Neurosurgical Review[JOURNAL]
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200 papers
Surgical selection algorithms and long-term functional outcomes in microsurgical revascularization for complex aneurysms: a six-year analysis.
Acha JL, Contreras L, Santos O
Neurosurg Rev · 2026 Jun · PMID 42287506 · Publisher ↗
Complex intracranial aneurysms represent a significant challenge when their morphology or location limits the use of direct clipping or standard endovascular techniques. In such cases, microsurgical revascularization rem...
Complex intracranial aneurysms represent a significant challenge when their morphology or location limits the use of direct clipping or standard endovascular techniques. In such cases, microsurgical revascularization remains a critical option, although patient selection and strategy optimization are essential to achieve durable outcomes. This study aimed to evaluate long-term functional outcomes and the technical reliability of a hemodynamically driven surgical selection algorithm in patients with complex intracranial aneurysms. We analyzed a consecutive cohort of 29 patients with complex intracranial aneurysms treated between 2019 and 2025. Ruptured aneurysms accounted for 55.2% of cases, while 44.8% were unruptured. Surgical strategies were categorized into three generations of bypass according to anatomical features and cerebral hemodynamic requirements. Functional outcomes were assessed using the modified Rankin Scale (mRS) at discharge and at 1, 3, 6, and 12 months. Longitudinal functional changes were analyzed using the Friedman test, and technical correlations were assessed with the Kruskal-Wallis test. A significant correlation was found between aneurysm diameter and the bypass generation selected (p = 0.0057). Functional outcomes demonstrated a favorable and stable trajectory over time (p < 0.0001). Median mRS improved from 2 (IQR 1-3) at discharge to 1 (IQR 0-1) at 12 months, with 86.2% of patients remaining functionally independent (mRS 0-2) at one year. Ischemic complications occurred in 13.8% of cases; however, intraoperative and follow-up imaging confirmed 100% bypass patency using indocyanine green videoangiography and digital angiography. Microsurgical revascularization is a reliable and effective strategy for managing complex intracranial aneurysms when simpler techniques are not feasible. A hemodynamically guided selection algorithm enables excellent graft patency and supports favorable long-term functional outcomes.
Flow reversal strategy for symptomatic vertebrobasilar dolichoectasia: a single-center experience with ECA-RA-PCA bypass.
Wu M, Tong X
Neurosurg Rev · 2026 Jun · PMID 42286207 · Publisher ↗
Symptomatic vertebrobasilar dolichoectasia (VBD) is associated with an extremely poor natural prognosis and presents significant clinical challenges. This study aims to evaluate the safety and efficacy of a flow reversal...
Symptomatic vertebrobasilar dolichoectasia (VBD) is associated with an extremely poor natural prognosis and presents significant clinical challenges. This study aims to evaluate the safety and efficacy of a flow reversal strategy based on extracranial carotid artery-radial artery-posterior cerebral artery (ECA-RA-PCA) bypass, combined with individualized proximal parent artery intervention, for the treatment of symptomatic VBD. We retrospectively analyzed the clinical data of 23 consecutive patients with symptomatic VBD treated with microsurgery between October 2019 and July 2025. Patients were categorized into ischemia-dominant (n = 13), compression-dominant (n = 8), and hemorrhage-dominant (n = 2) subtypes based on their primary clinical presentation. All patients underwent ECA-RA-PCA bypass. Differentiated treatment strategies were implemented based on clinical subtypes: ischemia-dominant patients mostly received bypass alone (12/13, 92.3%), whereas compression-dominant (6/8, 75.0%) and hemorrhage-dominant (2/2, 100%) patients primarily underwent bypass combined with proximal occlusion. Surgical success was achieved in all cases, with a graft patency rate of 100% intraoperatively and during follow-up. Over a median follow-up of 38 months (IQR 23-51), 69.6% (16/23) of patients achieved radiographic improvement (43.5% with lesion regression and 26.1% with obliteration), with no instances of aneurysm rupture or progression. The median Modified Rankin Scale (mRS) score improved from 3 (IQR 2-4) preoperatively to 2 (IQR 1-4) at the last follow-up. The overall favorable clinical outcome rate was 69.6%; the ischemia-dominant group achieved the highest favorable rate (84.6%), followed by the compression-dominant group (62.5%). Major complications included brainstem infarction (30.4%) and pneumonia (39.1%), both of which occurred at higher rates in the compression and hemorrhage groups. For complex symptomatic VBD unsuitable for conventional endovascular treatment, an individualized flow reversal strategy based on ECA-RA-PCA bypass and clinical subtyping is a feasible and effective therapeutic option, albeit with inherent high surgical risks. This strategy maintains long-term flow patency, promotes benign remodeling of the diseased vessel, and may be associated with favorable long-term neurological outcomes in carefully selected patients.
MIB-1 index predicts low recurrence risk after subtotal resection of meningiomas: a retrospective study of 505 patients.
Joonas L, Jenni M, Miikka K
Neurosurg Rev · 2026 Jun · PMID 42274815 · Full text
The Ki-67/MIB-1 index, a biomarker of cellular proliferation, holds prognostic value. In meningiomas, MIB-1 correlates with recurrence, with a proposed 4.1% cutoff. This study aimed to identify optimal patient groups for...
