Author: cba

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Robotic Spine Surgery: Systematic Review of Common Error Types and Best Practices

Operative Neurosurgery 28:295–302, 2025

• Robotic systems enhance accuracy in pedicle screw placement, reducing complications and hospital stays.

• Common errors in robotic spine surgery include registration, skiving, and interference errors.

• Registration errors occur due to imaging discrepancies or unexpected intraoperative movements.

• Skiving errors result from sliding of drilling instruments, often due to poor entry points.

• Interference errors arise from unintended interactions with soft tissue or robotic system malfunctions.

• Best practices include meticulous preoperative planning and careful patient positioning to minimize errors.

• High BMI and female sex are risk factors for screw deviation due to bone quality issues.

• Modern systems use sharp burrs to reduce skiving by ensuring smooth entry points.

• Soft tissue management is crucial to prevent interference errors during surgery.

• Intraoperative imaging helps confirm accurate screw placement, reducing registration errors.

• Screw failure rates: Registration errors (60%), skiving errors (26.8%), interference errors (19.5%).

• Newer robotic systems show improved accuracy but still face challenges with registration errors.

• Study limitations include varied resources, surgeon experience, and subjective error reporting.

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Aneurysm Wall Enhancement Can Predict Rupture Point in Intracranial Aneurysms With Multiple Blebs

Neurosurgery 96:593–599, 2025

• Aneurysm Wall Enhancement (AWE) can predict rupture points in intracranial aneurysms with multiple blebs.

• Vessel Wall MRI (VW-MRI) is used to visualize ruptured aneurysms, showing characteristic AWE.

• Higher AWE is associated with ruptured blebs, while lower wall shear stress (WSS) is observed in ruptured versus unruptured blebs.

• CRstalk (contrast ratio of the aneurysm wall against the stalk) is a significant predictor of rupture status, with higher values indicating ruptured blebs.

• AWE is independent of WSS in predicting rupture status and can guide treatment strategies.

• Study limitations include its retrospective nature and small sample size; future studies with high-resolution MRI are suggested.

• Clinical value: AWE helps determine which aneurysm to treat first, especially in cases with multiple aneurysms, improving surgical safety.

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Wartime penetrating traumatic brain injury of the anterior skull base involving the paranasal sinuses: a single-center, first-year experience from Dnipro, Ukraine

J Neurosurg 142:829–838, 2025

• Study Focus: The study explores wartime penetrating traumatic brain injuries (pTBIs) involving the anterior skull base and paranasal sinuses during the first year of the Russian-Ukrainian war.

• Objective: To identify factors associated with favorable short-term outcomes and survival in patients with pTBIs.

• Methodology: A single-center retrospective review was conducted on patients treated at Mechnikov Dnipropetrovsk Regional Clinical Hospital in Ukraine.

• Key Findings: High Glasgow Coma Scale (GCS) scores, favorable injury lateralization, and low Injury Severity Scores (ISS) were linked to better short-term outcomes.

• Treatment Protocol: The study implemented early primary neurosurgical treatment, including debridement and skull base reconstruction, which showed promising early results.

• Patient Outcomes: 84% of patients achieved a favorable outcome, with low rates of postoperative complications like CSF leaks and infections.

• Comparison with Other Conflicts: The study highlights differences in management strategies compared to US military experiences in Iraq and Afghanistan.

• Limitations: The study lacks a direct comparison group and long-term outcomes are not available due to follow-up challenges.

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Tobacco Use and Trigeminal Neuralgia: Clinical Features and Outcome After Microvascular Decompression

Neurosurgery 96:667–672, 2025

• Tobacco use affects trigeminal neuralgia (TN) outcomes: Smokers with TN tend to develop symptoms at a younger age and have worse long-term outcomes after microvascular decompression (MVD) surgery compared to nonsmokers.

• Smokers show more widespread facial pain: TN in smokers is associated with a more widespread distribution of facial pain, suggesting a more severe form of the disease.

• Immediate postoperative outcomes similar: There is no significant difference in immediate postoperative outcomes between smokers and nonsmokers, although smokers are less likely to be pain-free in the long term.

