Maroon JC, Wakelin SH, Agarwal N
… +2 more, Friedlander RM, Smith MA
Neurosurgery
· 2026 Jun · PMID 42274419
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BACKGROUND AND OBJECTIVES: Fast boat operators (FBOs) are exposed to thousands of high-G impacts while traveling up to 50 to 60 mph over 1- to 6-foot waves for hours at a time. This represents a potential risk factor for...BACKGROUND AND OBJECTIVES: Fast boat operators (FBOs) are exposed to thousands of high-G impacts while traveling up to 50 to 60 mph over 1- to 6-foot waves for hours at a time. This represents a potential risk factor for repetitive head impacts and traumatic brain injury (TBI). This study evaluates the burden of neurocognitive symptoms among FBOs and their association with a formal TBI diagnosis. METHODS: Two hundred forty-five FBOs were surveyed. The number of months served as an FBO on boat deployments, and the number of respondents diagnosed with TBI during their service were collected. Comparison of exposure and neurocognitive symptom burden between patients with and without TBI was performed through two-sided T-tests and χ2 analyses using Python. RESULTS: One hundred ninety-eight operators (80.8%) responded. Average age was 51.0 ± 10.1. Average years served as an FBO was 12.1 ± 6.4. Average months deployed on fast boats was 91.6 ± 62.9. Ninety operators (45.5%) were medically diagnosed with TBI. TBI diagnosis correlated with the number of years as an FBO (P = .001), months on fast-boat deployments (P = .004), diagnosis of post traumatic stress disorder (P < .001), and diagnosis of cervical spinal stenosis (P = .016). Multiple linear regression analyzing factors associated with neurobehavioral symptom inventory cognitive domain scores showed that TBI was the only factor associated with increased scores (Beta: 1.08, 95% CI: [0.19-1.97], P = .02). CONCLUSION: Our results indicate a significant neurocognitive burden among Special Warfare Combat Crewmen operators; however, compared with the level of symptom burden, relatively few respondents received a formal TBI diagnosis. Physicians caring for FBOs should remain vigilant to ensure that subtle signs of postconcussion syndrome are recognized, return to duty protocols are enforced, and safety measures are adopted to protect FBOs from TBI.
Robertson SE, Ramirez-Velandia F, Mensah EO
… +11 more, Wells JC, Clark WE, Schwartz SA, Lewis KL, Berns HF, Hakes K, Rapoport C, Alnajrani M, Granstein JH, Becker TA, Ogilvy CS
Neurosurgery
· 2026 Jun · PMID 42274255
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BACKGROUND AND OBJECTIVES: Flow diverters (FDs) can induce vascular remodeling in nontarget branches of the circle of Willis (CW), yet the hemodynamic drivers of these changes remain unclear. Using in vitro CW models, fl...BACKGROUND AND OBJECTIVES: Flow diverters (FDs) can induce vascular remodeling in nontarget branches of the circle of Willis (CW), yet the hemodynamic drivers of these changes remain unclear. Using in vitro CW models, flow rate alterations were quantified across both target and contralateral CW branches after FD deployment. METHODS: Four 3-dimensional-printed CW models were created (standard and hypoplastic variants) and integrated into a physiological pulsatile flow loop. Flow rates and pressures were recorded in all major branches before and after sequential deployment of 3 concentric FDs. Eight experiments were performed across the 4 models to capture anatomy-dependent hemodynamic responses. RESULTS: Across all 4 FD configurations, deployment produced significant flow redistribution both in the covered branch and in remote CW vessels. Covered vessels showed progressive flow reductions of up to 14% after 3 FDs, particularly in hypoplastic anatomies. Importantly, contralateral and collateral pathways also demonstrated measurable redistribution: contralateral anterior cerebral artery flow decreased by up to 4.7%, middle cerebral artery flow increased by 2% to 5%, and posterior cerebral artery flow shifted by 3% to 8% depending on the FD location. Several of these compensatory changes reached statistical significance despite occurring in branches not directly covered by the device, underscoring the CW's sensitivity to localized resistance changes. CONCLUSION: FD placement produced significant, anatomy-dependent changes in branch flow rate and pressures. Hypoplastic models exhibited more pronounced redistribution patterns than standard CW anatomy, highlighting the role of baseline vessel diameter. These findings support a mechanistic explanation for clinically reported post-treatment vascular remodeling.