The Ki-67/MIB-1 index, a biomarker of cellular proliferation, holds prognostic value. In meningiomas, MIB-1 correlates with recurrence, with a proposed 4.1% cutoff. This study aimed to identify optimal patient groups for the MIB-1 proliferation index threshold, hypothesizing improved recurrence prediction within stratified subgroups. We performed a retrospective cohort study of adult patients (≥ 18 years) undergoing primary meningioma resection (2005-2018) with available MIB-1 proliferation index and at least five years of MRI follow-up. Meningiomas of all WHO grades were included. Of 505 patients (median age 59 years) meeting inclusion criteria, 340 (67.3%) were female, with meningiomas predominantly WHO grade I (55.8%) or II (41.6%). subtotally resected (STR) WHO grade I meningiomas account for a total of 58 (20.6%) cases out of all 282 (GTR + STR) surgically treated grade I meningiomas. Of these 58 STR grade I meningiomas, 21 (36%) recurred within the 5-year follow-up period. Among 35 subtotally resected grade I meningiomas with MIB-1 values of ≤ 4%, only four (11%) recurred in five years. In the multivariable analysis, preoperative meningioma volume ((p = 0.02, HR 1.02) per 1 cm increase) and 4% cutoff for MIB-1 ((p = 0.02, HR 3.9) remained significant with respect to 5-year recurrence. Consistent with prior studies, the MIB-1 index of 4% seems to identify a subgroup of meningioma patients with low risk of recurrence. MIB-1 is likely to offer utility especially in designing individualized and less frequent imaging follow-up strategies after resection of WHO grade I meningiomas, where molecular genetics are not defined routinely.Clinical trial number: not applicable.
Endoscopic endonasal surgery for cholesteatomas of the posterior cranial fossa and parasellar region. A challenging pathology for experts.
Shkarubo A, Kutin M, Fomichev D … +7 more , Sharipov O, Chernov I, Andreev D, Donskoy A, Maksyutova G, Konyashin D, Kalinin P
Neurosurg Rev · 2026 Jun · PMID 42271088 · Publisher ↗
Endoscopic endonasal surgery (EES) offers a direct ventral corridor to the skull base, potentially enabling maximal resection of extensive cholesteatomas (epidermoid cysts) in the posterior cranial fossa and parasellar r...
Endoscopic endonasal surgery (EES) offers a direct ventral corridor to the skull base, potentially enabling maximal resection of extensive cholesteatomas (epidermoid cysts) in the posterior cranial fossa and parasellar region. However, outcomes and complications specific to this approach require detailed analysis. A retrospective review was conducted on 34 patients who underwent EES for cholesteatomas of the posterior fossa and parasellar region at a single center from 2011 to 2025 year. Extent of resection (near-total > 95%, subtotal 90-95%), complications, and neurological outcomes were analyzed. Near-total resection was achieved in 65% of cases and subtotal in 35%. The most frequent complications were postoperative cerebrospinal fluid (CSF) leakage (23.5%) and meningitis (23.5%; 33.3% in patients with intradural extension). Rates were significantly higher than for other skull base tumors. Only visual symptoms showed consistent postoperative improvement. New or worsened cranial nerve deficits occurred in 12% of cases. Arrested hydrocephalus requiring shunting developed in 14.7% of patients. The endoscopic endonasal approach is one of the surgical options for patients with cholesteatomas involving the posterior cranial fossa and the chiasmatic-sellar region. However, it is associated with a notably higher risk of CSF leakage and meningitis compared to EES for other pathologies, attributable to the lesion's adhesive and inflammatory characteristics. Furthermore, significant recovery of preoperative neurological deficits (except visual) is uncommon. These findings underscore that indications for selecting this approach must be strictly justified, taking into account the risk of complications.
Spontaneous resorption of disc herniations in adjacent segment after endoscopic spine surgery: Cohort study.
Wang S, Sun K, Li J … +2 more , Chen Y, Shi J
Neurosurg Rev · 2026 Jun · PMID 42268474 · Publisher ↗
BACKGROUND: Although spontaneous resorption of lumbar disc herniation (LDH) has been documented in the literature, its occurrence specifically in adjacent segments following endoscopic spine surgery remains unreported. T...
BACKGROUND: Although spontaneous resorption of lumbar disc herniation (LDH) has been documented in the literature, its occurrence specifically in adjacent segments following endoscopic spine surgery remains unreported. This study aimed to investigate whether spontaneous resorption occurs in adjacent segments after endoscopic discectomy and to evaluate the associated clinical and radiological outcomes. METHODS: A cohort of 91 patients diagnosed with single-segment LDH who underwent endoscopic surgery between 2020 and 2022 was included. Patients were classified into a Herniated group (n = 46) and a Bulging group (n = 45) based on preoperative MRI findings. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score and Visual Analog Scale (VAS). Radiological parameters, including disc height, protrusion volume, lumbar lordosis (Cobb angle), and paraspinal muscle morphology, were measured preoperatively and at final follow-up. Logistic regression was performed to identify predictors of resorption. RESULTS: Both groups showed significant improvements in JOA and VAS scores postoperatively (P < 0.05). At final follow-up, reductions in disc height, lumbar curvature, protrusion volume, and protrusion ratio were observed in adjacent segments. Logistic regression analysis identified age (OR = 1.290, p = 0.009), preoperative protrusion volume (OR = 4.511, p = 0.014), and preoperative lumbar lordosis (OR = 0.481, p = 0.015) as independent predictors of spontaneous resorption. CONCLUSIONS: Spontaneous resorption of adjacent-segment LDH can occur after endoscopic surgery, particularly in younger patients with smaller protrusions and relatively preserved spinal alignment. These findings support a conservative, expectant management approach for asymptomatic or minimally symptomatic adjacent-segment protrusions, potentially reducing unnecessary surgical intervention. LEVEL OF EVIDENCE: III.
Pre-operative MRI-Based Radiomics for Predicting Telomerase Reverse Transcriptase Promoter Mutation Status in Glioma Patients: A Systematic Review and Meta-analysis.
Foodeh T, Korani MA, Teymourzadeh M … +12 more , Hassanpour-Fard-Khor M, Abdollahi Z, Hatami B, Payandeh A, Shojaeshafiei F, Seyed Ebrahimi SM, Fayazbakhsh F, Delshad M, Khodadadi S, Karimi S, Mortezaei A, Shahidi R
Neurosurg Rev · 2026 Jun · PMID 42265510 · Publisher ↗
TERT promoter (TERTp) mutations shape glioma prognosis and therapy, yet tissue testing can be limited by sampling error and surgical inaccessibility. MRI-based radiomics offers a non-invasive alternative. This study aime...
