient Mortality.
Beucler N, Tinois J, Silva Baticam N … +6 more , Iuga M, Do Tran A, Guyot B, Mouramba M, Dagain A, Bernard C
Neurosurgery · 2026 Jun · PMID 42377909 · Publisher ↗
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In Reply: Interhospital Variation in Operative Intervention for Firearm-Related Penetrating Traumatic Brain Injury and Associations With Inpatient Mortality.
Vattipally VN, Azad TD
Neurosurgery · 2026 Jun · PMID 42377405 · Publisher ↗
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Position Statement of the American Society for Stereotactic and Functional Neurosurgery on Focused Ultrasound Lesioning of the Brain by Non-neurosurgeons.
Danish SF, Rosenow JM, Schwalb JM … +13 more , Air EL, Sweet J, Willie JT, Rolston JD, Englot DJ, Lipsman N, Zemmar A, Neimat JS, Cosgrove GR, Asaad WF, Ali R, Pilitsis JG, Hamani C
Neurosurgery · 2026 Aug · PMID 42341199 · Publisher ↗
Since its US Food and Drug Administration approval in 2016, magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy has grown into one of the procedures of choice among patients with essential tremor (ET). Appr...
Since its US Food and Drug Administration approval in 2016, magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy has grown into one of the procedures of choice among patients with essential tremor (ET). Approved applications for the procedure have expanded over time from unilateral thalamotomy to treat ET and Parkinson disease tremor to bilateral staged thalamotomy for ET. As the procedure expands to healthcare environments beyond large academic centers, guidance is required to ensure that the responsible clinicians are appropriately trained to undertake this operative procedure. Although multidisciplinary movement disorder teams are important for the optimal management of patients, MRgFUS lesions are inherently surgical interventions. Neurosurgeons are trained to evaluate these patients, consider surgical alternatives and conduct these operations, particularly after completing a fellowship in the subspecialty of stereotactic and functional neurosurgery. At present, all high-level evidence regarding the safety and efficacy of MRgFUS lesions to treat movement disorders derives from procedures performed by neurosurgeons, so those results may not be generalizable to other physicians. Based on these considerations and potential liability issues, the American Society for Stereotactic and Functional Neurosurgery, which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, puts forth this position statement that only neurosurgeons appropriately trained to conduct functional neurosurgery procedures should conduct MRgFUS surgical lesions.
First Report of Staged Adaptive Frameless Stereotactic Radiosurgery in 3 "Pulses" to Salvage Brain Metastases that Failed Previous Radiosurgery.
Tong D, Shor D, Zhang B … +12 more , Ruschin M, Detsky JS, Dinakaran D, Soliman H, Tseng CL, da Costa L, Das S, Heyn C, Holden L, Atenafu EG, Sahgal A, Chen H
Neurosurgery · 2026 Jun · PMID 42340322 · Publisher ↗
BACKGROUND AND OBJECTIVES: Staged stereotactic radiosurgery (SRS) for brain metastases (BMets) takes advantage of longer intervals between fractions to reduce treatment-related side effects while maintaining effectivenes...
BACKGROUND AND OBJECTIVES: Staged stereotactic radiosurgery (SRS) for brain metastases (BMets) takes advantage of longer intervals between fractions to reduce treatment-related side effects while maintaining effectiveness. We report our approach for frameless staged SRS consisting of 3 fractions of 8 Gy, 8 Gy, and 4 Gy every 2 weeks as salvage reirradiation of BMets that progressed after previous SRS. METHODS: Patients treated with frameless staged SRS for both intact and postoperative metastases were identified from our institutional database. Only metastases that failed previous SRS were included. The primary outcome was the rate of radiation necrosis (RN), and secondary outcomes included local failure (LF) and overall survival (OS). Outcomes were calculated using Kaplan-Meier or competing-risks methods. Cox regression and Fine-Gray competing-risks regression were used to identify factors associated with RN, LF, and OS. RESULTS: Fifty patients with 89 metastases were treated with staged SRS. The majority were patients with breast (34.8%) and lung (41.6%) cancer. Seventy-seven (86.5%) lesions were intact, and 20 (22.5%) were from radioresistant primaries. Median follow-up was 9.6 months. RN rates were 6.8%, 12.4%, and 13.8% at 6, 12, and 18 months, respectively. At 1 year, 4 (4.5%) RN events were Grade 1 or 2, and 7 (7.9%) were Grade 3. LF and OS rates at 6, 12, and 18 months were 16.1%, 28%, 30.8%, and 81.6%, 60.4%, 42.3%, respectively. On regression analysis, maximum dose within the target lesion as a weighted average (hazard ratio = 1.14 per additional Gy, P = .048) predicted for RN. There was a trend toward worse LF in radioresistant lesions (hazard ratio = 2.09, P = .078). A reduction in target volume was observed in 63% and 75% of all treated lesions between fractions 1 to 2 and 2 to 3, respectively. CONCLUSION: Our staged SRS regimen was an effective and well-tolerated adaptive treatment of reirradiation of BMets with a favorable RN profile.