Bétourné A, Texakalidis P, Raheb Khelo R
… +3 more, Campbell M, Sadiq SA, Boulis NM
Neurosurgery
· 2026 Jul · PMID 42263252
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BACKGROUND AND OBJECTIVES: Riluzole is the only treatment known to improve survival in amyotrophic lateral sclerosis (ALS) patients. However, its efficacy and dosing are limited by hepatic toxicity and interindividual ph...BACKGROUND AND OBJECTIVES: Riluzole is the only treatment known to improve survival in amyotrophic lateral sclerosis (ALS) patients. However, its efficacy and dosing are limited by hepatic toxicity and interindividual pharmacokinetic variability. Recent experimental studies in hounds have shown that continuous intrathecal (IT) administration of riluzole is well tolerated and achieves significantly higher spinal cord tissue levels. We report the first 2 human ALS cases treated with IT riluzole. METHODS: A catheter was inserted into the lumbar cistern and advanced to the midcervical region under fluoroscopic guidance and connected to a subcutaneous pump. Therapy was initiated at 0.1 mg/h of riluzole. The infusion rate was gradually increased until it reached a maximum of 4.8 mg/d. RESULTS: The 2 patients tolerated dose escalation and treatment for over 2 years without apparent motor or sensory complications. Patients reported no asthenia, a central side effect often reported as a reason to abandon oral therapy. CONCLUSION: This is the first report of chronic IT riluzole infusion in humans at a dose found to be safe in canines. A phase 1 study is planned to establish the maximum tolerated human dose, followed by a randomized placebo-controlled trial to determine the safety and tolerability of IT riluzole in patients with ALS.
Goyal AD, Gajjar AA, Gupta N
… +2 more, Sbaih O, Paul AR
Neurosurgery
· 2026 Jun · PMID 42262420
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BACKGROUND AND OBJECTIVES: Effective patient education is essential in neurosurgery, but many materials exceed recommended readability levels, which can limit comprehension and informed consent. Simplification can also a...BACKGROUND AND OBJECTIVES: Effective patient education is essential in neurosurgery, but many materials exceed recommended readability levels, which can limit comprehension and informed consent. Simplification can also alter tone, potentially introducing bias. Recent studies have used large language models such as Chat Generative Pre-trained Transformer (ChatGPT) to simplify neurosurgical patient education materials (PEMs), but the impact of this process on sentiment and emotional tone remains unclear. Our objective was to assess the sentiment and emotional tone of neurosurgical PEMs before and after conversion to a lower reading level by ChatGPT. METHODS: A total of 336 neurosurgical PEMs covering stroke, spinal stenosis, hydrocephalus, epilepsy, and pituitary brain tumors were analyzed for readability, sentiment, and emotion. Each was then simplified to a seventh grade level using GPT-4.0. Readability was evaluated using Flesch-Kincaid Grade, Flesch Reading Ease, Gunning Fog Index, Automated Readability Index, Coleman-Liau Index, and Simple Measure of Gobbledygook. Sentiment and emotional tone were described using the Valence Aware Dictionary and sEntiment Reasoner (VADER) algorithm and National Research Council Canada Emotion Lexicon. Paired statistical t-tests assessed the significance of changes. RESULTS: Simplification produced substantial improvements in readability across all 6 indices and all neurosurgical topics (P < .001). Sentiment shifted toward increased positivity, reflected by higher VADER compound scores, more positive tokens, and fewer neutral tokens. Disgust decreased significantly across every topic, whereas sadness, surprise, and joy increased modestly; fear and anger showed no significant change. Topic-level analyses mirrored global patterns, demonstrating consistent directional effects. Overall, simplification achieved large readability gains while introducing small but measurable alterations in emotional tone. CONCLUSION: The decrease in neutral and negative sentiment suggests a shift toward more persuasive language. Modest but consistent shifts in sentiment and emotional tone accompanying artificial intelligence-assisted simplification highlight the potential for unintended affective shifts during artificial intelligence simplification and warrant monitoring when deploying large language models for patient-facing materials. Current PEMs pose a communication barrier between patient and provider, but providers must be careful.