TERT promoter (TERTp) mutations shape glioma prognosis and therapy, yet tissue testing can be limited by sampling error and surgical inaccessibility. MRI-based radiomics offers a non-invasive alternative. This study aimed to quantify the diagnostic accuracy of pre-operative MRI radiomics for predicting TERTp status and compare radiomics-only, clinical-only, and combined models.We conducted a PRISMA-DTA-conformant, PROSPERO-registered systematic review and meta-analysis. PubMed, Embase, Web of Science, and Scopus were searched to 13 October 2025. Eligible studies evaluated MRI-derived radiomics models and reported accuracy on non-training data against a molecular reference standard. Risk of bias was appraised with QUADAS-AI. Bivariate random-effects models pooled sensitivity, specificity, and AUC, prioritizing external test performance when available. Fourteen retrospective studies including 2,863 patients were eligible for systematic review; 13 studies were included in the quantitative meta-analysis. MRI-only radiomics models demonstrated pooled sensitivity of 0.76 (95% CI, 0.66-0.84), specificity of 0.70 (95% CI, 0.63-0.77), and AUC of 0.79 (95% CI, 0.75-0.82), indicating moderate discriminative performance with substantial heterogeneity. Deeks' funnel plot asymmetry test was not significant (p = 0.78). Clinical-only models yielded pooled sensitivity of 0.73 (95% CI, 0.61-0.82), specificity of 0.57 (95% CI, 0.34-0.77), and AUC of 0.73 (95% CI, 0.69-0.77). Combined radiomics-clinical models showed numerically higher pooled performance, with sensitivity of 0.78 (95% CI, 0.70-0.85), specificity of 0.76 (95% CI, 0.67-0.84), and AUC of 0.82 (95% CI, 0.79-0.85), although this finding should be interpreted descriptively rather than as definitive evidence of superiority. Subgroup analyses suggested that classifier type, validation strategy, and feature-extraction software may contribute to performance variability. Sensitivity analysis showed that the overall findings remained broadly stable after excluding the influential study. Pre-operative MRI-based radiomics shows moderate accuracy for predicting TERTp mutation status in glioma. Combined radiomics-clinical models achieved numerically higher performance, but current evidence remains limited by retrospective designs, internal validation, and methodological heterogeneity. These models should be considered adjunctive rather than replacement tools, and prospective multicenter external validation with standardized workflows is required before clinical implementation.
External frontal bone transillumination for frontal sinus mapping in anterior skull base surgery: technical note.
Fiori L
Neurosurg Rev · 2026 Jun · PMID 42260201 · Publisher ↗
BACKGROUND: Accurate identification of frontal sinus boundaries is a critical step in anterior skull base surgery, particularly in transsinusal approaches, as it allows optimization of the surgical bony window while mini...
BACKGROUND: Accurate identification of frontal sinus boundaries is a critical step in anterior skull base surgery, particularly in transsinusal approaches, as it allows optimization of the surgical bony window while minimizing unnecessary bone removal. OBJECTIVE: To describe a simple and reproducible technique of external frontal bone transillumination for intraoperative frontal sinus mapping. METHODS: After bicoronal exposure of the frontal bone, a standard fiber-optic light cable connected to the operating room light source is applied in direct contact with the frontal squama under low ambient light conditions. When properly applied, the frontal sinus appears as a brighter translucent area, allowing accurate delineation of its margins. Postoperative CT imaging was retrospectively reviewed to assess correspondence between the intraoperatively identified margins and the actual anatomical boundaries. RESULTS: Between 2015 and 2024, the technique was applied in 14 consecutive patients undergoing anterior skull base surgery, including olfactory groove meningiomas, post-traumatic anterior skull base cerebrospinal fluid fistulas, and one case of intrasinusal osteoma. In all cases, external transillumination enabled clear identification of frontal sinus boundaries and facilitated creation of an adequate surgical window. Postoperative imaging confirmed correspondence between the planned opening and the actual anatomical extent of the frontal sinus opening. No sinus-related complications or postoperative cerebrospinal fluid leaks were observed. CONCLUSION: External frontal bone transillumination is a simple, fast, and reliable method for intraoperative frontal sinus mapping during anterior skull base surgery. Its ease of adoption and use of routinely available equipment make it a useful adjunct to preoperative imaging for optimizing surgical exposure.
Timing of cranioplasty after decompressive craniectomy and neurological recovery: A systematic review and meta-analysis.
Roa Castro JA, Alfonso-Cedeño DF, Brenner LBO … +3 more , Palavani LB, Bertani R, Ordoñez-Rubiano E
Neurosurg Rev · 2026 Jun · PMID 42260006 · Full text
Decompressive craniectomy (DC) creates a large skull defect that may alter cerebral physiology and impair neurological recovery. Cranioplasty (CP) may reverse these effects and enhance functional and cognitive outcomes;...
Decompressive craniectomy (DC) creates a large skull defect that may alter cerebral physiology and impair neurological recovery. Cranioplasty (CP) may reverse these effects and enhance functional and cognitive outcomes; however, the optimal timing remains uncertain. Prior systematic reviews have been limited in scope and have not fully examined cognitive outcomes, ultra-early CP (< 45 days), or traumatic brain injury (TBI)-specific effects. We conducted an updated. Systematic review and meta-analysis following PRISMA 2020 guidelines, prospectively registered in PROSPERO (CRD420251130762). MEDLINE, Embase, and LILACS were searched. Eligible studies included adults undergoing CP after DC with extractable timing comparisons (early ≤ 90 days vs. late > 90 days). Functional and cognitive outcomes were assessed using validated instruments. Two reviewers independently performed study selection, data extraction, and quality assessment (Newcastle-Ottawa Scale). Statistical analyses were conducted in R (metafor). Twenty-one studies (1682 patients; 691 early, 991 late) were included. CP, regardless of timing, was associated with significant neurological improvement. In post-CP analyses, early CP demonstrated significantly better outcomes across several functional scales, including BI, FIM, and KPS, and across pooled functional scores (SMD = 0.52 [0.21-0.83], I² = 87.2%). Cognitive recovery assessed by MMSE also favored early CP (SMD = 0.57 [0.34-0.79], I² = 0%). In TBI-only analyses, the effect remained significant (SMD = 0.74 [0.32-1.15], I² = 88.5%). Ultra-early CP showed a favorable but non-significant trend. Heterogeneity was substantial across analyses. Cranioplasty after DC is associated with significant functional and cognitive improvement. Early cranioplasty (≤ 3 months) is associated with better neurological outcomes than delayed reconstruction, with consistent effects across functional scales and in TBI populations. While these findings are biologically plausible, causality remains uncertain as evidence remains largely observational and with substantial heterogeneity. Well-designed multicenter randomized trials are needed to define optimal timing and strengthen clinical guidance.