Response of Spinal Cord Blood Flow to Hypotensive and Adrenergic Challenges: Doppler Ultrasound of the Porcine Sulcal Artery.
Routkevitch D, Davidar AD, Jiang K … +20 more , Weber-Levine C, Babu N, Bhimreddy M, Lopez AF, Menta AK, Kramer P, Vattipally VN, Darby Z, Chinedozi I, Kang JK, Steger L, Baca E, Soulé Z, Kats N, Hersh AM, Ashayeri K, Smit C, Manbachi A, Thakor NV, Theodore N
Neurosurgery · 2026 Jun · PMID 42340304 · Publisher ↗
BACKGROUND AND OBJECTIVES: Management of spinal cord injury includes surgical decompression and pharmacologic elevation of mean arterial pressure (MAP) to augment cord perfusion. However, the relationship between MAP aug...
BACKGROUND AND OBJECTIVES: Management of spinal cord injury includes surgical decompression and pharmacologic elevation of mean arterial pressure (MAP) to augment cord perfusion. However, the relationship between MAP augmentation and spinal cord blood flow remains poorly characterized, and it is unclear whether different adrenergic agents produce differential effects on cord perfusion. Thus, our objective was to directly characterize dynamic spinal cord blood flow responses to controlled MAP perturbations and compare the effects of common vasopressors. METHODS: We developed a Doppler ultrasonography platform to measure dynamic blood flow signals in the sulcal arteries of uninjured porcine spinal cord. Eight female Yorkshire pigs underwent controlled hypotensive challenges using hemorrhage and hypertensive challenges with 4 adrenergic agonists: phenylephrine (α-agonist), dobutamine (β-agonist), norepinephrine (mixed α/β), and epinephrine (mixed α/β). Mean flow velocity (MFV) and mean power Doppler (MPD) were extracted from spectral Doppler recordings and analyzed in relation to step changes in MAP. RESULTS: During hypotensive challenges, reductions in MAP were accompanied by decreases in MFV and MPD, with minimal recovery toward baseline. During pharmacologic MAP augmentation, all agents produced increases in MAP, MFV, and MPD. However, dobutamine produced a greater change in blood flow measures when compared with norepinephrine, phenylephrine, and epinephrine. CONCLUSION: These findings represent the first dynamic measurements of spinal cord blood flow signals in vivo and demonstrate that MAP elevation does not uniformly translate to increased cord perfusion. Pure β-adrenergic stimulation with dobutamine produced a favorable blood flow profile, whereas agents with α-agonist activity may limit effective perfusion through vasoconstriction. This work provides a mechanistic framework for optimizing vasopressor selection in spinal cord injury and lays groundwork for future studies of spinal cord autoregulation.
Reevaluating the Effectiveness of Intracranial Pressure Monitoring in Severe Traumatic Brain Injury: Influence of Withdrawal of Life-Sustaining Treatments.
Lazaridis C, Lo E, Badillo-Goicoechea E … +3 more , Fakhri F, Wisniewski SR, Chesnut RM
Neurosurgery · 2026 Mar · PMID 42335082 · Publisher ↗
BACKGROUND AND OBJECTIVES: To examine the effectiveness of intracranial pressure (ICP)-guided management on mortality and dispositional outcomes of patients with severe traumatic brain injury (sTBI). METHODS: Comparative...
