Category: Oncology

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Imaging-based surgical stratification of parasagittal meningiomas involving the superior sagittal sinus: a case analysis of 62 patients

Neurosurg Focus 61(3):E7, 2026

The surgical challenge of a parasagittal meningioma extends beyond determining whether the superior sagittal sinus is invaded. Safe exposure and resection also depend on residual venous flow, collateral drainage, bridging-vein anatomy and extension across the falx or adjacent convexity dura. Li and colleagues propose an imaging-based framework that brings these relationships into preoperative planning. Their study is most useful as an anatomical guide to the operative strategy, rather than as evidence that a particular sinus-directed maneuver improves outcomes.

Objective

To evaluate the Superior Sagittal Sinus Involvement Grading system (SSIG) in relation to established invasion grading, operative complexity and resection strategy.

Methods

This retrospective, single-center series included 62 consecutive resections performed by one surgeon. Fifty-five tumors were primary and seven recurrent. SSIG was assigned by consensus among three senior neurosurgeons using contrast-enhanced coronal MRI. CT or MR venography was available in 49 patients to assess sinus patency and collateral drainage.

The framework distinguishes convexity-adjacent disease with an intact sinus wall (grade 1), falcine involvement with deeper wall invasion (grade 2), predominantly intraluminal tumor (grade 3), continuous convexity-sinus-falx involvement with residual flow (grade 4a), more extensive invasion with severe stenosis or functional near occlusion (grade 4b), and complete sinus occlusion (grade 5).

For comparisons, grades 1, 2 and 4a formed a low-involvement group of 44 patients; grades 3, 4b and 5 formed a high-involvement group of 18. This grouping reflects anticipated sinus management rather than a simple numerical progression.

Main results

SSIG correlated with Sindou grade (Spearman r = 0.790) and venography-based involvement in the 49 evaluable patients (r = 0.742). Operative time and blood loss differed across the six SSIG categories. However, in the binary low-versus-high comparison, blood loss remained significantly different whereas operative time did not.

Simpson grade I resection was recorded in 38 of 44 low-involvement cases and six of 18 high-involvement cases. Simpson grades II-III were correspondingly more frequent with high involvement: 66.7% versus 13.6%. In this study, that category represented gross tumor removal with preservation of the invaded sinus wall or segment, rather than necessarily indicating a visible residual mass.

Neurological adverse events occurred in 10 patients (16.1%), including seven with new or worsened limb numbness or weakness. The authors also reported systemic morbidity, including lower-extremity venous thrombosis in 22 patients and one pulmonary embolism. Surgery-related complication rates did not differ significantly between the two involvement groups, but the small sample does not establish equivalent safety. No radiographic recurrence or progression was observed during a mean follow-up of 13.3 months.

Interpretation – operative relevance

The first practical contribution concerns exposure. In the authors’ practice, grade 1-2 lesions generally required an ipsilateral parasagittal craniotomy reaching the midline. When intraluminal work or contralateral exposure was anticipated, the bone flap crossed the midline to permit visualization and control of the relevant sinus segment. Thus, falcine and convexity extension help determine the operative corridor in addition to the depth of sinus invasion.

The second concerns venous dissection. The described principles include internal tumor decompression, dissection along the arachnoid interface, sharp separation of adherent veins and particular protection of bridging-vein entry zones. Early treatment of the dural or falcine attachment is integrated with preservation of the functioning venous pathways.

The distinction between grades 4a and 4b is especially useful. Both may involve the convexity, sinus and falx, but residual effective flow favors conservative handling of the sinus wall. Severe narrowing or near occlusion requires a more detailed assessment of compensatory drainage before contemplating sinus-directed resection. An imaging label alone cannot demonstrate that a venous segment is expendable.

For completely occluded grade 5 lesions, the authors describe selected resections without sinus reconstruction after assessment of collateral compensation and protection of the venous drainage at the segment boundaries. This is their reported strategy, not a general recommendation to sacrifice an occluded sinus. The series does not compare reconstruction with nonreconstruction or validate a universal threshold for safe ligation.

Limitations

The study is retrospective and restricted to one surgeon. Subgroups were uneven, with only one grade 3 lesion, and venography was unavailable in 13 patients. Although grading was assigned by consensus, interobserver reproducibility was not formally established. Exploratory comparisons were not adjusted for multiple testing, and the small number of events limits complication analysis. Short follow-up without progression cannot establish long-term tumor control or the superiority of a resection strategy.

Clinical takeaway

Plan the exposure and resection boundary around functional venous anatomy, not sinus invasion alone. SSIG offers a useful structure for reviewing convexity and falcine extension, residual flow and collateral pathways; its principal value is to organize surgical judgment while keeping preservation of effective venous drainage central to the operation.