Impact of middle meningeal artery embolization on neurological complications and discharge outcomes in chronic subdural hematoma: A machine learning-based comparative study.
Ghaith AK, Kanbar K, Yang X … +12 more , Radwan H, Amatya B, Rios-Zermeno J, Tang L, Alfonzo-Horowitz M, Ghaith M, Hamadeh N, Khoury JVME, Hamouda AM, Salem MM, Fox WC, Tawk R
Neurosurg Rev · 2026 Jun · PMID 42257776 · Publisher ↗
INTRODUCTION: Chronic subdural hematoma (cSDH) predominantly affects older adults, often those with prior head trauma, anticoagulation therapy, or chronic comorbidities. Traditional management involves surgical evacuatio...
INTRODUCTION: Chronic subdural hematoma (cSDH) predominantly affects older adults, often those with prior head trauma, anticoagulation therapy, or chronic comorbidities. Traditional management involves surgical evacuation; however, middle meningeal artery (MMA) embolization has emerged as a less invasive alternative with the potential for fewer complications. This study compares outcomes of surgical evacuation, MMA embolization, and combination therapy using machine learning to identify predictors of neurological complications and discharge disposition. METHODS: Patients with cSDH from the 2017-2020 National Inpatient Sample (NIS) were categorized into surgical evacuation, MMA embolization, or combined treatment groups. Patient demographics, clinical variables, and outcomes were analyzed. Tree-based classifiers (Random Forest, Decision Tree, LGBM, CatBoost) were employed to predict two primary outcomes: post-interventional neurological complications and home discharge. Model performance was evaluated using classification accuracy and area under the receiver operating characteristic curve (AUC). Feature importance was assessed via minimal depth analysis, and partial dependence plots were used to visualize key predictors. RESULTS: Among 5,754 patients with cSDH, 4,872 underwent surgical evacuation, 726 received MMA embolization, and 156 received both. Surgical evacuation was more common in males, Medicare beneficiaries, and patients with chronic kidney disease or anticoagulant use (all p < 0.05). MMA embolization was more frequent in privately insured patients and urban hospitals. The combined approach was associated with higher rates of neurological and pulmonary complications (p = 0.001), longer hospital stays, and higher total costs (both p < 0.001). MMA embolization showed the highest rate of discharge to home (40.2%, p = 0.004). Among machine learning models, Random Forest achieved the highest accuracy (98.7%), identifying ischemic stroke history, insurance status, age, and treatment type as key predictors of outcomes. Surgical evacuation had the highest predicted complication probability (0.45), while MMA embolization had the lowest (0.20) and the highest predicted home discharge rate (0.58). CONCLUSION: MMA embolization was associated with discharge disposition and neurological complication outcomes after adjustment for measured baseline characteristics; however, these findings should be interpreted as associative rather than causal because treatment allocation was nonrandom and residual confounding from unmeasured radiographic and clinical variables remains possible. Combined surgical evacuation plus MMAE was associated with longer length of stay, higher hospitalization cost, and higher observed neurological and pulmonary complication rates. Model-derived partial dependence findings were exploratory and should not be interpreted as causal estimates or direct observed event rates. Tree-based machine learning models, particularly the Random Forest Classifier, identified ischemic stroke history, insurance status, age, and treatment type as key predictors of outcomes. Prospective multicenter studies incorporating granular clinical, radiographic, procedural, and longitudinal follow-up data are needed to define the comparative effectiveness of MMA embolization and surgical evacuation strategies in cSDH.
Rho-associated kinase inhibitors in cerebral cavernous malformations: a preclinical systematic review.
Uslu I, Senturk E, Celikkiran ZE … +6 more , Kara B, Turkmenel MG, Kilic B, Alomari O, Demir Yangi DD, Yangi K
Neurosurg Rev · 2026 Jun · PMID 42252346 · Publisher ↗
Cerebral cavernous malformations (CCMs) are vascular abnormalities characterized by clusters of dilated capillaries. They are most associated with loss-of-function mutations in three genes (Ccm1, Ccm2, and Pdcd10/Ccm3)....
Cerebral cavernous malformations (CCMs) are vascular abnormalities characterized by clusters of dilated capillaries. They are most associated with loss-of-function mutations in three genes (Ccm1, Ccm2, and Pdcd10/Ccm3). In capillary endothelial cells, mutations activate the Rho-associated coiled-coil-containing protein kinase (ROCK), leading to non-heme iron deposition and lesion formation, thereby contributing to CCM pathophysiology. To address this, ROCK inhibitors are being explored as potential stabilizing therapies in CCM. By reviewing the existing literature, this study aims to provide a descriptive evaluation of their effects on non-heme iron deposition and lesion formation in murine models. This systematic review followed the PRISMA 2020 guideline and was registered in PROSPERO (CRD420251048073). PubMed, Embase, Web of Science, and Scopus were searched from inception to 2 February 2026. Eligible studies included in vivo murine CCM models with mutations in the Ccm1, Ccm2, and Pdcd10/Ccm3 genes. Studies had to evaluate direct ROCK inhibitors, such as fasudil and BA-1049, or indirect modulators of the RhoA/ROCK pathway, such as statins, regardless of dosage, route, or duration, and provide molecular evidence of RhoA/ROCK pathway modulation. The primary outcome was lesion burden, and the secondary outcomes included non-heme iron deposition and ROCK activity. Systematic searches identified 389 records, of which 4 studies were included, demonstrating that fasudil, a ROCK inhibitor, consistently reduced non-heme iron deposition and lesion burden in preclinical CCM models in mice. In Ccm1+/-Msh2-/- mice, fasudil reduced non-heme iron deposition and stage 2 lesions; in Ccm2+/-Msh2-/- mice, fasudil reduced non-heme iron deposition and lesion burden. One study demonstrated that BA-1049 caused a dose-dependent reduction in non-heme iron deposition and lesion burden. Studies have shown that ROCK pathway modulation reduces non-heme iron deposition and lesion burden. Further clinical investigations involving patients with CCM are essential to verify whether these experimental benefits can be reproduced in clinical settings.