BACKGROUND AND OBJECTIVES: To examine the effectiveness of intracranial pressure (ICP)-guided management on mortality and dispositional outcomes of patients with severe traumatic brain injury (sTBI). METHODS: Comparative effectiveness study with propensity score matching and mediation analysis, using the Trauma Quality Improvement Program of the National Trauma Data Bank from 2017 to 2022. Included sTBI patients with abbreviated injury severity 3 to 5 in the head region and <3 in other regions, Glasgow Coma Scale <9, age 16 to 60 years, and at least one reactive pupil. Matching was based on demographics, presenting clinical characteristics, and preexisting conditions. Exposures: ICP monitoring vs no monitoring. Outcomes: Mortality, hospital discharge disposition, and withdrawal of life sustaining treatments (WLST). Measures: Age, initial blood pressure and oxygen saturation, 24 hours highest Glasgow Coma Scale score, computed tomography midline shift, and pupillary reactivity. Mediators: neurosurgical intervention after the first 24 hours, hospital complications, and WLST. RESULTS: From 10 851 patients, 4769 received ICP monitoring matched with 6082 who did not. Mortality 23.0% ICP monitoring group vs 17.3% for the no-ICP group. ICP monitored patients were more likely to die during their hospital stay (odds ratio [OR] 1.278, CI 1.139-1.434, P < .001, E 1.874). ICP monitored patients were less likely to have a favorable discharge outcome (OR 0.705, CI 0.642-0.775, P < .001, E 2.189). With WLST as the mediator, the direct effect of ICP monitoring on mortality was no longer significant (OR 1.011, CI 0.995-1.030, P = .16); the indirect effect of WLST accounted for most of the total effect of ICP on mortality (proportion mediated 0.714, P -value <.001). CONCLUSION: ICP monitoring was associated with increased mortality and worse discharge outcomes in patients with sTBI. Increased mortality was largely mediated by WLST. These results question the effectiveness of ICP-guided management and highlight the major impact that decisions to WLST have on treatment effects and patient outcomes.
Serum Neuroglobin in Acute Traumatic Brain Injury in Children: A Multicenter Case-Control Study.
Saad K, Abdelmotogaly HSM, El-Ashry AH … +15 more , El-Shokhaiby UM, Bakr MM, Beheiry A, Elkholy WM, Mohamed KR, Hassan AM, Elhoufey A, Elgenidi A, Abdel-Sadek ZM, Aly SE, Hussein WM, Alnusayri A, Abdou MS, Alruwaili TAM, Taha SF
Neurosurgery · 2026 Jun · PMID 42333607 · Publisher ↗
BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) represents a significant cause of morbidity and mortality in children. This study aimed to delineate the temporal profile of serum neuroglobin in children after TBI...
BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) represents a significant cause of morbidity and mortality in children. This study aimed to delineate the temporal profile of serum neuroglobin in children after TBI and to evaluate its utility as a potential biomarker for assessing TBI severity and predicting clinical outcomes in pediatric age groups. METHODS: A multicenter case-control study was conducted involving 110 children with TBI (≤18 years) admitted to 5 tertiary-care hospitals in Egypt. The study included 100 healthy children as a control group. Serum neuroglobin concentrations were measured using enzyme-linked immunosorbent assay at 3 time points: on admission and at 24 and 72 hours thereafter. The temporal kinetics of serum neuroglobin were analyzed in relation to admission Glasgow Coma Scale scores and clinical outcomes assessed 6 months after trauma using the Glasgow Outcome Scale. RESULTS: Serum neuroglobin levels were significantly higher in children with TBI than in controls at admission (P < .001), reached the highest levels at 24 hours postinjury (P < .001), and then declined by 72 hours. Peak serum neuroglobin showed a significant inverse correlation with Glasgow Coma Scale scores (P < .0001), indicating higher levels in more severe injuries. Receiver operating characteristic analysis revealed that peak neuroglobin is a strong predictor of poor outcomes, with area under the curve of 0.89. CONCLUSION: Serum neuroglobin appears to be a promising early prognostic biomarker in pediatric patients with TBI. This preliminary study supports its potential role in early risk stratification. Its rapid rise with a peak at 24 hours postinjury, together with its association with 6-month functional outcomes, supports its potential role in early risk stratification and outcome prediction.
Comparative Analysis of the Prognostic Value of Simpson Grade Versus MRI-Based Extent of Resection Paradigms Across Meningioma Histomolecular Subgroups.
Al-Adli NN, Ehret F, Nguyen MP … +14 more , Choudhury A, Magill ST, Capper D, Kaul D, Haddad AF, Villanueva-Meyer J, Bush NAO, Mirchia K, Lucas CG, Theodosopoulos PV, McDermott MW, Chen WC, Raleigh DR, Morshed RA
Neurosurgery · 2026 Jun · PMID 42333592 · Publisher ↗
BACKGROUND AND OBJECTIVES: Extent of resection (EOR) predicts local freedom from recurrence (LFFR) for meningiomas and is a key clinical trial design parameter. Simpson grade (SG) defines EOR based on intraoperative asse...