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Spinal meningiomas: histopathological grading using a benchmark radiomics model with notes on disease control

Neurosurg Focus 61(3):E8, 2026

Could preoperative imaging help anticipate the biological behavior of spinal meningiomas?
This study applies radiomics—quantitative analysis of imaging features—to distinguish tumor pathology groups.
The model showed promising discrimination using open-source tools and internal validation.
Its potential role is to inform counselling, but clinical adoption requires independent testing.

Objective

To develop a preoperative radiomics classifier for spinal meningioma pathology and explore factors associated with disease control.

Methods

Investigators retrospectively reviewed institutional surgical records from 2012–2025. Manually segmented contrast-enhanced images underwent PyRadiomics feature extraction. An ensemble classifier used 10 features and nested cross-validation.

The study’s “high-grade” category combined WHO grade 2 tumors with grade 1 tumors showing atypia; this is not equivalent to conventional WHO high-grade classification.

Main results

Among 74 patients, the model achieved an area under the receiver-operating-characteristic curve of 0.879 and a mean F1 score of 0.748.

The clinical analysis included 55 patients, with median radiographic follow-up of 22.2 months and four recurrences. Subtotal resection was associated with poorer progression-free survival than gross-total resection: HR 10.62 (95% CI 1.46–77.05; P=.019). Institutional abstract

Interpretation

The imaging approach merits further investigation, but discrimination within one institution does not establish performance across scanners, imaging protocols or patient populations. An AUC of 0.879 should not be described as “87.9% diagnostic accuracy.”

The recurrence analysis is exploratory. Its wide confidence interval signals considerable uncertainty, and it does not justify pursuing complete resection at the expense of neurological function.

Limitations

The small retrospective cohort and internal validation limit generalizability. The unconventional pathology grouping complicates comparison with other grading studies. Four recurrence events provide limited support for prognostic modelling.

Publisher and PubMed retrieval failed; verification relied on the authors’ institutional abstract. Full methodological details and supplementary material could not be assessed.

Clinical takeaway

Radiomics is a promising research adjunct for preoperative assessment of spinal meningiomas. This model should not yet determine resection extent, radiation treatment or surveillance schedules without external validation and confirmation of clinical utility.

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Perioperative Management of Targeted and Immunologic Agents in Neurosurgical Oncology

Neurosurgery 99:519–529, 2026

Targeted therapy and immunotherapy have complicated the traditional decision of which antineoplastic drugs to stop before neurosurgery. This systematic review organizes the relevant agents around wound healing, bleeding and immune dysfunction. Anti-VEGF antibodies and mTOR inhibitors require particular caution because of impaired healing, while VEGF-receptor and Bruton’s tyrosine kinase inhibitors raise hemorrhagic concerns. Several immunomodulators increase infection risk, but the evidence is sparse for other widely used classes. The resulting framework is useful for multidisciplinary planning, although many intervals still rest on indirect evidence and expert consensus.

Objective

To provide a clinically actionable framework for perioperative interruption and resumption of targeted and biologic therapies in patients undergoing neurosurgical procedures.

Methods

The authors systematically reviewed pivotal trials, US Food and Drug Administration safety information, meta-analyses and society guidance. Drug classes were assessed by mechanism, pharmacokinetics and adverse effects relevant to wound healing, hemostasis and immune regulation. Recommendations were stratified by risk and combined the available evidence with expert consensus.

Main results

Anti-VEGF monoclonal antibodies carried the greatest wound-healing concern; the review recommends a preoperative interruption of at least 4 weeks and generally delaying postoperative treatment for 2–4 weeks. For mTOR inhibitors, the proposed preoperative interval was at least 1 week.

VEGF-receptor tyrosine kinase inhibitors and Bruton’s tyrosine kinase inhibitors were most concerning for bleeding and may require holds of up to 1 week, with resumption after 3–7 days once hemostasis is secure. CDK4/6 inhibitors, Janus kinase inhibitors and biologics directed at TNF, IL-6 or CD20 were linked to immunosuppression and infection risk; interruptions of 2–7 days and postoperative delays of 1–2 weeks were often proposed. Evidence remained limited for BRAF/MEK and immune-checkpoint inhibitors.

Interpretation

A single “stop all systemic therapy” rule is neither safe nor oncologically neutral. Timing should reflect the drug’s biological effect, half-life, operative magnitude, wound requirements and the consequences of delaying cancer control. The review is best used as a structured starting point for joint decisions among neurosurgery, oncology, anesthesia and pharmacy—not as a rigid calendar.

Limitations

Much of the evidence comes from non-neurosurgical populations, safety reports and expert interpretation rather than prospective perioperative trials. Recommendations within a class may not apply equally to every agent. The review cannot quantify the competing risk of oncological progression during interruption for an individual patient.

Clinical takeaway

At the preoperative visit, record the exact agent, last dose, half-life and principal surgical risk. Agree on stop and restart dates with the treating oncologist, verify wound healing and hemostasis before resumption, and document explicitly when limited evidence makes the plan individualized.

