Gopakumar A, Bhatia S, McKay W
… +8 more, Frederico SC, Sharma N, Anand SK, Sridhar S, Abou-Al-Shaar H, Mallela AN, Andrews EG, Zenonos GA
Neurosurgery
· 2026 Jun · PMID 42301230
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BACKGROUND AND OBJECTIVES: Patients with trigeminal neuralgia (TN) with concomitant continuous pain constitute a challenging population to treat. Lesioning procedures are associated with high rates of neuropathic pain de...BACKGROUND AND OBJECTIVES: Patients with trigeminal neuralgia (TN) with concomitant continuous pain constitute a challenging population to treat. Lesioning procedures are associated with high rates of neuropathic pain deterioration. Meckel's cave methylprednisolone/bupivacaine injections may afford pain control in this subset of patients with low rates of neuropathic pain deterioration. Our aim was to identify predictors of pain response after methylprednisolone/bupivacaine injections in patients with medically refractory TN with concomitant continuous pain. METHODS: A retrospective analysis of percutaneous methylprednisolone/bupivacaine injections for TN with concomitant continuous pain from 2020 to 2024 with a minimum of 1-year follow-up at a single institution was conducted. Demographics and operative data were collected. The primary outcomes were immediate (at first follow-up) and long-term (at last follow-up) pain relief. Univariate and multivariable Cox proportional hazards regression analysis and Kaplan-Meier survival analysis assessed prognostic factors for immediate and long-term pain relief. RESULTS: A total of 42 patients underwent 54 percutaneous methylprednisolone/bupivacaine injections. No procedures were performed in the setting of active neurovascular compression. Dull pain was the predominant pain component in 55.6% and the minor component in 44.4% of cases. The immediate pain relief rate was 78.4%. On multivariable analysis at the first follow-up, predominantly dull pain predicted improved immediate pain relief (hazard ratio [HR]: 0.26; 95% CI [0.08-0.91]; P = .04), whereas age ≥61 years was associated with a higher risk of persistent immediate pain (HR: 4.93; 95% CI [1.05-23.1]; P = .04). The long-term pain relief rate was 35.2%, resulting in a median pain relief duration of 19.9 months. On multivariable analysis at the last follow-up, only repeat injections were associated with higher risk of inadequate long-term pain relief (HR: 2.84; 95% CI [1.17-6.86]; P = .02). Postoperative transient hypoesthesia was reported in 12.9% of cases. Importantly, no patients had deterioration of the neuropathic pain component. CONCLUSION: Percutaneous methylprednisolone/bupivacaine injections provide effective immediate pain relief for patients with TN with concomitant continuous pain with minimal risk of deteriorating neuropathic symptoms.
Joncas CT, Kristt M, Lee V
… +4 more, Chang YF, Di Stefano G, Truini A, Sekula RF
Neurosurgery
· 2026 Jun · PMID 42300235
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BACKGROUND AND OBJECTIVES: The surgical treatment of trigeminal neuralgia (TN) in young patients is challenging, and there is mixed evidence regarding the efficacy of microvascular decompression (MVD) in this patient pop...BACKGROUND AND OBJECTIVES: The surgical treatment of trigeminal neuralgia (TN) in young patients is challenging, and there is mixed evidence regarding the efficacy of microvascular decompression (MVD) in this patient population. We examined long-term clinical outcomes after MVD in patients with pediatric and young-onset TN. METHODS: Between 2007 and 2023, 22 patients with classical TN symptom onset before age 30 years underwent MVD for TN at or before age 30 years. A retrospective chart review was used to gather information on clinical characteristics, imaging, and long-term outcomes in these patients. RESULTS: Twenty-two patients-15 women (68.2%) and 7 men (31.8%) with a median age at surgery of 26.7 years (range 20-30 years)-underwent MVD for TN: 17 patients experienced purely paroxysmal pain (PPP) (77.3%) and 5 patients experienced concomitant continuous pain (CCP) (22.7%). Nine of 22 patients (40.9%) were immediately pain free without medication following MVD, while 14 of 22 (63.6%) patients were pain free without medication at a median follow-up of 9.38 years, all 14 of whom experienced PPP. Lesser occipital neuralgia occurred in 2 patients (9.1%). Five patients (22.7%) required subsequent procedures for TN during the follow-up period. The absence of CCP was significantly associated with pain freedom without medication at the final follow-up (P = .0021). CONCLUSION: MVD is safe and effective for the treatment of TN in patients aged 30 years or younger who exhibit symptoms consistent with classical TN. However, long-term pain relief may be less likely in young-onset TN patients with CCP compared with those who have PPP.