Uppalapati SC, Godzik J, Harmon DK
… +7 more, Okor M, Walker HC, McGregor KM, Vazquez do Campo R, Earley CJ, Hadley MN, Holland MT
Neurosurgery
· 2026 Jun · PMID 42262376
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BACKGROUND AND OBJECTIVES: Lumbar laminectomy is routinely performed for neurogenic claudication and radicular pain from lumbosacral stenosis. Restless legs syndrome (RLS) causes nocturnal discomfort with sleep disruptio...BACKGROUND AND OBJECTIVES: Lumbar laminectomy is routinely performed for neurogenic claudication and radicular pain from lumbosacral stenosis. Restless legs syndrome (RLS) causes nocturnal discomfort with sleep disruption and can coexist with lumbosacral radiculopathy. We evaluated whether laminectomy in patients with neurologist-diagnosed RLS and imaging-confirmed root compression is associated with RLS symptom resolution. METHODS: We performed a retrospective 1:1 propensity-matched cohort study (158 laminectomy, 158 nonoperative) with a prospectively assessed subset. The primary outcome was complete RLS resolution, defined as symptom absence and discontinuation of RLS pharmacotherapy. Secondary outcomes included International Restless Legs Scale (IRLS) scores, levodopa equivalent daily dose, Oswestry Disability Index, and pain recurrence in the surgical cohort. RESULTS: Complete RLS resolution occurred in 74% of surgical patients vs 23% of nonsurgical patients (risk ratio 3.16; P < .001). In the prospectively assessed subset, baseline IRLS was similar (25.0 ± 6.2 vs 24.0 ± 7.1), but follow-up scores were lower after laminectomy (6.0 ± 7.3 vs 17.0 ± 8.1; P < .001). A total of 78% vs 35% achieved ≥50% IRLS reduction. Levodopa equivalent daily dose decreased in surgical patients (140.0 ± 40.5 to 25.0 ± 45.8 mg/day) but increased in nonoperative patients (145.0 ± 45.7-153.0 ± 87.1 mg/day; P < .001). A total of 70% vs 24% discontinued dopaminergic therapy. Oswestry Disability Index improved more after laminectomy (mean change -13.6 ± 18.1 vs -5.9 ± 16.7; P < .001). Pain recurred in 29.1% of surgical patients. Lack of RLS resolution was associated with higher pain recurrence risk (hazard ratio 2.06; 95% CI 1.13-3.77). CONCLUSION: In patients with RLS and lumbosacral root compression, laminectomy was associated with improvements in RLS symptoms, decreased medication burden, and durability of pain relief, in addition to its conventional analgesic benefits. RLS symptom burden may represent an under-recognized dimension of outcome in spine surgery and supports routine RLS assessment when considering decompression.