The enigmatic occipital emissary vein, foramina, and canals: anatomical study with application to skull base surgery.
Campbell A, Hines B, Baudoin JM … +10 more , Komune N, Donofrio CA, Badaloni F, Fioravanti A, Iwanaga J, Aslam R, Johnson K, Lockwood J, Dumont AS, Tubbs RS
Neurosurg Rev · 2026 Jun · PMID 42252332 · Full text
Compared with mastoid emissary veins, occipital emissary veins have been less studied, and published descriptions of their foramina are inconsistent. This anatomical investigation aimed to clarify their prevalence, morph...
Compared with mastoid emissary veins, occipital emissary veins have been less studied, and published descriptions of their foramina are inconsistent. This anatomical investigation aimed to clarify their prevalence, morphology, and relevance to skull base surgery. Two hundred fifty adult skulls were examined for internal and external occipital foramina. Selected samples were sagittally sectioned through the foramina. Ten latex-injected adult cadaveric heads were dissected, then sagittally cut to visualize intradiploic and intracranial venous courses. Portions of vein and surrounding bone were sent for histology. Four additional dry skulls underwent blue latex injection via internal or external foramina followed by selective removal of the inner or outer table. No foramina were present in 16% of skulls. External foramina were absent in 34% and internal foramina in 22%. External foramina connecting to an internal foramen occurred on the left in 10% and right in 8%, typically forming a diagonal pathway with a descending trajectory. Most external foramina were 1-2 cm from midline; 8% were bilateral. Internal foramina clustered near the internal occipital protuberance. Isolated foramina frequently ended in blind pits. Latex-injected specimens demonstrated internal or external veins in 50% of cases, with two showing an accompanying artery. Injection studies revealed no through-passage but did show diploic spread. External openings of the occipital foramina are unreliable surgical landmarks, as their position does not predict intracranial venous entry. Internal emissary veins may exist without an external foramen and risk injury during dural elevation. Separate internal and external diploic communication systems likely exist.
Trends in mortality and disability-adjusted life years (DALYs) attributable to subarachnoid hemorrhage in South Asia (2000-2023).
Raheem A, Waheed S, Muneer K … +4 more , Khan MW, Shamim MS, Janjua TK, Khan NU
Neurosurg Rev · 2026 Jun · PMID 42249971 · Publisher ↗
This study aimed to analyze two-decade trends in mortality and disability-adjusted life years (DALYs) attributable to subarachnoid hemorrhage (SAH) across South Asian countries, highlighting regional and gender dispariti...
This study aimed to analyze two-decade trends in mortality and disability-adjusted life years (DALYs) attributable to subarachnoid hemorrhage (SAH) across South Asian countries, highlighting regional and gender disparities and informing strategies for stroke prevention and care. Ecological trend analysis using publicly available population-level data from the Global Burden of Disease (GBD) database for the years 2000-2023.Population-level data for five South Asian countries: India, Pakistan, Bangladesh, Nepal, and Bhutan. Age-standardized mortality rates and DALYs per 100,000 population attributable to SAH. DALYs were further stratified into years of life lost (YLLs) and years lived with disability (YLDs). Gender-specific trends and country-level variations were assessed. Between 2000 and 2023, age-standardized rates for SAH showed significant variation in South Asian countries with increasing from 3.2 per 100,000 in 2000 to 4.2 per 100,000 in 2023, marking a 29.5% rise and an average annual percent change of 1.2% (95%CI:1.0-1.4). However, due to population growth and aging, absolute number of SAH related deaths increase from 26,951 to 65,635 deaths. India recorded the highest age-standardized mortality rate (36.1%) and absolute deaths (20,645 to 51,767), followed by Pakistan (25.3%). Bangladesh on the contrary showed a slight decline to 5.6 per 100,000 in 2023. DALY rates increased by 23.9% from 110.4 to 136.8 per 100,000, with an average annual percent change of 0.9% (95%CI:0.7-1.1). India and Pakistan experienced the most significant increases in absolute DALYs (India 851,404 to over 1.8 million and Pakistan 115,227 to 250,736). DALY rate in South Asia increased from 164.8 to 174.5 per 100,000) with average annual percent change of 0.3%. Our study showed both persistent growth and decreasing gender disparity in SAH related mortality and DALYs in South Asia. The age standardized mortality rate was 4.0 per 100,000 for females and 2.5 for males with an absolute difference of -1.5 and a relative difference of -37.2% in 2000. This remained high for females in 2023 at 4.6 and 3.7 for males showing a decrease in absolute difference of -0.8 and the relative difference to -18.0%. The risk factors that are contributing to SAH mortality in South Asia were hypertension, smoking, household air pollution due to solid fuel and body mass index. The burden of subarachnoid hemorrhage in South Asia has increased substantially, with rising age-standardized rates and a marked growth in absolute deaths and DALYs, particularly in India and Pakistan. Although gender disparities have narrowed over time, females continue to experience higher mortality rates than males. Targeted prevention addressing hypertension, smoking, household air pollution, and body mass index is urgently needed to reduce SAH burden in the region.
Transcranial orbital approaches: comparison of the surgical access and the importance of the zygomatic arch removal.