Hajikarimloo B, Tos SM, Ferguson R
… +59 more, Mantziaris G, Shinya Y, Chan JW, Sneed PK, McDermott MW, Seymour ZA, Grills I, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Bin-Alamer O, Lunsford LD, Niranjan A, Peker S, Samanci Y, Lee CC, Yang HC, Sheehan D, Sheehan K, Liscak R, Chytka T, Alzate J, Kondziolka D, Meng Y, Martinez Moreno N, Martinez Álvarez R, Hallan DR, Fritch C, Jareczek FJ, Sciscent BY, Mathieu D, Carrier L, Abdelsalam A, Starke RM, Benjamin C, Almeida T, Pratap Singh S, Tripathi M, Speckter H, Lazo E, Chen CJ, Esquenazi Y, Becerril-Gaitan A, Amsbaugh MJ, Blanco AI, Upadhyay R, Palmer JD, Franzini A, Picozzi P, Alberto Andrea Lanterna L, Bowden GN, Peterson JL, Warnick RE, Chiang VL, Pikis S, Sheehan JP
Neurosurgery
· 2026 Jun · PMID 42300133
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BACKGROUND AND OBJECTIVES: Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosu...BACKGROUND AND OBJECTIVES: Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosurgery (SRS) is often unsuitable due to constraints on dose-volume toxicity. Volume-staged SRS (VS-SRS) enables sequential dosing of large nidus volumes, potentially enhancing safety while maintaining efficacy. Evidence in children remains limited. We aimed to evaluate outcomes of VS-SRS for large AVMs in pediatric patients. METHODS: A multicenter retrospective cohort was assembled from 21 centers, including patients aged younger than 21 years treated with VS-SRS for AVMs >10 cm3. Clinical and radiological end points included obliteration, hemorrhage, and permanent symptomatic radiation-induced changes (RIC). RESULTS: A total of 103 patients were included (median age 14 years; IQR, 12-17). The median nidus volume at first stage was 18.2 cm3 (IQR, 12.3-25.6). Median prescription dose per stage was 17 Gy (IQR, 16-18). The median clinical follow-up from the first stage was 57.5 months (IQR, 25-138). Obliteration occurred in 42 of 103 patients (40.8%), with actuarial rates of 6.9% (95% CI: 2.8-14) at 3 years and 29% (95% CI: 20-39) at 5 years. Hemorrhage occurred in 17 of 103 patients (16.5%) during follow-up, and permanent RIC was observed in 9 of 103 patients (8.7%). CONCLUSION: VS-SRS is a reasonably safe, selected option for pediatric large-volume AVMs when microsurgical or endovascular cure is not feasible or prudent. Delivering ≥17 Gy per stage while limiting each treatment volume to <15 cm3 supports durable nidus control with acceptable toxicity. VS-SRS represents a key modality in multidisciplinary management of this historically difficult-to-treat population.
Meng Y, Mashiach E, Donahue B
… +5 more, Bernstein K, Silverman JS, Golfinos J, Sulman E, Kondziolka D
Neurosurgery
· 2026 Jun · PMID 42294942
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Stereotactic radiosurgery evolved from the desire to achieve highly precise and accurate target ablation using radiation energy. Over the past 3 decades, the range of indications for stereotactic radiosurgery has expande...Stereotactic radiosurgery evolved from the desire to achieve highly precise and accurate target ablation using radiation energy. Over the past 3 decades, the range of indications for stereotactic radiosurgery has expanded significantly, making it a valuable treatment option-and often a first-line approach-for various intracranial conditions, including benign and malignant brain tumors, vascular malformations, and functional disorders. This narrative review offers a comprehensive, yet not exhaustive, overview of the current evidence, technical considerations, and areas of nuance and controversy regarding these indications and dose selection. It serves as a quick reference guide for neurosurgeons and radiation oncologists working in this field. In addition, tables are included that detail the indications, expected results, dose prescriptions, and anticipated outcomes, assisting clinicians in both clinical settings and procedural planning.