Wang B, Budde MD, Raju VB
… +3 more, Koch KM, Banerjee A, Vedantam A
Neurosurgery
· 2026 Jun · PMID 42262370
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BACKGROUND AND OBJECTIVES: Demyelination and axonal injury are the principal pathological substrates in degenerative cervical myelopathy (DCM) and vary with duration of symptoms. Distinguishing potentially reversible and...BACKGROUND AND OBJECTIVES: Demyelination and axonal injury are the principal pathological substrates in degenerative cervical myelopathy (DCM) and vary with duration of symptoms. Distinguishing potentially reversible and persistent microstructural spinal cord injury is expected to improve prognostication of postsurgical outcomes. In this study, we aimed to determine how symptom duration modulates the prognostic value of quantitative MRI measures of demyelination and axonal injury. METHODS: DCM patients from a single academic medical center underwent presurgical quantitative cervical spinal cord MRI as well as baseline and postsurgical (3 months after surgery) functional assessments. Demyelination was quantified using magnetization transfer ratios (MTR) both above and below the level of maximum spinal cord compression, and axonal injury was quantified using filtered diffusion weighted imaging (Daxial). Linear mixed effects models were used to determine the prognostic value of quantitative MRI and the effect of symptom duration on the prognostic value of each MRI metric. RESULTS: Sixty-five patients (median age 63 years, 60% male) were included. Baseline symptom scores and hand dexterity were significantly associated with white matter MTR rostral to the level of maximum cord compression and white matter Daxial at the caudal level. Longer symptom duration attenuated the association between rostral MTR and dexterity recovery (β = -0.27, 95% CI: [-0.52, -0.02], P = .043) but strengthened the association between caudal Daxial, dexterity (β = -7.83, 95% CI: [-13.00, -2.66], P = .003) and modified Japanese Orthopedic Association score recovery (β = 3.32, 95% CI: [0.40, 6.24], P = .025). CONCLUSION: In patients with DCM, symptom duration modulates the relative prognostic contributions of demyelination and axonal injury. Myelin integrity was the dominant predictor of baseline function and postsurgical recovery, particularly rostral to the level of compression and in earlier disease, whereas axonal injury was increasingly prognostic with longer symptom duration, more prominently at the caudal level.
Piano M, Vitiello A, Lozupone E
… +36 more, Remida P, Cristaudo C, Politi MA, Mardighian D, Ferrara M, Iannucci G, Santini PM, Cerini P, Quinto F, Paladini A, Pauciulo A, Micieli C, Ferrara V, Delehaye L, Monti I, Lazzarotti GA, Cosottini M, Bergui M, Di Paola F, Patassini M, Burdi N, Quillici L, Arpesani R, Romi A, Bracco S, Allegretti L, Pedicelli A, Zimatore DS, Limbucci N, Menozzi R, Ruggiero M, Buonomo O, Romano DG, Besana M, Giordano F, Valvassori L
Neurosurgery
· 2026 Jun · PMID 42257491
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BACKGROUND AND OBJECTIVE: Flow diverter devices have revolutionized the treatment of intracranial aneurysms, but evidence on newer-generation devices remains limited. The Surpass Evolve (SE) was designed to improve deliv...BACKGROUND AND OBJECTIVE: Flow diverter devices have revolutionized the treatment of intracranial aneurysms, but evidence on newer-generation devices remains limited. The Surpass Evolve (SE) was designed to improve deliverability and vessel wall apposition compared with its predecessors. This registry aimed to evaluate the feasibility, safety, and efficacy of SE in a large, real-world multicenter cohort with long-term follow-up. METHODS: Between May 2019 and December 2022, 275 consecutive aneurysms in 272 patients were treated with the SE flow diverter across 28 Italian centers. Clinical and imaging follow-up was completed by January 2024. Mid-term (≤6 months) and long-term (≤24 months) follow-ups, including clinical assessment, angiography, and cross-sectional imaging (computed tomography/magnetic resonance), were systematically collected and independently reviewed by a central Core Lab. RESULTS: The mean maximum diameter of the aneurysm was 11.2 mm, and the mean neck size was 5.4 mm. A total of 258 aneurysms were unruptured (93.8%), and 17 (6.2%) were ruptured. The majority arose from the anterior circulation (87.6%), with 12.4% in the posterior circulation. Device deployment was unsuccessful in 5/278 procedures (1.8%), and misdeployment occurred in 28/278 (10%). The overall device-related mortality was 0.7%, and the morbidity was 5.4%. At mid-term follow-up, complete or near-complete occlusion was achieved in 66% of aneurysms, increasing to 92% at long-term. According to mass criteria, 82% of aneurysms were considered cured, whereas sac enlargement occurred in 0.5% and 17% remained unchanged in volume. CONCLUSION: Our experience using SE for endovascular treatment of intracranial aneurysms showed a high safety and efficacy profile, substantially equivalent to that of the other flow diverter devices commonly used.