Ozdemir AF, Turkis OF
Neurosurg Rev · 2026 Jun · PMID 42243524 · Publisher ↗
Orbital surgery may be encountered in neurosurgical practice because of the proximity of lesions to cranial structures and potential transcranial extension. Orbital surgery is divided into microsurgical and endoscopic ap...
Orbital surgery may be encountered in neurosurgical practice because of the proximity of lesions to cranial structures and potential transcranial extension. Orbital surgery is divided into microsurgical and endoscopic approaches. Microsurgical techniques can be classified as transorbital or transcranial. To perform these surgical approaches, a thorough understanding of orbital anatomy is essential. Six cadaveric orbits from three silicone-injected adult heads were used in this study. Following a pterional craniotomy and orbitotomy, central, medial, and lateral transcranial approaches were performed to all specimens. Additionally, a modification to the lateral route was introduced. In this study, we discuss transcranial orbital approaches, identifying suitable approaches for specific lesion locations and highlighting their advantages through cadaveric dissections. Moreover, we demonstrate that the accessible surgical space can be expanded by incorporating a modification to the lateral transcranial approach. In orbital surgery, the appropriate surgical technique should be selected based on the lesion's location. Mastery of orbital anatomy is a prerequisite for these procedures, and the surgical exposure can be enhanced using the modifications described in our study.
Safety and efficacy of stereotactic radiosurgery for selected borden type III dural arteriovenous fistulas.
Hirata T, Umekawa M, Shinya Y … +4 more , Hasegawa H, Koizumi S, Katano A, Saito N
Neurosurg Rev · 2026 Jun · PMID 42240877 · Publisher ↗
Stereotactic radiosurgery (SRS) is a treatment option for intracranial dural arteriovenous fistulas (DAVFs); however, its effectiveness in Borden type III remains unclear. This study aimed to clarify clinical characteris...
Stereotactic radiosurgery (SRS) is a treatment option for intracranial dural arteriovenous fistulas (DAVFs); however, its effectiveness in Borden type III remains unclear. This study aimed to clarify clinical characteristics, indications, and outcomes of SRS for Borden type III DAVFs. Patients who underwent SRS between 1990 and 2024 were retrospectively analyzed, including primary SRS and adjuvant SRS after endovascular treatment (EVT) or surgery. Borden type was determined from pre-SRS angiography. Primary outcome was complete fistula obliteration, and secondary outcomes were post-SRS hemorrhage, improvement of DAVF-related symptoms, and radiation-induced complications. Seventeen patients were included, with a median age of 65 years (interquartile range [IQR] 52-75 years) and follow-up of 30 months (IQR 15-75 months). Among five hemorrhagic-onset patients, four underwent EVT and/or surgery before SRS. Primary SRS was performed in six patients (35.3%) for low-flow shunts, and adjuvant SRS in eleven (64.7%) for remnant/recurrent shunts after previous treatment. The median prescription dose was 18 Gy (IQR 18-20 Gy). Complete fistula obliteration was achieved in 13 patients (76.5%), with cumulative 2- and 5-year rates of 60.3% and 76.2%, and no difference between primary and adjuvant SRS (log-rank test, p = 0.340). DAVF-related symptoms improved in five of six patients (83.3%). No post-SRS hemorrhage or radiation-induced complications occurred. In conclusion, SRS could be a safe and effective treatment option for selected Borden type III DAVFs utilized as primary treatment for low-flow shunts or as adjuvant treatment for remnant/recurrent shunts, when other treatment modalities are not indicated.
Early pain relief and segmental realignment after two-stage lateral lumbar interbody fusion (LLIF) with posterior instrumentation in degenerative lumbar pathology.
Ivren M, Ishak B, Ille S … +3 more , Dugas M, Krieg SM, Lenga P
Neurosurg Rev · 2026 Jun · PMID 42240749 · Full text
Two-stage circumferential fusion incorporating lateral lumbar interbody fusion (LLIF) is increasingly used to treat degenerative lumbar disorders, yet evidence on perioperative safety, clinical benefit, and optimal seque...
Two-stage circumferential fusion incorporating lateral lumbar interbody fusion (LLIF) is increasingly used to treat degenerative lumbar disorders, yet evidence on perioperative safety, clinical benefit, and optimal sequencing remains limited. We evaluated clinical outcomes, radiographic realignment, perioperative morbidity, and predictors of complications in patients undergoing staged LLIF with posterior fixation. We retrospectively reviewed 20 patients (mean age 67.7 years) who underwent two-stage lumbar fusion, either LLIF followed by posterior instrumentation or vice versa. We assessed pain (NRS scale), segmental lordosis (SL), blood loss, ICU and hospital length of stay, and complications. Subgroup analysis compared LLIF-first vs. posterior-first sequencing. Logistic regression identified predictors of complications. Patients showed a median age-adjusted Charlson Comorbidity Index [ACCI] of 3.0. LLIF was performed first in 65%. Mean NRS pain scores improved from 6.5 preoperatively to 4.1 after the first stage (p = 0.006) and to 3.1 after the second (p < 0.001). Early pain relief tended to be greater with LLIF-first (ΔNRS - 2.46 vs. - 1.75). Posterior-first sequencing involved more instrumented levels (median 4 vs. 2, p = 0.014), greater blood loss (628.6 vs. 142.3 mL, p = 0.01), and longer hospitalization (18.9 vs. 10.8 days, p < 0.001). LLIF-first yielded greater intervertebral height gain (6.5 vs. 3.7 mm, p = 0.05). SL improved mainly at upper lumbar levels (+ 6.4°). ACCI was the only independent predictor of complications (OR 2.6 per point; p = 0.045). Staged lateral lumbar interbody fusion with posterior instrumentation appears to be a feasible treatment option for complex degenerative lumbar disease, associated with early pain relief and segmental alignment changes. Performing the interbody fusion as the first stage may offer potential advantages; however, these findings should be interpreted cautiously given the small sample size of our cohort.
Stand-alone versus supplemented ALIF: a systematic review and meta-analysis of pseudarthrosis and reoperation rates.