BACKGROUND AND OBJECTIVES: Lumboperitoneal shunt (LPS) is often regarded as a secondary treatment option for various forms of hydrocephalus. While some studies have compared its results to conventional treatments, there...BACKGROUND AND OBJECTIVES: Lumboperitoneal shunt (LPS) is often regarded as a secondary treatment option for various forms of hydrocephalus. While some studies have compared its results to conventional treatments, there needs to be more comprehensive evidence systematically evaluating its isolated outcomes. METHODS: The authors systematically searched the Embase, PubMed, and Web of Science databases to identify articles of patients submitted to LPS. Random effects with single-proportion statistics were used to pool the outcomes. Subanalyses for normal pressure hydrocephalus, communicating hydrocephalus, and idiopathic intracranial hypertension were applied. RESULTS: A total of 49 of 3091 retrieved studies involving 2696 patients submitted to LPS were included in the analysis. Normal pressure hydrocephalus (631), communicating hydrocephalus (693), and idiopathic intracranial hypertension (275) accounted for 1599 cases. The risk of requiring shunt revision was 25% (95% CI: 18%-32%, I2 = 93%). For communicating hydrocephalus, idiopathic intracranial hypertension, and normal pressure hydrocephalus, the pooled revision rate was 21%, 46%, and 10%, respectively. Notably, headaches were reported in 91 patients, with minimal overall risk, but considerable heterogeneity (I2 = 63%). Overdrainage was observed in 119 patients, also showing high heterogeneity (I2 = 75%) but minimal risk. Similarly, tonsillar herniations were observed in 19 patients with minimal risk and significant heterogeneity (I2 = 50%). Infections affected 68 patients at a 1% risk (95% CI: 1%-2%, I2 = 25%). Three patients died from shunt-related complications (0.1%). The main reasons for shunt revisions were obstruction (30% [95% CI: 16%-42%; I2 = 93%]) and shunt migration, slippage, or fracture (20% [95% CI: 13%-28%; I2 = 65%]). CONCLUSION: LPS displays safety across multiple studies, demonstrating acceptable revision and complication rates when compared with ventriculoperitoneal shunts. However, substantial heterogeneity limits the strength of conclusions. There is a compelling argument for Western countries to actively advocate for the integration of LPS into their neurosurgical practices. Further clinical trials are necessary to optimize the management of hydrocephalus.
Tavanaei R, Alikhani A, Fahim F
… +5 more, Khannejad S, Naghizadeh S, Momeni MA, Zali A, Oraee-Yazdani S
Neurosurgery
· 2026 Jun · PMID 42294917
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BACKGROUND AND OBJECTIVES: External ventricular drain (EVD) placement is widely used in neurosurgery for managing elevated intracranial pressure, but EVD-related infections (ERIs) remain a serious complication. Current p...BACKGROUND AND OBJECTIVES: External ventricular drain (EVD) placement is widely used in neurosurgery for managing elevated intracranial pressure, but EVD-related infections (ERIs) remain a serious complication. Current prophylactic strategies, including systemic antibiotics and coated catheters, offer inconsistent protection. This study evaluated the safety and efficacy of prophylactic intraventricular vancomycin and gentamicin, individually and in combination, to prevent ERIs. METHODS: In a four-arm, randomized, double-blind, placebo-controlled trial, 200 patients requiring EVD placement were randomized into 4 groups: vancomycin with gentamicin (group VG), vancomycin (group V), gentamicin (group G), and normal saline as the placebo (group C). Multivariate regression analysis was also performed to identify potential independent predictors of ERI and estimate odds ratios (ORs). RESULTS: No serious adverse event attributable to the study drugs was found throughout the present study. During the study period, a total of 12 (24.0%), 7 (14.0%), 8 (16.0%), and 2 (4.0%) patients developed ERI in groups C, G, V, and VG, respectively. The incidence rate of ERI was significantly different among the study groups (P = .042). In addition, a statistically significant difference was noted among the study groups in duration of EVD placement (P = .032), intensive care unit stay (P = .015), and hospitalization (P = .022), as well as catheter replacements (P = .021) and time-to-infection (P = .045). Multivariate analysis confirmed that combination of vancomycin and gentamicin significantly reduced (OR = 0.083 [95% CI, 0.014-0.471], P = .005) infection odds, while subarachnoid hemorrhage/intraventricular hemorrhage (OR = 6.5 [95% CI 1.7-25.0], P = .006) and immunosuppression (OR = 21.9 [95% CI, 5.0-95.2], P < .001) were independent risk factors for ERI. CONCLUSION: Single-dose prophylactic intraventricular vancomycin-gentamicin combination significantly reduces ERI incidence and improves clinical outcomes, offering a potentially cost-saving and scalable infection control strategy particularly in resource-limited conditions. Future multicenter studies are warranted to confirm these findings.