• Potential benefits of smoking cessation: Patients with a remote history of smoking have outcomes similar to those who never smoked, indicating potential benefits of quitting smoking before surgery.

• Study limitations: The study is a single-center retrospective analysis and may not be generalizable to all TN patients or those undergoing different treatments.

• Implications for treatment: Findings suggest the need for presurgical counseling and support for smoking cessation to improve outcomes for TN patients undergoing MVD.

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Prone Lateral Transpsoas Approach to the Spine: A Technical Guide for Mastery

Int J Spine Surg 2025, 19 (S1) S19-S27

• The prone lateral transpsoas (PTP) approach offers an alternative to traditional lateral lumbar interbody fusion (LLIF), allowing direct posterior access without repositioning the patient.

• Advantages of PTP include improved segmental lordosis, single-position surgery, and ease of posterior techniques, though it has a distinct learning curve.

• The technical guide aims to shorten the learning curve, optimize surgical workflow, and ensure patient safety through preoperative planning and technical adjustments.

• Preoperative imaging is crucial for assessing anatomical characteristics and guiding surgical approach decisions.

• Patient positioning in PTP involves prone positioning on a radiolucent table, with special attention to stabilizing the pelvis and optimizing working angles.

• Intraoperative monitoring with triggered electromyography (t-EMG) is essential to minimize lumbar plexus injury risk.

• Technical pearls include strategies for retractor positioning, minimizing retraction time, and using intraoperative navigation to enhance safety and efficiency.

• Conclusion: PTP LIF is a viable alternative to traditional methods, offering significant benefits but requiring mastery of its unique technical nuances.

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Lateral Transpsoas Interbody Fusion

International Journal of Spine Surgery, Vol. 19, No. S1, 2025, pp. S7–S18

• The lateral transpsoas approach to lumbar interbody fusion is widely adopted for various indications, offering benefits like disc height restoration and alignment correction, despite its risks such as bowel and vascular injury.

• XLIF (Extreme Lateral Interbody Fusion) is a minimally invasive technique introduced in 2006, primarily for degenerative disc disease, and has since expanded for other spinal conditions.

• The approach’s benefits include preserving the anterior and posterior longitudinal ligaments and creating a stable mechanical environment for alignment correction.

• Risks and complications include potential nerve injuries with variable incidences, anterior thigh pain, and vascular injuries, especially at L4-L5 levels due to anatomical constraints.

• Preoperative imaging and patient positioning are crucial for safety, involving detailed assessments of neurovascular structures and careful positioning to minimize risks.

• Intraoperative neuromonitoring is essential for protecting the lumbar plexus, with multimodal approaches recommended for enhanced safety.

• Outcomes of the approach have shown reliable fusion rates and significant improvements in pain and function, making it a valuable tool in spine surgery.

• Training and technique precision are critical for minimizing complications and maximizing the benefits of this minimally invasive approach.

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Is multilevel MIS-TLIF with bilateral facetectomy a lordosing procedure?

J Neurosurg Spine 42:158–168, 2025

• Objective: The study aimed to evaluate the outcomes of 3-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and its effect on sagittal balance, particularly in patients with different preoperative segmental lordosis (SL) values.

• Methods: A retrospective analysis of 47 patients who underwent 3-level MIS-TLIF was conducted, with a focus on radiological and clinical outcomes.

• Surgical Techniques: The procedure involved using bullet-shaped static polyetheretherketone cages filled with autologous bone graft and demineralized bone matrix (DBM).

• Results: Patients with a preoperative SL ≤ 27° showed significant improvements in spinopelvic parameters, while those with SL > 27° had insignificant changes.

• Clinical Outcomes: All patients reported clinical improvements, as evidenced by the Oswestry Disability Index and visual analog scale scores.

• Conclusions: The study concluded that 3-level MIS-TLIF can effectively improve sagittal balance, especially in patients with a smaller preoperative lordotic curve.

• Implications: The findings suggest that MIS-TLIF is beneficial for restoring lumbar alignment and improving clinical outcomes in specific patient groups.

• Limitations: The study’s limitations include a small sample size and lack of a control group, which may affect the generalizability of the results.