BACKGROUND AND OBJECTIVES: Extent of resection (EOR) predicts local freedom from recurrence (LFFR) for meningiomas and is a key clinical trial design parameter. Simpson grade (SG) defines EOR based on intraoperative assessment of tumor removal, but MRI-based methods represent promising alternatives. The aim of this study was to compare the prognostic performance of SG vs MRI-based EOR paradigms for predicting recurrence and survival across histomolecular subgroups. METHODS: International multicenter, retrospective cohort study included 475 meningiomas, resected between 1983 and 2024, which were classified by World Health Organization grade and molecular subgroups (DNA methylation, gene expression, and integrated grade). Area under the curve (AUC) was calculated for LFFR and overall survival (OS) from Cox models with a histomolecular subgroup and an EOR paradigm. Delta AUC (ΔAUC) compared EOR predictive performance within each subgroup, and log-rank comparisons of LFFR and OS were performed. RESULTS: MRI-defined gross total resection was associated with significantly longer LFFR and OS when compared with subtotal resection across most histomolecular subgroups. SG1-3 vs 4 distinguished differences in LFFR across several subgroups, but there were no consistent differences in outcomes when comparing degrees of dural treatment. Multivariable Cox including gene expression groups revealed that volumetric EOR (%) had a significantly higher AUC than SG (ΔAUC 0.07, P = .036) for 5-year OS; otherwise, there were no other differences between MRI-based or SG EOR paradigms for 5-year LFFR or OS. Additional significant differences for predicting 10-year LFFR all favored MRI-based EOR paradigms. CONCLUSION: Although SG and MRI-based EOR paradigms provide similar prognostic performance for predicting LFFR and OS in the era of molecular classification, MRI-based definitions may be preferred for future clinical trial inclusion criteria.
Workflow Patterns and Clinical Consequences of External Ventricular Drain Timing: A 6-Year Analysis of 26 020 Cases From the American College of Surgeons National Trauma Data Bank.
Darabi N, Lauinger AR, Nyaaba W … +5 more , Blake S, Angadi A, Grannie C, Polites GM, Arnold PM
Neurosurgery · 2026 Jun · PMID 42333581 · Publisher ↗
BACKGROUND AND OBJECTIVES: External ventricular drains (EVDs) are critical for monitoring and managing intracranial pressure in acute traumatic brain injury patients. However, there is a lack of consensus on optimal EVD...
BACKGROUND AND OBJECTIVES: External ventricular drains (EVDs) are critical for monitoring and managing intracranial pressure in acute traumatic brain injury patients. However, there is a lack of consensus on optimal EVD placement timing. Previous studies suggest benefits in early placement but are limited by smaller cohorts and lack of adjustment for illness severity. We sought to characterize EVD timing patterns and examine clinical characteristics and outcomes associated with early placement. METHODS: We performed a retrospective study of patients in the National Trauma Data Bank (2018-2023) who received EVD placement for traumatic brain injury. Early EVD was defined as placement ≤24 hours from admission. Multivariable regression models evaluated associations between EVD timing, patient characteristics (demographics, comorbidities, and injury severity), and in-hospital outcomes including mortality, severe sepsis, extended hospitalization (>14 days), ventilator duration, and secondary EVD placement. RESULTS: Of 26 020 patients, 77.3% received early placement. Patients receiving early EVD were independently more likely to be younger and to have lower Glasgow Coma Scale. Placement was delayed in patients with comorbidities such as hypertension, diabetes, smoking, and dementia. Early EVD was associated with higher in-hospital mortality (adjusted odds ratio [aOR] 1.39), with lower mortality odds for each 24-hour delay (aOR 0.96). However, early EVD was also associated with lower odds of severe sepsis (aOR 0.60) and prolonged hospitalization (>14 days) (aOR 0.44). Secondary EVD placement occurred in 8.2% of patients with less frequent and more delayed placement after early first EVD (aOR 0.84). CONCLUSION: Early EVD placement often identifies severe neurological compromise and is associated with higher mortality. However, early placement was also associated with lower complication rates, shorter hospitalization, and fewer and later EVD revisions. These findings suggest early EVD to be both a marker of severe injury and practice pattern reflecting efficient care, underscoring the need for distinguishing procedural benefit from confounding by indication.
Dose De-escalation in Stereotactic Radiosurgery for Melanoma Brain Metastases in Patients on Concurrent Immunotherapy or Targeted Therapy: A Multicenter Experience.
Tos SM, Hajikarimloo B, Mantziaris G … +39 more , Cassimatis ND, Pikis S, Ishaque M, Brantley C, Lunsford LD, Niranjan A, Wei Z, Lohia V, Esquenazi Y, Blanco AI, Amezquita-Contreras C, Becerril-Gaitan A, Picozzi P, Franzini A, Raspagliesi L, Bailey D, Zacharia BE, Benjamin CG, Costa RS, Passos G, Lee CC, Yang HC, Shepard MJ, Wegner RE, Kite T, Peker S, Samanci Y, Sumi T, Kano H, Mathieu D, Blanchard J, Moreno NM, Álvarez RM, Warnick RE, Egnot ML, Dumot C, Protopappa M, Shinya Y, Sheehan JP
Neurosurgery · 2026 Jun · PMID 42333577 · Publisher ↗
BACKGROUND AND OBJECTIVES: The American Society for Radiation Oncology guidelines for stereotactic radiosurgery dose suggestions for brain metastases provide excellent local control but at the expense of higher adverse r...