Chaker AN, Kahn G, Springer K
… +25 more, Jarabek K, Hu J, Schultz L, Schaub N, Yeh HH, Ruesch T, Kim E, Al Tekreeti A, Yeo H, Melhem M, Saad J, Kagithala D, Telemi E, Mansour T, Abdulhak M, Nerenz DR, Taliaferro K, Tong D, Khalil JG, Perez-Cruet M, Easton R, Easton K, Kazemi N, Aleem I, Chang V
Neurosurgery
· 2026 Jun · PMID 42294881
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BACKGROUND AND OBJECTIVES: Given the ongoing opioid epidemic, postoperative opioid dependency prevention in patients undergoing spine surgery is paramount. For these patients, postoperative opioid use at 90 days may be a...BACKGROUND AND OBJECTIVES: Given the ongoing opioid epidemic, postoperative opioid dependency prevention in patients undergoing spine surgery is paramount. For these patients, postoperative opioid use at 90 days may be a significant risk factor of continued opioid use at 1 and 2 years. Since 2022, the Michigan Spine Surgery Improvement Collaborative has set postoperative, morphine milliequivalent (MME) prescribing guidelines for opioid-naïve patients undergoing cervical and lumbar spine surgery. This study evaluated how the implementation of these opioid prescription guidelines effect elective spine surgery outcomes. METHODS: Using the Michigan Spine Surgery Improvement Collaborative database, we identified opioid-naïve patients who underwent elective cervical or lumbar spine surgery and were prescribed postoperative opioids. Patients were grouped according to compliance with MME guidelines, ≤225 MME for cervical and lumbar decompression and ≤320 MME for lumbar fusion surgery. Multivariate analysis was conducted to examine independent relationships between MME cutoff compliance and patient outcomes, controlling for confounding variables. Outcomes included opioid use at follow-up, readmission, emergency department visit, return to work, and patient-reported outcomes related to satisfaction, physical function, and pain. RESULTS: Fifteen thousand nine hundred and three patients were included. Postimplementation, MME compliance rates increased from 63.1%-71.4% to 81.3%-88.5%, depending on surgery type. For all surgeries, MME cutoff compliance significantly reduced the risk of opioid use at 90 days (odds ratio [OR] 0.53, CI 0.40-0.71, P < .001, OR 0.56, CI 0.40-0.77, P < .001, and OR 0.61, CI 0.50-0.74, P < .001, respectively), and at 1 year for lumbar fusion (OR 0.63, CI 0.48-0.84, P = .001). Importantly, no significant differences were observed in patient satisfaction, patient-reported outcomes, or adverse events. CONCLUSION: We conducted the first study demonstrating 1-year clinical outcomes after implementing a statewide MME prescription cutoff in elective spine surgery. Our findings suggest that statewide opioid prescription cutoff guidelines for elective spine surgery can reduce postoperative opioid dependency without hindering patient recovery.
Schulz EL, Bock HC, Flüh C
… +5 more, Kück F, Mielke D, Rohde V, Knerlich-Lukoschus F, Abboud T
Neurosurgery
· 2026 Jun · PMID 42294867
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BACKGROUND AND OBJECTIVES: This retrospective single-center cohort study evaluated the role of early postoperative computed tomography (EPOCT) after pediatric intracranial tumor resection, a practice that remains controv...BACKGROUND AND OBJECTIVES: This retrospective single-center cohort study evaluated the role of early postoperative computed tomography (EPOCT) after pediatric intracranial tumor resection, a practice that remains controversial. Although EPOCT is frequently used to detect early postoperative complications, evidence supporting its routine use in neurologically stable children is limited, and concerns regarding radiation exposure persist. The aim of this study was to assess the clinical relevance of routine EPOCT after elective intracranial tumor surgery in children and adolescents and to identify clinical and perioperative predictors of abnormal imaging findings and emergency return to the operating room (RTOR). METHODS: We included 240 pediatric patients (0-18 years) who underwent elective intracranial tumor resection and received EPOCT within 4 hours postoperatively. Clinical, surgical, and radiological variables were analyzed for associations with abnormal EPOCT findings and RTOR. Multivariable logistic regression and receiver operating characteristic analyses were performed to assess predictive value. RESULTS: No emergency RTOR was triggered by EPOCT findings alone in neurologically stable patients. Abnormal EPOCT findings were identified in 17/240 patients (7.1%). Emergency RTOR occurred in 12/240 cases (5.0%) unrelated to residual tumor; all were associated with postoperative neurological deterioration. Postoperative neurological deficits showed the strongest association with abnormal EPOCT (odds ratio 15.33). Additional significant predictors included surgical duration, preoperative external ventricular drain placement, ventricular size, and perioperative red blood cell transfusion. Neurological examination demonstrated higher sensitivity (100%) and negative predictive value (100%) for predicting emergency RTOR than EPOCT. CONCLUSION: EPOCT after pediatric intracranial tumor resection provides limited therapeutic benefit in clinically stable patients. Postoperative imaging should be applied selectively, guided primarily by neurological deterioration and supported by specific perioperative risk factors. A selective, clinically driven imaging strategy may reduce unnecessary radiation exposure without compromising patient safety.