 

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Lateral compartment of the cavernous sinus from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

• Objective: The study investigates the lateral compartment of the cavernous sinus (CS) and its surgical relevance in adenoma surgery using the endoscopic endonasal approach.

• Methods: Dissection was performed on 22 colored silicone-injected specimens to identify anatomical landmarks and techniques for mobilizing the internal carotid artery (ICA).

• Findings: The lateral compartment is divided into two subcompartments, with the upper housing the lateral parasellar ligament (LPL) and inferolateral trunk (ILT), and the lower containing sympathetic nerve branches.

• LPL and ILT: The LPL was identified in 86% of hemispheres, with varying configurations, and the ILT was found in 93%, primarily originating from the horizontal ICA segment.

• Techniques: Transection of the LPL, ILT, and COM facilitates medial ICA mobilization, enhancing access to the lateral compartment.

• Conclusions: The study underscores the anatomical intricacies of the lateral compartment and the potential benefits of the lateral transcavernous approach.

• Limitations: The study’s findings are based on cadaveric dissections, which may not fully replicate live surgical conditions.

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Improved clinical and radiographic outcomes with expandable cages in transforaminal lumbar interbody fusion

J Neurosurg Spine 42:147–157, 2025

• Expandable cages improve clinical and radiographic outcomes in TLIF compared to static cages.

• Patients with expandable cages experienced greater increases in segmental lumbar lordosis (SL).

• Expandable cages resulted in fewer readmissions and less adjacent-segment disease (ASD).

• Lower estimated blood loss (EBL) with expandable cages, but similar operative times.

• No significant differences in intraoperative or perioperative complications between cage types.

• Patients with expandable cages were more likely to be symptom-free at last follow-up.

• Expandable cages showed persistent improvements in radiographic parameters over time.

• Propensity score matching used to create comparable cohorts for analysis.
• Study focused on one or two-level open TLIF procedures to reduce heterogeneity.

• Expandable cages allow for better restoration of SL without the need for complex surgeries.

• Study limitations include absence of randomized controlled trials and short follow-up durations.

• Findings may not apply to minimally invasive TLIFs or multilevel surgeries.

• Data collected retrospectively from Brigham and Women’s Hospital from 2016 to 2023.

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Gamma Knife Radiosurgery for Hypothalamic Hamartoma: A Multi-Institutional Retrospective Study on Safety, Efficacy, and Complication Profile

Neurosurgery 96:426–437, 2025

• Study Overview:

•Retrospective multicentric study on 39 patients with hypothalamic hamartomas (HH).

•Mean age of patients was 16 years, with a range from 6 months to 53 years.

•Ethical clearance obtained for data sharing from participating centers.

• Treatment Details:

•Gamma Knife Radiosurgery (GKRS) used with a median margin dose of 16 Gy.

•Target volume median was 0.55 cc, ranging from 0.1 to 10.00 cc.

•Majority of patients received ≥16 Gy targeting complete HH.

• Seizure Outcomes:

•55.2% achieved good seizure control (Engel I/II).

•44.8% were in Engel III/IV status.

•No significant difference in seizure outcomes based on prescribed dose.

• Complications and Side Effects:

•Two patients developed new onset hormonal deficiency.

•No new onset visual deterioration observed.

•Eight patients experienced a transient increase in seizures.

• Endocrinological Impact:

•17.9% of patients presented with both precocious puberty (PP) and epilepsy.

•No significant change in endocrinological profile post-radiosurgery.

• Follow-up and Long-term Effects:

•Median follow-up duration was 5 years.

•Regression in hamartoma volume observed in 28% of patients.

•Long-term follow-up essential for observing significant outcomes

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MRI‑guided laser interstitial thermal therapy in epilepsy: indications, technique and outcome in an adult population. A single‑center data analysis

Acta Neurochirurgica (2025) 167:39

• MRI-guided Laser Interstitial Thermal Therapy (MRIgLITT) is explored as a treatment for drug-resistant epilepsy (DRE), offering a minimally invasive alternative to open surgery.