BACKGROUND AND OBJECTIVES: The American Society for Radiation Oncology guidelines for stereotactic radiosurgery dose suggestions for brain metastases provide excellent local control but at the expense of higher adverse radiation effects (ARE). This study provides evidence that lower single-fraction prescription doses for patients with melanoma metastases who are concurrently receiving immunotherapy or targeted therapy are equally effective and safe. METHODS: This retrospective, multicenter study included 335 patients with melanoma brain metastases who underwent stereotactic radiosurgery between 2009 and 2024. After covariate balancing, 137 patients with 590 metastases were included in the high dose (HD) group and 59 patients with 590 metastases in the reduced dose (RD) group. The RD limits were set at <20 Gy for <2 cm lesions and <18 Gy for ≥2 to <3 cm lesions. RESULTS: After matching, the median diameter (6 vs 5.8 mm, P = .5) and imaging follow-up (6 vs 6 months, P = .13) were comparable. Cumulative incidence of progressing metastases was significantly higher in the HD group compared with the RD group (P < .001) overall, but lower prescription doses resulted in higher progression rates for metastases >2 cm (P = .023). Higher prescription volumes and HD-group prescription doses were linked with local progression in multivariable analysis. Radiographic AREs were significantly more common in the HD group compared with the RD group overall (P < .001) but similar for metastases >2 cm (P = .7). Higher prescription volumes, HD-group prescription doses, and concurrent BRAF or other tyrosine kinase inhibitors were linked with an increased risk of radiographic ARE, whereas concurrent immunotherapy was associated with lower rates of radiographic ARE. CONCLUSION: This study provides evidence that treatment with prescription doses under the currently the American Society for Radiation Oncology-suggested doses for brain melanoma metastases <2 cm is safe, having at least equal local control rate and lower radiographic AREs. Reducing prescription dose for lesions between 2 and 3 cm does not seem to convey reduced ARE rates and could potentially increase local failure.
Treatment of Idiopathic Intracranial Hypertension With Bilateral Trans-stenotic Pressure Gradients: Unilateral Versus Bilateral Venous Sinus Stenting.
El-Hajj VG, Gharios M, Roy JM … +11 more , Musmar B, Momin A, Kim WJ, Rizzuto M, Ellens N, Alshahrani R, Atallah E, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P
Neurosurgery · 2026 Jun · PMID 42307224 · Publisher ↗
BACKGROUND AND OBJECTIVES: Venous sinus stenting (VSS) is an established treatment for medically refractory idiopathic intracranial hypertension (IIH), yet the clinical significance of bilateral trans-stenotic venous pre...
BACKGROUND AND OBJECTIVES: Venous sinus stenting (VSS) is an established treatment for medically refractory idiopathic intracranial hypertension (IIH), yet the clinical significance of bilateral trans-stenotic venous pressure gradients and the optimal stenting strategy in this setting remains poorly defined. METHODS: We retrospectively reviewed prospectively collected data on consecutive IIH patients undergoing VSS at a single institution (2021-2024). Only patients with a trans-stenotic gradient ≥8 mm Hg confirmed by venous manometry were included. Primary outcomes included symptom improvement, overall treatment response, and need for repeat VSS. RESULTS: Ninety-two patients were included, of whom 44 (48%) demonstrated bilateral venous pressure gradients. Bilateral gradients were more prevalent among Black patients (P = .041) but were not associated with differences in lumbar puncture opening pressure, presenting symptoms, or emergent presentation (P ≥ .05). Among patients with bilateral gradients, unilateral stenting was associated with lower rates of satisfactory clinical response (23% vs 74%; P = .002) and higher rates of repeat intervention (62% vs 3.2%; P < .001) compared with bilateral stenting. Tinnitus resolution was significantly more frequent following bilateral stenting (11% vs 68%; P = .005). Clinical outcomes after staged bilateral stenting after failed unilateral treatment were comparable with those achieved with index bilateral stenting. CONCLUSION: Bilateral venous pressure gradients are common in IIH and identify a subgroup in whom unilateral stenting alone may be insufficient. In these cases, up-front bilateral stenting is often necessary, safe, and associated with superior clinical outcomes.
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