Anisman EJ, Mandloi S, Alani A
… +15 more, Kaplan Z, Bitner BF, D'Souza G, Alapati R, Shing SR, Benedict PA, Bray D, Naamani KE, Gooch MR, Farrell C, Toskala E, Rosen M, Rabinowitz M, Evans JJ, Nyquist GG
Neurosurgery
· 2026 Jun · PMID 42240359
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BACKGROUND AND OBJECTIVES: Spontaneous cerebrospinal fluid (CSF) leaks are often secondary to elevated intracranial pressure (ICP). Successful closure of a CSF leak does not treat the underlying elevated ICP. Thus, after...BACKGROUND AND OBJECTIVES: Spontaneous cerebrospinal fluid (CSF) leaks are often secondary to elevated intracranial pressure (ICP). Successful closure of a CSF leak does not treat the underlying elevated ICP. Thus, after repair, patients may continue to have symptoms and develop a recurrent CSF leak. Treatment options for elevated ICP include diuretics, weight loss, ventriculoperitoneal shunting (VPS), and venous sinus stenting (VSS). We present one of the largest series to include surgery, VPS, and VSS for the management of spontaneous CSF leaks in the modern era. METHODS: A retrospective review of spontaneous anterior or lateral skull base CSF leaks treated with surgery was conducted. Radiographic imaging, lumbar puncture opening pressures, and outcomes were studied to develop a treatment algorithm. RESULTS: One hundred ninety patients underwent surgery for a spontaneous CSF leak between 2005 and 2025. Elevated ICP was managed with VPS in 34.2% (n = 65) of patients, VSS in 5.8% (n = 11) of patients, and a combination of VPS and VSS in 2.1% (n = 4) of patients. Postoperative CSF leak occurred in 4.2% of patients who underwent repair. These patients did not undergo VPS or VSS. After VPS and/or VSS placement, there was one CSF leak recurrence. After VPS, 26% of patients experienced a complication. There were no complications after VSS in our cohort. CONCLUSION: Surgical closure of skull base defects followed by management of elevated ICP is a successful treatment approach for spontaneous CSF leaks. The proposed algorithm supports obtaining lumbar puncture opening pressures at the time of surgery and trans-stenotic pressure gradients after surgical closure in patients with dural venous sinus stenosis on imaging to guide medical and surgical recommendations for elevated ICP.