• The study conducted a retrospective analysis of 32 MRIgLITT procedures at a single center, focusing on seizure control and cognitive outcomes.

• Patient Demographics: 28 patients with various pathologies, including hippocampal sclerosis (HS), hypothalamic hamartoma (HH), and focal cortical dysplasia (FCD).

• Outcomes: High rates of seizure freedom were observed, particularly in HS and HH patients, with Engel I outcomes achieved in a significant portion.

• Cognitive Changes: 71.44% of patients showed cognitive stability or improvement one year after the procedure.

• Advantages of MRIgLITT: Offers quicker recovery, better cognitive preservation, and is effective for deep or complex epileptic foci.

• Challenges: The relationship between clinical factors and outcomes remains unclear, necessitating further large-scale studies.

• Methodology: The procedure involves precise trajectory planning and real-time MRI monitoring to ensure accurate ablation with minimal impact on surrounding tissues.

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Surgical Strategy for Dumbbell-Shaped Cervical Schwannoma at the Vicinity of the Vertebral Artery

Operative Neurosurgery 28:165–174, 2025

• Objective: The study proposes a surgical strategy for preserving the vertebral artery (VA) during the excision of dumbbell-shaped cervical schwannomas using anatomic layers, specifically the perineurium.

• Methods: A retrospective analysis was conducted on 37 patients who underwent surgery for cervical schwannomas from January 2004 to July 2023.

• Results: The perineurium acted as a protective barrier during surgery, preventing VA injury in most cases. Gross total resection was achieved in 67.6% of patients.

• Complications: VA injury occurred in one patient, but no new neurological deficits were reported post-surgery.

• Subperineurial Dissection: This technique is crucial for safeguarding adjacent structures and preventing VA injury.

• Residual Tumor Management: Residual tumors were observed in some cases, with regrowth occurring near the neural foramen requiring secondary surgery.

• Conclusion: Subperineurium dissection is a vital strategy in preventing VA injury during schwannoma resection.

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Association of Global Ultraviolet Radiation With the Incidence of Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 96:396–401, 2025

• Study Focus: The research investigates the association between global ultraviolet (UV) radiation and the incidence of aneurysmal subarachnoid hemorrhage (SAH).

• Inverse Correlation: A significant inverse correlation between UV radiation and SAH incidence was found, suggesting higher UV exposure is linked to lower SAH rates.

• Methodology: Data from 32 countries were analyzed using UV indices from the Tropospheric Emission Monitoring Internet Service, with statistical analyses performed using R and Excel.

• Geographic Variations: The study found significant regional differences, with higher UV indices in Europe associated with lower SAH incidences, but this was not significant in non-European countries.

• Biological Implications: UV radiation may reduce inflammation, potentially decreasing the risk of aneurysm rupture, and may also boost vitamin D synthesis, which is linked to improved immune response.

• Limitations: The study faced limitations, including lack of data from some countries and inability to assess seasonal influences due to variability in study periods.

• Conclusion: The findings suggest that environmental factors like UV exposure may influence SAH incidence, warranting further investigation into potential therapeutic implications.

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Management of incisional cerebrospinal fluid leak in open cranial surgeries and the “folding technique” in duraplasty

Neurosurg Focus 58(2):E7, 2025

• The study focuses on the management of incisional cerebrospinal fluid (CSF) leaks in open cranial surgeries, emphasizing the “folding technique” in duraplasty as an alternative to conventional methods.

• The incidence of iatrogenic incisional CSF leaks was found to be 1.8% among 2149 patients who underwent open cranial surgeries between 2019 and 2024.

• Conservative methods like resuturing and acetazolamide were initially used for CSF leak management, but more invasive procedures like lumbar external drainage (LED), external ventricular drainage (EVD), or surgical reexploration were required when these methods failed.

• The folding technique in duraplasty is highlighted as an effective method for achieving watertight closure, reducing the risk of CSF leakage.

• The study noted that patients who underwent radiotherapy had a longer interval between surgery and leakage onset, suggesting a potential risk factor for delayed CSF leakage.

• Meningitis was a complication in 23.1% of patients with CSF leaks, and the study underscores the importance of maintaining a watertight dura to prevent such complications.