Patel J, Dunbar A, D'Amico A
… +7 more, Shah T, Olmos M, Kanter M, Ualiyeva S, Kryzanski J, Arkun K, Riesenburger RI
Neurosurgery
· 2026 Jun · PMID 42283495
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BACKGROUND AND OBJECTIVES: Amyloid deposition in the ligamentum flavum (LF) occurs in 25% to 45% of patients with lumbar stenosis (LS). Amyloid-positive LF is associated with greater LF thickness and healthier interverte...BACKGROUND AND OBJECTIVES: Amyloid deposition in the ligamentum flavum (LF) occurs in 25% to 45% of patients with lumbar stenosis (LS). Amyloid-positive LF is associated with greater LF thickness and healthier intervertebral discs on MRI, suggesting an alternative pathophysiologic mechanism for LF hypertrophy may be present in these patients. Whether this increased thickness reflects changes in the LF collagen and elastin composition is unknown. METHODS: LF specimens from 64 patients with LS were analyzed in a case-control design, drawn from a database of 324 consecutive cases with amyloid status confirmed by Congo Red staining and mass spectrometry. Thirty-two amyloid-positive patients were age-matched and diagnosis-matched to 32 amyloid-negative controls. Two adjacent sections per specimen were stained with Masson Trichrome and Verhoeff-Van Gieson stain. Collagen and elastin content were quantified using a random forest pixel classifier developed in QuPath and validated against manual segmentation supervised by a board-certified pathologist. Primary analysis compared the collagen-to-elastin ratio between groups, and secondary analysis compared the individual collagen and elastin content. RESULTS: Both collagen and elastin classifiers agreed with manual segmentation in the Bland-Altman analysis and showed bias of <1% tissue area. Amyloid-positive LF demonstrated a greater collagen-to-elastin ratio of 1.36 compared with 1.05 in amyloid-negative patients (P = .014). This was primarily driven by a lower elastin content, which occupied 7.5% less tissue area in amyloid-positive LF per secondary analyses (P = .008). The average LF thickness at a lumbar level was 0.538 mm thicker on T2-weighted MRI for amyloid-positive patients. CONCLUSION: Amyloid-positive LF exhibits a higher collagen-to-elastin ratio, driven by reduced elastin, suggesting distinct extracellular matrix remodeling in these patients with LS. This ratio may explain the greater LF thickness seen on MRI in amyloid-positive patients. There may be an amyloid-associated pathway contributing to LF hypertrophy in some patients, and further studies of this are warranted.