Harland TA, Silva J, Ortiz S
… +7 more, Velez J, Barats M, Paul A, Dalfino J, Boulos A, Field N, Entezami P
Neurosurgery
· 2026 Jun · PMID 42240333
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BACKGROUND AND OBJECTIVES: Chronic subdural hematoma care is evolving beyond burr holes and craniotomy to minimally invasive options such as subdural evacuating port system (SEPS) and middle meningeal artery (MMA) emboli...BACKGROUND AND OBJECTIVES: Chronic subdural hematoma care is evolving beyond burr holes and craniotomy to minimally invasive options such as subdural evacuating port system (SEPS) and middle meningeal artery (MMA) embolization. The optimal initial strategy and role of combined SEPS and MMA remains uncertain. The aims of this study were to compare outcomes after SEPS alone, MMA embolization alone, and combined SEPS and MMA and to assess the effect of hematoma size and antithrombotic therapy on treatment durability. METHODS: We conducted a retrospective cohort study of patients with chronic subdural hematoma treated at a single level 1 trauma center between January 2021 and March 2024. Patients were categorized by initial intervention (SEPS, MMA, or combined SEPS and MMA). Outcomes included treatment failure, radiographic worsening ≤6 months, clinical improvement, length of stay, and discharge disposition. Subgroup analyses were stratified by hematoma thickness (<20 vs ≥ 20 mm) and by anticoagulant (AC)/antiplatelet (AP) use, including timing of resumption. RESULTS: Among 220 patients (SEPS 149, MMA 31, combined 40), the median hematoma size was 20 mm and differed by treatment (SEPS 21 mm, MMA 16 mm, combined 17.5 mm; P < .001). Treatment failure occurred in 23.6% overall (SEPS 26.8%, MMA 16.1%, combined 17.5%; P = .09). The Kaplan-Meier test suggested greater durability for MMA and combined therapy (log-rank P = .088). Among smaller hematomas (<20 mm), MMA had the lowest observed failure rates, while outcomes converged for larger hematomas (≥20 mm). In the AC/AP subgroup (N = 104), MMA-based strategies trended toward lower failure rates and were associated with earlier and more frequent AC/AP resumption compared with SEPS. CONCLUSION: MMA embolization, whether performed alone or with SEPS, was associated with favorable durability and facilitated earlier AC/AP resumption. MMA alone trended toward lower failure rates in smaller collections, while combining SEPS with MMA achieved comparably durable outcomes in larger or more complex cases. Prospective, size-stratified trials are warranted to validate these findings.
Perdikis B, Palla A, Goff NK
… +6 more, Khan HA, Rai S, Budimlija Z, Lau D, Frempong-Boadu A, Laufer I
Neurosurgery
· 2026 Jun · PMID 42240329
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BACKGROUND AND OBJECTIVES: Intramedullary spinal cord tumor (IMSCT) resection carries a high risk of postoperative neurological deficit because of neural tract manipulation and myelotomy. Although short-term and long-ter...BACKGROUND AND OBJECTIVES: Intramedullary spinal cord tumor (IMSCT) resection carries a high risk of postoperative neurological deficit because of neural tract manipulation and myelotomy. Although short-term and long-term neurological recovery represent key treatment outcomes, current prognostication methods are lacking and would benefit from further complex analysis. METHODS: From March 2009 to August 2025, all adult IMSCT resections at our institution were reviewed. Demographic, oncologic, and perioperative data were extracted from electronic medical records. This included preoperative and follow-up neurological examination data in the form of American Spinal Injury Association Impairment Scale (AIS) grading, Modified McCormick Scale (MMCS), and ambulatory status. Independent ambulation served as the primary outcome for 4 machine learning models. Each model was sequentially evaluated using area under the receiver operating characteristic curve (AUROC). RESULTS: Fifty-four patients underwent 55 surgeries for IMSCT resection. Encapsulated lesions predominated IMSCT pathology, with grade II ependymoma comprising 28 (50.9%) resections, 5 hemangioblastomas (9.1%), and 5 cavernous hemangiomas (9.1%). Gross total resection was achieved in 36 cases (65.5%), with encapsulated tumors more readily achieving gross total resection vs unencapsulated (84.6% vs 18.8%, P < .01). By 4 weeks, conversion of MMCS, but not AIS grade, significantly correlated with concurrent ambulatory conversion (P < .01 vs P = .15). At 6 months, both AIS grade conversion (P < .01) and MMCS conversion (P < .01) significantly correlated with ambulatory conversion. For predicting ambulation at latest follow-up from 4 weeks postoperatively, the comprehensive granular model achieved an AUROC of 0.833, outperforming the AIS grade (0.583), American Spinal Injury Association Motor Score (0.667), and MMCS (0.667) models. By the 6-month follow-up, the comprehensive granular model achieved strong discrimination (AUROC 1.00). CONCLUSION: Follow-up IMSCT data demonstrate a postoperative lability that stabilizes by 6 months into a reliably modeled outcome. By enhancing the granularity of recovery data, accurate independent ambulation modeling may improve counseling for patients with IMSCT.