• The study concludes that the folding technique could be a worthy replacement for conventional suturing techniques in dural repair, potentially lowering morbidity associated with CSF leaks.

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Hook Fixation at Uppermost Instrumented Vertebra +1 Reduced Proximal Junctional Failure in Adult Patients With Spinal Deformity Having Achieved Optimal Deformity Correction by Sagittal Age-Adjusted Score

Neurosurgery 96:308–317, 2025

• Study Focus: The study investigates risk factors for proximal junctional failure (PJF) in elderly patients undergoing spinal deformity surgery despite achieving optimal sagittal correction.

• Methodology: Retrospective analysis of patients aged 60+ who underwent ≥5-level spinal fusion, focusing on those achieving optimal sagittal correction relative to the sagittal age-adjusted score (SAAS).

• Key Findings: High body mass index (BMI), high lumbar distribution index (LDI), and absence of hook fixation at UIV + 1 are significant risk factors for PJF.

• Statistical Analysis: Multivariate analysis confirmed these risk factors, with BMI and LDI showing significant predictive power for PJF development.

• Clinical Implications: Managing BMI, LDI, and ensuring hook fixation at UIV + 1 could reduce PJF rates, even with optimal sagittal correction.

• Limitations: The study’s generalizability is limited by the predominance of patients with UIV in the lower thoracic spine and inconsistent use of preventive methods.

• Conclusion: Proper management of identified risk factors, along with optimal sagittal correction, may further decrease PJF incidence.

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A taxonomy for cerebellar cavernous malformations: subtypes of cerebellar lesions

J Neurosurg 142:380–393, 2025

• A novel taxonomy for cerebellar cavernous malformations (CMs) is proposed, introducing six distinct subtypes based on anatomical location.

• The study was conducted over a 25-year period and involved 143 cerebellar CMs treated microsurgically.

• The subtypes include suboccipital, tentorial, petrosal, vermian, tonsillar, and deep nuclear lesions.

• Favorable neurological outcomes were achieved in 91% of cases, with a mean follow-up of 37.4 months.

• Surgical approaches were guided by the CM subtypes, aiming to minimize tissue transgression and preserve function.

• Complete resection was achieved in 94% of cases, with no significant differences in outcomes between subtypes.

• The taxonomy aids in selecting craniotomy and approach to enhance patient safety and optimize outcomes.

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Intracranial Arteriovenous Malformations During Pregnancy and Puerperium

Neurosurgery 96:346–355, 2025

Study Overview

• Focus: Brain AVM during pregnancy and puerperium.

• Method: Retrospective cohort study in Finland from 1987 to 2016.

• Data Sources: National Hospital Discharge Register, Medical Birth Register, and AVM registry.

Key Findings

• AVM Rupture: Occurred mostly in the second and third trimesters.

• Previous Pregnancies: Most women with AVM rupture had previous pregnancies.

• Treatment Timing: 35.7% received treatment during pregnancy or puerperium.

• Outcomes: No significant difference between treated and conservatively managed mothers.

Maternal and Fetal Outcomes

• Maternal Mortality: Last AVM-related fatality during pregnancy was in 1988.

• Newborn Health: Most had favorable outcomes, with Apgar scores similar between groups.

• Delivery: Average gestation at delivery was 38 weeks.

Clinical Implications

• Management: Multidisciplinary approach recommended for AVM treatment during pregnancy.

• Research Needs: More studies needed on AVM rupture risk related to delivery method.

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Genomic Alterations in Molecularly Defined Oligodendrogliomas

Neurosurgery 96:328–337, 2025

• Study Focus: Genomic alterations in oligodendrogliomas using standardized NGS panels.

• Key Genes: CIC, FUBP1, and TERTp are the most frequently altered genes.

• Patient Cohort: Retrospective analysis of 95 patients with NGS reports.

• Methodology: Kaplan-Meier plots and log-rank tests for survival analysis.

• Findings: CIC alterations linked to reduced PFS at earlier time points.

• Additional Genes: NOTCH1 and PIK3CA show potential prognostic value.