Riechelmann RS, Onishi FJ, Belsuzarri TAB … +2 more , Cavalheiro S, Iunes EA
Neurosurg Rev · 2026 Jun · PMID 42234274 · Full text
Anterior lumbar interbody fusion (ALIF) is widely used for degenerative lumbar disc disease, offering restoration of disc height and sagittal alignment. However, pseudarthrosis remains a relevant complication, and the be...
Anterior lumbar interbody fusion (ALIF) is widely used for degenerative lumbar disc disease, offering restoration of disc height and sagittal alignment. However, pseudarthrosis remains a relevant complication, and the benefit of supplemental posterior fixation over stand-alone constructs is still debated. To compare the incidence of pseudarthrosis following stand-alone ALIF versus ALIF combined with posterior pedicle screw fixation. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD42024581358). PubMed/MEDLINE, Embase, Cochrane Library, and BVS were searched for studies published between 2013 and September 2024. Clinical studies including patients with degenerative lumbar disease undergoing ALIF with at least 12 months of follow-up were eligible. Study selection and data extraction were performed independently by two reviewers. Risk of bias was assessed using the Joanna Briggs Institute (JBI) tool for observational studies and Risk of Bias 2 (RoB 2) for randomized trials. Random-effects models were used to estimate pooled pseudarthrosis prevalence and clinical outcomes. Fourteen studies comprising 917 patients and over 1,000 operated levels were included. The pooled prevalence of pseudarthrosis was 8.17% (95% CI: 5.04-11.31), with substantial heterogeneity (I²=70.8%). Pseudarthrosis rates were numerically higher in stand-alone ALIF (8.95%; 95% CI: 4.54-13.37) compared with ALIF combined with posterior fixation (6.76%; 95% CI: 3.58-9.94), although the difference was not statistically significant (p = 0.429). Significant clinical improvement was observed, with a mean reduction of 4.16 points in VAS and a 24.46-point improvement in ODI. Meta-regression demonstrated no association between pseudarthrosis rates and clinical outcomes. Notably, stand-alone ALIF was associated with a significantly higher risk of reoperation for symptomatic pseudarthrosis (RR 6.8; 95% CI: 1.9-24.5; p < 0.01). ALIF provides substantial pain relief and functional improvement, with a relatively low overall rate of pseudarthrosis. Although stand-alone constructs showed a trend toward higher pseudarthrosis rates without statistical significance, they were associated with a markedly increased risk of reoperation. These findings suggest that, while fusion rates may appear comparable, supplemental posterior fixation may confer greater mechanical reliability and reduce clinically meaningful failure in selected patients.
Lower deep-to-superficial extensor muscle ratio (DSR) as an independent risk factor for early titanium implant subsidence following single-level anterior cervical corpectomy and fusion.
Geng H, Wang H, Li X … +1 more , Zhou F
Neurosurg Rev · 2026 Jun · PMID 42234185 · Publisher ↗
To investigate the impact of cervical paraspinal muscle characteristics on early implant subsidence following single-level anterior cervical corpectomy and fusion (ACCF). A retrospective analysis was conducted on 110 pat...
To investigate the impact of cervical paraspinal muscle characteristics on early implant subsidence following single-level anterior cervical corpectomy and fusion (ACCF). A retrospective analysis was conducted on 110 patients who underwent single-level ACCF with titanium implants. The cross-sectional area (CSA) of paraspinal muscles was measured on preoperative magnetic resonance imaging (MRI), and the deep-to-superficial extensor muscle ratio (DSR) was calculated. Sagittal alignment parameters-including C2-7 sagittal vertical axis (SVA), C2-7 Cobb angle, and C7 Slope (C7S) were also assessed. Patients were stratified into two groups based on implant subsidence (≥ 3 mm segmental height loss [SH loss]). Univariate, multivariate linear and logistic regression analyses were performed to identify risk factors. Implant subsidence occurred in 19 patients (17.3%). No significant differences were found in demographic characteristics between groups. The subsidence group demonstrated significantly lower DSR at the C6 level (C6 DSR, p = 0.001) and higher C7S (p = 0.003) compared to the non-subsidence group. After adjusting for confounding variables, both C6 DSR (p = 0.006) and C7S (p = 0.014) remained significantly associated with SH loss in the multivariate linear regression model. Further multivariate logistic regression identified C6 DSR (p = 0.002) and C7S (p = 0.004) as independent predictors of subsidence. The area under the receiver operating characteristic (ROC) curve (AUC) for the model was 0.810. Reduced C6 DSR and increased C7S are significant independent risk factors for early titanium implant subsidence following ACCF. These findings underscore the importance of cervical extensor muscle balance and sagittal alignment in maintaining implant stability.
Endovascular revascularization for progressive stroke beyond conventional time windows: safety, efficacy, and predictors of technical failure and restenosis.
Du J, Lu Z, Wu D … +5 more , Zhang H, Feng H, Yan S, Tan H, Ma L
Neurosurg Rev · 2026 Jun · PMID 42223689 · Publisher ↗
Progressive stroke (PS) due to intracranial large vessel lesions (LVLs) has limited treatment options. While endovascular revascularization (EVR) is proposed as a salvage therapy, evidence beyond the conventional therape...