Neurosurgery
· 2026 Jun · PMID 42233682
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BACKGROUND AND OBJECTIVE: Risk stratification for unruptured intracranial aneurysms largely relies on meta-analyses that synthesize heterogeneous primary data. However, fundamental differences in study design, particular...BACKGROUND AND OBJECTIVE: Risk stratification for unruptured intracranial aneurysms largely relies on meta-analyses that synthesize heterogeneous primary data. However, fundamental differences in study design, particularly between cross-sectional rupture-status analyses and prospective natural history cohorts, may influence the reported associations between aneurysm morphology and rupture risk. This umbrella review aimed to determine the extent to which study design affects these associations and whether the current evidence base supports clinically interpretable estimates of rupture risk. METHODS: An umbrella review of systematic reviews and meta-analyses (1999-2025) was conducted across PubMed, Embase, and Scopus. Methodological quality was assessed using AMSTAR-2. Effect estimates for aneurysm size, location, and selected morphometric parameters (irregular shape, aspect ratio, size ratio) were descriptively compared between meta-analyses of prospective cohorts (incident rupture risk) and cross-sectional rupture-status studies. RESULTS: Seventeen meta-analyses encompassing more than 200 000 aneurysms were included. Moderate overlap among studies was observed (corrected covered area 8.9%), with high redundancy among natural history cohorts and minimal overlap in computational modelling studies. Effect estimates for morphological variables were generally larger in cross-sectional rupture-status syntheses than in prospective analyses. However, prospective data incorporating standardized quantitative morphometric assessments were limited, event rates were low, and potential selection bias constrained causal interpretation. Machine learning and radiomics studies predominantly focused on rupture status rather than time-to-event risk and rarely underwent external validation. CONCLUSION: Reported associations between aneurysm morphology and rupture vary substantially according to study design. Cross-sectional rupture-status analyses and prospective natural history studies address different clinical questions and should not be interpreted interchangeably. The current evidence base is further constrained by the scarcity of contemporary prospective cohorts integrating standardized morphometric assessment. Advancing clinically meaningful rupture risk stratification will require large-scale prospective natural history studies capable of supporting externally validated, time-to-event prediction models that incorporate morphology in a standardized and biologically interpretable framework.
de Souza DN, Frome S, Wen Q
… +10 more, Suryadevara CM, Sen RD, Pinheiro-Neto CD, Lieberman SM, Lebowitz RA, Placantonakis DG, Sen C, Golfinos JG, Gardner PA, Pacione DR
Neurosurgery
· 2026 Jun · PMID 42233665
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BACKGROUND AND OBJECTIVES: Little is known about how accelerated discharge strategies compare with established enhanced recovery pathways after endoscopic endonasal surgery (EES). This study aimed to evaluate the efficac...BACKGROUND AND OBJECTIVES: Little is known about how accelerated discharge strategies compare with established enhanced recovery pathways after endoscopic endonasal surgery (EES). This study aimed to evaluate the efficacy and safety of an accelerated discharge protocol after EES. METHODS: This was a retrospective analysis of adults who underwent EES for pituitary adenomas at a single academic center between 2012 and 2025. Patients were managed under 1 of 4 postoperative pathways dependent on year of surgery: (1) No institutional protocol; (2) First-generation recovery protocol; (3) Enhanced recovery after surgery (ERAS); and (4) Expedited one-day discharge. Demographic and clinical variables were extracted from the electronic medical record using automated natural-language-processing methods. Primary outcomes were length of stay (LOS) and 30-day all-cause readmission or reoperation. All data processing, visualization, and statistical analyses were performed using Python version 3.12. RESULTS: Six hundred patients who underwent 630 surgeries were included. Median LOS was 3 days, with a 30-day readmission rate of 14.3% and a 30-day postdischarge reoperation rate of 2.5%. LOS differed significantly across protocol eras, with progressively shorter hospital stays observed over time and the shortest median stay occurring under the expedited discharge protocol (P < .0001). Readmission rates were highest in the preprotocol (16.2%) and initial protocol periods (17.2%), declining to 8.3% under the ERAS protocol and 10.0% under the expedited discharge protocol (P = .039). 30-day postdischarge reoperation rates did not statistically differ across protocols. In multivariate analyses, both the ERAS (rate ratio = 0.899, P = .021) and expedited discharge protocols (rate ratio = 0.819, P = .024) demonstrated significantly shorter hospital stays compared with the preprotocol era, without differences in 30-day readmission or reoperation rates. CONCLUSION: The expedited discharge protocol safely shortened hospital stays without increasing 30-day readmissions or reoperations. These findings support the feasibility of accelerated postoperative pathways after EES. Broad adoption has the potential to produce substantial resource savings without compromising patient safety.