Gabriel El-Hajj V, Musmar B, Roy JM
… +41 more, El Naamani K, Piper K, Patel S, Kim WJ, Ellens N, Rizzuto M, Alshahrani R, Chen CJ, Jabre R, Saad H, Grossberg JA, Dmytriw AA, Patel AB, Khorasanizadeh M, Ogilvy CS, Thomas AJ, Monteiro A, Siddiqui A, Orscelik A, Savastano L, Cortez GM, Hanel RA, Porto G, Spiotta AM, Piscopo AJ, Hasan DM, Ghorbani M, Weinberg J, Nimjee SM, Bekelis K, Salem MM, Burkhardt JK, Zetchi A, Matouk C, Howard BM, Lai R, Du R, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour P
Neurosurgery
· 2026 Jun · PMID 42283475
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BACKGROUND AND OBJECTIVES: Moyamoya disease (MMD) is a progressive occlusive arteriopathy marked by stenosis of the major cerebral arteries and the development of fragile basal collaterals. Although ischemic and hemorrha...BACKGROUND AND OBJECTIVES: Moyamoya disease (MMD) is a progressive occlusive arteriopathy marked by stenosis of the major cerebral arteries and the development of fragile basal collaterals. Although ischemic and hemorrhagic phenotypes of MMD are well described, comparative evidence evaluating differences in surgical safety and long-term treatment response between these subgroups remains limited. This study aimed to compare perioperative complications and long-term stroke risk after revascularization surgery in patients with ischemic-type vs hemorrhagic-type MMD. METHODS: We conducted a multicenter retrospective cohort study across 13 North American academic centers (2008-2022), including 485 patients with 502 revascularized hemispheres for angiographically confirmed MMD. Hemispheres were stratified by presenting phenotype. Primary outcomes were overall postoperative complications and long-term stroke events. Propensity score matching (2:1) and multivariable logistic regression were used. A sensitivity analysis including only hemispheres with ≥2 years of follow-up was performed. RESULTS: Of 502 hemispheres, 423 (84%) presented with ischemia and 79 (16%) with hemorrhage. Before and after matching, ischemic-onset MMD demonstrated significantly higher overall postoperative complication rates (post-match: 10% vs 2.6%, P = .043). Stroke patterns at long-term follow-up reflected initial presentation: ischemic-onset hemispheres experienced predominantly ischemic recurrences, whereas hemorrhagic-onset hemispheres showed higher rates of hemorrhagic or mixed-pattern strokes (P < .001). In the sensitivity cohort (≥2-year follow-up; mean 78.5 months), hemorrhagic presentation was independently associated with an 8-fold higher risk of long-term stroke, as compared with ischemic presentation (adjusted odds ratio 8.23; 95% CI 1.84-36.8; P = .006). Stroke risk did not differ significantly between hemorrhage subtypes. CONCLUSION: Ischemic and hemorrhagic MMD represent distinct clinical phenotypes with meaningful differences in safety and long-term response to surgical revascularization. Ischemic-type MMD is more prone to postoperative complications, whereas hemorrhagic-type MMD was associated with a substantially elevated long-term stroke risk. These findings underscore the need to consider MMD phenotypes as separate entities when counseling patients, choosing treatment strategies, and initiating long-term surveillance.
Arora V, Sadeghi A, Lim B
… +12 more, Germann J, Shah B, Davidson B, Lipsman N, Buongermini R, Su YH, Ibrahim GM, Pichardo S, Chen R, Lozano AM, Darmani G, Boutet A
Neurosurgery
· 2026 Jun · PMID 42283469
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BACKGROUND AND OBJECTIVES: Motivated by growing literature suggesting that skull density ratio (SDR) has limitations in patient selection and outcome prediction for magnetic resonance‑guided focused ultrasound treatments...BACKGROUND AND OBJECTIVES: Motivated by growing literature suggesting that skull density ratio (SDR) has limitations in patient selection and outcome prediction for magnetic resonance‑guided focused ultrasound treatments, this study sought to systematically review imaging-based alternatives to SDR that have been explored in relation to clinical and technical outcomes. METHODS: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and was registered in the International Prospective Register of Systematic Reviews (CRD420251081059). We searched MEDLINE, Embase, and Scopus from inception to February 2025 for studies evaluating imaging-derived alternatives to SDR in human magnetic resonance‑guided focused ultrasound procedures. Data were extracted independently by 2 reviewers and studies were grouped into 4 categories: skull geometric factors, histogram-based SDR analysis, patient-specific multivariate modeling, and advanced imaging processing. Each category was also assessed for clinical implementation feasibility based on imaging processing complexity, required expertise, and scalability. RESULTS: Of 1684 screened studies, 23 met the inclusion criteria. Skull geometric factors (n = 9), particularly skull thickness and volume, were the most commonly studied and showed consistent associations with both thermal and clinical outcomes. Histogram-based SDR metrics (eg, skewness) occasionally had stronger correlations with outcomes than mean SDR. Multivariate models and advanced imaging showed strong technical correlations but comparatively lower clinical feasibility due to complexity and computing demands. CONCLUSION: Although SDR remains the approved screening metric, our review suggests potential imaging-based alternatives to SDR. Specifically, readily available and implementable metrics such as skull geometric features show promising correlations with clinical and technical outcomes. Other methods, such as multivariate modeling, show promise but will need more time to become validated, accessible, and widely implemented.