• Clinical Implications: Potential integration of genomic alterations into clinical practice.

• Future Research: Larger studies needed to validate findings.

• Seizures: Most common presenting symptom in patients.

• Treatment: Majority underwent surgery followed by observation.

• Tumor Grade: Predominantly WHO grade 2 at first surgery.

• Mutation Analysis: 435 cancer-related genes analyzed.

• Statistical Tools: MATLAB R2022b used for analysis.

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Clinical Predictors of Overall Survival in Very Elderly Patients With Glioblastoma: A National Cancer Database Multivariable Analysis

Neurosurgery 96:373–385, 2025

• Study Focus: The study analyzes clinical predictors of overall survival in very elderly patients (aged 80 and older) with glioblastoma, using data from the National Cancer Database.

• Patient Demographics: It includes 578 very elderly patients and 2836 elderly patients (aged 65-79), highlighting differences in insurance status and treatment patterns.

• Treatment Patterns: Very elderly patients are less likely to receive gross total resection (GTR), radiotherapy (RT), or chemotherapy (CT) compared to younger elderly counterparts, despite these treatments improving overall survival.

• Survival Outcomes: GTR, RT, and CT are associated with improved survival in very elderly patients, suggesting aggressive treatment may benefit selected patients.

• Statistical Methods: The study employs multivariable regression analysis and Cox proportional-hazards models to assess the effects of age and treatment on survival.

• Key Findings: Aggressive treatment approaches, including GTR, RT, and CT, should be considered for very elderly patients, aligning with patient and family goals.

• Limitations: The study acknowledges limitations in meeting the Cox proportional hazard assumption and suggests further research on quality of life post-treatment.

• Conclusion: The study supports offering standard multimodal treatment protocols for glioblastoma to patients aged 65 and older, enhancing external validity across the U.S.

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Characteristics of optic canal invasion in the large midline nontuberculum sellae anterior skull base meningiomas and the surgical outcomes

Acta Neurochirurgica (2025) 167:31

There is a lack of available data regarding the incidence and characteristics of optic canal invasion (OCI) in large midline non-tuberculum sellae anterior skull base meningiomas (NTSAM), specifically those originating predominantly from the olfactory groove and planum sphenoidale. This study aims to describe the incidence and characteristics of OCI as well as clinical and visual outcomes following extensive tumor resection with optic canal exploration in intra-optic canal tumor removal. In addition, the predictive performance of OCI by preoperative magnetic resonance imaging (MRI) is investigated.

Materials and methods From 2016 to 2024, we retrospectively reviewed 24 patients with large midline NTSAM who underwent extensive tumor resection in our institution. The OCI was evaluated and compared between preoperative MRI and intraoperative findings. The OCI was classified as follows. Type 1 represented no invasion, type 2 represented secondary invasion, type 3 represented partial wall invasion (two subtypes), and type 4 represented invasion into the superior-medialinferior walls of the optic canal. Visual functions were assessed before and after surgery.

Results Among 24 patients, a mean tumor size of 57.2 mm (range 39.0–79.0). The OCI was observed intraoperatively in 22 cases (91.7%), with 19 cases exhibiting bilateral OCI. Among the 48 optic canals in the 24 patients, 18 (37.5%) were type 4, 12 (25.0%) were type 3-inferomedial, 9 (18.8%) were type 3-superomedial, and 2 (4.2%) were type 2, where 7 (14.6%) optic canals were without OCI. A significant correlation was observed between intraoperative OCI and the tumors that exhibited involvement of the tuberculum sellae (TS) on MRI (p < 0.001). For patients with visual impairment, the vision in 27 of 38 (71.1%) eye sides showed improvement following the surgery. There was 1 (4.2%) case of tumor recurrence at the mean follow-up time of 27.3 months (range 4–73 months).

Conclusions A high incidence of OCI was observed in the large midline NTSAM. The identification of TS involvement on MRI can serve as a strong predictor of OCI. Therefore, optic canal exploration to remove the optic canal invasion during the surgical removal of these particular tumors should be contemplated to attain radical tumor resection to enhance the possibility of improving visual function and reduce the risk of recurrence.

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