Singh RD, van Dijck JTJM, den Boogert HF
… +5 more, de Ruiter GCW, Depreitere B, Chesnut RM, van Essen TA, Peul WC
Neurosurgery
· 2026 Jun · PMID 42223273
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The notorious Queen vs Dudley and Stephens case highlights the persistent potential conflict between safeguarding individual rights and serving the collective good, a dilemma that also arises in clinical research. Doctor...The notorious Queen vs Dudley and Stephens case highlights the persistent potential conflict between safeguarding individual rights and serving the collective good, a dilemma that also arises in clinical research. Doctors face the challenge of providing the best possible care for each patient while contributing to medical progress through randomized clinical trials. A key concept is equipoise: Fried emphasized personal uncertainty, whereas Freedman proposed clinical equipoise, grounded in professional disagreement among experts. In neurosurgery, strong personal preferences, time-sensitive decisions, and limited evidence deepen these challenges, often reducing trial participation. The clinical judgment principle offers a potential solution by combining community-based and individual perspectives, allowing patient enrollment when both treatments are considered medically reasonable. This balanced approach supports ethical neurosurgical trials while promoting scientific advancement and protecting patient interests.
Cross KA, Koenig E, Wei W
… +5 more, Whipple LR, Melin M, Tolossa M, Bari A, Pouratian N
Neurosurgery
· 2026 Jun · PMID 42223261
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BACKGROUND AND OBJECTIVES: MRI-guided focused ultrasound (MRgFUS) thalamotomy is an effective therapy for contralateral upper extremity tremor, but outcomes are variable across patients. In addition, speech, sensory, mot...BACKGROUND AND OBJECTIVES: MRI-guided focused ultrasound (MRgFUS) thalamotomy is an effective therapy for contralateral upper extremity tremor, but outcomes are variable across patients. In addition, speech, sensory, motor, and gait side effects can be more common acutely after MRgFUS thalamotomy than after deep brain stimulation to the same target. Using objective quantification with inertial measurement units and a digitizing tablet, we performed an observational cohort study to identify sources of outcome variability, relationships between efficacy and side effects, and objective measures of gait dysfunction after MRgFUS. METHODS: Gait, static balance, and tremor were assessed in 54 patients (7 with Parkinson disease, 47 with essential tremor) immediately before and within 48 hours after MRgFUS therapy. RESULTS: Tremor efficacy was robust for contralateral tremor, with postural, rest, and spiral-drawing demonstrating greater improvement than finger-to-nose task. Patients with more severe tremor had greater reduction but also greater residual tremor. Ipsilateral postural but not kinetic tremor improved, albeit to a small degree. Side effects were unrelated to tremor benefits. Gait asymmetry increased after the procedure on average; however, no specific gait features explained the subjective gait imbalance that was reported by 70% of patients. CONCLUSION: Tremor efficacy depends on task and pretreatment severity. A lack of relationship between efficacy and side effects suggests that robust tremor reduction may be achieved without side effects and that improved targeting has potential to improve the safety of MRgFUS.