Zheng V, Gaily E, Karppinen A
… +3 more, Koroknay-Pál P, Lehtinen H, Metsähonkala EL
Neurosurgery
· 2026 Jun · PMID 42283468
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BACKGROUND AND OBJECTIVES: Drug-resistant epilepsy is defined as failure of 2 appropriately chosen and tolerated antiseizure medications (ASMs), after which referral for surgical evaluation is recommended. However, many...BACKGROUND AND OBJECTIVES: Drug-resistant epilepsy is defined as failure of 2 appropriately chosen and tolerated antiseizure medications (ASMs), after which referral for surgical evaluation is recommended. However, many children undergo additional ASM trials before referral. We aimed to identify preoperative factors associated with a higher number of ASM trials before referral in a nationwide, population-based pediatric epilepsy surgery cohort. METHODS: We conducted a retrospective study of all children (younger than19 years) undergoing resective epilepsy surgery at the national pediatric epilepsy surgery center in Finland between 2002 and 2022. Patients were identified from a prospective surgical registry. Preoperative clinical characteristics, including etiology, seizure frequency, and resection location, were analyzed. Patients were categorized according to ≤3 vs >3 ASM trials before referral. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of referral after >3 ASM trials. Seizure outcomes 2 years after the final surgery were classified using the Engel classification. RESULTS: Among 239 children, the median number of ASM trials before referral was 4.0 (IQR, 3.0); 68% were referred after >3 ASMs. Younger age at epilepsy onset, daily seizures, and extratemporal, multilobar, or hemispheric resections were independently associated with referral after >3 ASM trials. Compared with patients referred after ≤3 ASMs, those referred after >3 ASMs had longer onset-to-referral intervals and were less likely to achieve Engel class 1 (odds ratio 2.0, 95% CI 1.0-3.9, P = .047) and more likely to require reoperation (20.9% vs 5.3%, P = .002). The number of prereferral ASM trials decreased over time. CONCLUSION: In this population-based cohort, most children underwent more ASM trials than recommended before referral for epilepsy surgery. Greater ASM exposure was associated with more severe epilepsy phenotypes. These findings reinforce the importance of timely recognition of drug-resistant epilepsy and consideration of surgical evaluation alongside escalation of ASM trials.
Singh A, Robinson AL, Robinson Y
… +8 more, Rudström J, Lafta MS, Möller AK, Ivars K, Elmi-Terander A, MacDowall A, Olerud C, Gerdhem P
Neurosurgery
· 2026 Jun · PMID 42274420
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BACKGROUND AND OBJECTIVES: The treatment of displaced odontoid type II fractures in the elderly is controversial. The objective of this study was to compare surgical intervention with cervical collar treatment. METHODS:...BACKGROUND AND OBJECTIVES: The treatment of displaced odontoid type II fractures in the elderly is controversial. The objective of this study was to compare surgical intervention with cervical collar treatment. METHODS: This open-label, randomized controlled superiority trial included neurologically intact participants 75 years and older with displaced odontoid type II fractures, randomized to posterior C1-C2 surgery or cervical collar treatment. The primary outcome was Neck Disability Index (NDI) at the 1 year follow-up. Secondary outcomes included the EuroQol 5 Dimensions (EQ-5D) index, EuroQol-visual analogue scale, radiological data and mortality. Between-group comparisons used the Mann-Whitney U test; within-group comparisons used the Wilcoxon signed-rank test. Multiple imputation was used to account for missing data in NDI and EQ-5D index. RESULTS: Forty-seven participants (25 surgical group, 22 cervical collar group) were randomized. Median [IQR] baseline NDI was 40% [18%-60%] in the surgical group and 44% [27%-65%] in the cervical collar group. At 1 year, NDI was 24% [5%-33%] in the surgical group and 34% [8%-50%] in the cervical collar group (P = .29 for group comparison, and P = .028 and P = .16 for within group change, respectively). Median EQ-5D index at 1 year was 0.71 [0.39-0.94] and 0.62 [0.195-1], and EuroQol-visual analogue scale was 70 [45-77.5] and 60 [37.5-75]. Bony union and radiological stability were more frequent in the surgical group. One year mortality was 7 and 3 participants, respectively (P = .3). CONCLUSION: Surgical intervention was not superior to treatment with a cervical collar for displaced type II odontoid fractures.