Progressive stroke (PS) due to intracranial large vessel lesions (LVLs) has limited treatment options. While endovascular revascularization (EVR) is proposed as a salvage therapy, evidence beyond the conventional therapeutic window is scarce. This multicenter retrospective study evaluated the safety, efficacy, and durability of EVR in PS patients attributable to intracranial LVLs beyond the conventional therapeutic window. We retrospectively analyzed PS patients (NIHSS increase ≥ 4) with intracranial LVLs (severe stenosis > 70% or occlusion), infarct core ≤ 70 mL, and confirmed hypoperfusion who underwent EVR at three centers (2020-2024). Outcomes included technical success, perioperative complications, restenosis, and stroke recurrence. A total of 76 patients (median age 62 years; 71.4% male) were included: with 46 presenting with stenosis and 30 with occlusion. The mean interval from symptom onset to progression was 3.92 ± 1.59 days. Technical success was achieved in 96.1% (73/76) of patients; the three failures were all Mori C lesions with blunt stump morphology on baseline angiography, consistent with chronic occlusions of relatively long duration. Perioperative complications occurred in 7.9% (6/76), with only 2.6% (2/76) resulting in disabling symptoms at discharge. The mean NIHSS score decreased significantly from 10.11 ± 3.43 preoperatively to 5.14 ± 3.07 at discharge (p < 0.001). Over a mean follow-up of 11.9 months, the overall restenosis rate was 22.9% (16/70), with 6.8% (5/70) being symptomatic. Restenosis rates varied significantly by treatment modality: 31.3% for balloon angioplasty alone, 22.6% for self-expanding stents, and 11.5% for balloon-expandable stents (p for trend = 0.041). Critically, within the balloon-expandable cohort, no in-stent restenosis was observed in the drug-eluting NOVA stent subgroup (0/12, 0%), compared to 21.4% (3/14) in the bare-metal Apollo stent subgroup. Smoking was identified as an independent risk factor for restenosis, with continued smoking after EVR associated with significantly higher ISR rates (69.2% vs. 29.4%; OR = 5.40, p = 0.038). The rate of recurrent ischemic events in the target territory was 8.2% (6/73). EVR appears to be feasible, safe and effective in carefully selected PS patients with LVLs beyond conventional time windows. However, long-term durability seems dependent on the revascularization modality, with intracranial DES showing encouraging patency. Additionally, smoking cessation may significantly reduce restenosis risk. These findings support the integration of EVR into the therapeutic options for PS and highlight the necessity of preoperative imaging evaluation. Nevertheless, these results require confirmation in larger prospective studies.
The role of bone flap explantation in the recurrence of surgical site infection after elective craniotomy: A multicenter propensity-matched cohort study.
Lucia K, Schwarzmann T, Ottenhausen M … +6 more , Pollok J, Prinz V, Barth M, Tüttenberg J, Ringel F, Czabanka M
Neurosurg Rev · 2026 Jun · PMID 42223499 · Full text
Surgical site infection (SSI) after craniotomy is a serious complication, and the optimal surgical strategy during revision remains controversial. This multicenter, propensity-matched cohort study compared outcomes betwe...
Surgical site infection (SSI) after craniotomy is a serious complication, and the optimal surgical strategy during revision remains controversial. This multicenter, propensity-matched cohort study compared outcomes between bone flap explantation and reimplantationin revision surgery and identified predictors of reinfection. A total of 160 patients undergoing revision surgery for SSI after elective craniotomy were included; 80 underwent bone flap reimplantation and 80 explantation. Patients were matched for age and FRAIL score. Clinical, radiological, microbiological, and surgical variables were analyzed, and predictors of recurrent SSI were assessed using Cox regression analysis. Recurrent SSI occurred significantly less often after bone flap explantation than reimplantation (18% vs. 49%, p = 0.001). Despite signs of more extensive infection in the explantation group, postoperative hospitalization was shorter (7 vs. 12 days, p = 0.051). Factors associated with reduced recurrence included infection limited to subcutaneous tissue, perioperative antibiotic administration, and shorter post-revision hospital stay. This study offers multicenter evidence that bone flap explantation is associated with substantially lower reinfection rates compared with immediate reimplantation which ultimately can improve outcomes and reduce healthcare burden.
A systematic review of extraocular movement-related schwannomas (CN III, IV, VI). Part II: Surgical outcomes and prognostic factors for postoperative nerve function.
Shibao S, Yoshida K, Morinaga Y … +1 more , Akutsu H
Neurosurg Rev · 2026 Jun · PMID 42219397 · Publisher ↗
OBJECTIVE: Extraocular movement-related schwannomas (EOMS)-arising from the oculomotor (CN III), trochlear (CN IV), or abducens (CN VI) nerves-are rare, and comparative data on nerve-specific surgical outcomes and progno...
OBJECTIVE: Extraocular movement-related schwannomas (EOMS)-arising from the oculomotor (CN III), trochlear (CN IV), or abducens (CN VI) nerves-are rare, and comparative data on nerve-specific surgical outcomes and prognostic factors are limited. This paper represents Part II of a two-part study on EOMSs. While Part I addressed tumor localization, clinical features, and surgical approaches, the present paper focuses on surgical outcomes and prognostic factors for postoperative neurological function. METHODS: Systematic review identified surgically treated EOMS. Of 156 patients found, 117 had complete pre-/postoperative data; with the three institutional cases, 120 patients were analyzed. Variables extracted were tumor size, extent of resection (EOR), cavernous sinus involvement (CSI), and postoperative function of the nerve of origin. Univariate and multivariable logistic regression identified predictors of persistent postoperative origin nerve-related deficits. RESULTS: The cohort comprised 52 CN III (43.3%), 34 CN IV (28.3%), and 34 CN VI (28.3%) tumors. Mean diameter was 30.1 mm. CSI occurred in 43.3% (more frequent in CN III and CN VI). Gross-total resection (GTR) was achieved in 69.2% overall and more often in CN IV (94.1%). Preoperative nerve deficits were present in 73.3%; among these, postoperative improvement occurred in 31.8%. New postoperative palsy developed in 40.6% of patients without preoperative palsy. At final follow-up, persistent nerve-of-origin deficits were present in 60.0%. On multivariable analysis, tumor diameter ≥ 35 mm (OR 2.47, 95% CI 1.06-5.73; p = 0.0354), CSI (OR 2.56, 95% CI 1.05-6.27; p = 0.039), and trochlear origin versus abducens (OR 3.24, 95% CI 1.03-10.1; p = 0.0438) were independently associated with persistent origin nerve-related deficits. CONCLUSION: Persistent nerve-of-origin deficits are common after EOMS surgery. Larger tumors (≥ 35 mm), CSI, and trochlear origin confer higher risk, whereas EOR does not independently determine functional outcome. For high-risk subsets, a function-preserving strategy may better balance tumor control and neurological function.
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