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Intractable epilepsy before and/or after awake functional mapping–based surgery for IDH-mutant grade 2 glioma: a consecutive series of 105 patients

J Neurosurg 145:623–633, 2026

Seizure control is a central component of the oncofunctional result after surgery for diffuse grade 2 glioma. This long-term series examines patients with drug-resistant epilepsy before or after awake mapping–guided resection. Just over half became completely seizure-free, whereas persistent or newly intractable epilepsy affected the remainder. Tumor location, preoperative volume and extent of resection were associated with the epileptic outcome, which in turn tracked functional status and return to work. The study argues for integrating seizure goals into surgical planning without compromising functional boundaries.

Objective

To characterize intractable epilepsy before and after awake functional mapping–based surgery for IDH-mutant grade 2 glioma and examine its relationship with tumor, surgical and quality-of-life outcomes.

Methods

The authors retrospectively selected patients operated between June 2002 and March 2024 who had intractable epilepsy before and/or after surgery and more than 1 year of follow-up. All resections were performed awake with functional mapping. Patients were divided into those with preoperative intractable epilepsy who became completely seizure-free (Engel IA), those with intractable epilepsy both before and after surgery, and those who developed it only postoperatively.

Main results

The series comprised 105 patients and 134 awake procedures, with a mean follow-up of 8.3 years. At diagnosis, 101 patients (96.2%) had seizures and 82 (78.1%) had intractable epilepsy. The mean extent of resection was 86.8%; persistent postoperative deterioration occurred in one patient.

Sixty patients (57.1%) achieved Engel IA seizure freedom. Twenty-two (21.0%) had persistent intractable epilepsy and 23 (21.9%) developed it postoperatively. Larger preoperative volume and lower extent of resection correlated with intractable epilepsy. Patients rendered seizure-free had higher postoperative Karnofsky scores and a higher return-to-work rate.

Interpretation

For grade 2 glioma, seizure control is not a secondary outcome: it is closely linked to autonomy and social reintegration. The association with resection extent supports maximizing removal within individually mapped functional limits. The anatomical signal—particularly the poorer pattern in central tumors—also indicates that epileptological success depends on the network involved, not simply on residual volume.

Limitations

This was a retrospective, highly selected single-team series restricted to patients with intractable epilepsy, not the entire grade 2 glioma population. Surgical, molecular and adjuvant-treatment practice evolved over more than two decades. Associations between resection, epilepsy and function do not prove causality, and postoperative antiseizure-medication strategies were not randomized.

Clinical takeaway

Discuss seizure freedom explicitly when planning awake surgery for IDH-mutant grade 2 glioma. Pursue the greatest functionally safe resection, document the epileptogenic network as well as eloquent function, and maintain structured long-term epileptological follow-up even in patients without preoperative pharmacoresistance.

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Comparative Outcomes of Frontal, Bifrontal, and Pterional Craniotomies for Resection of Large Anterior Skull Base Meningiomas

Operative Neurosurgery 31:484–494, 2026

Large anterior skull-base meningiomas can be approached through unilateral frontal, bifrontal or pterional craniotomies, but anatomy and case complexity strongly influence that choice. This retrospective series compares the three exposures and uses propensity matching to reduce baseline imbalance. Bifrontal procedures had more medical and surgical complications and poorer cosmetic results after matching. Frontal procedures showed shorter progression-free survival, with subtotal resection emerging as an adverse predictor. The findings help frame approach selection but do not establish that one craniotomy is intrinsically superior for every tumor.

Objective

To compare outcomes after frontal, bifrontal and pterional craniotomy for large anterior skull-base meningiomas and identify approach-specific predictors of complications and tumor control.

Methods

The study retrospectively included 337 adults operated at one institution between 2010 and 2024, each with at least 1 year of follow-up. Eighty patients underwent bifrontal, 189 frontal and 68 pterional craniotomy. Propensity-score matching balanced groups for tumor size, grade and preoperative Karnofsky Performance Status. Complications, cosmetic outcomes and progression-free survival were then compared.

Main results

Before matching, patients selected for bifrontal surgery had larger tumors and lower functional status, whereas the frontal group had higher-grade tumors. After matching, medical complications occurred in 25.0% and surgical complications in 22.5% of the bifrontal group, both significantly more often than in the other groups. Unsatisfactory cosmetic outcomes were also more frequent after bifrontal surgery (6.25%).

Kaplan-Meier analysis showed more minor complications after bifrontal craniotomy and shorter progression-free survival in the frontal group. Olfactory-groove location predicted poorer outcomes in the pterional cohort, while subtotal resection predicted poorer outcome in the frontal cohort.

Interpretation

The bilateral exposure carries a morbidity cost even after adjustment for several markers of complexity. However, approach is inseparable from anatomy: midline extension, vascular encasement, optic involvement, surgeon experience and the probability of safe complete resection must shape the decision. A unilateral route should not be selected merely to avoid the statistical risk associated with bifrontal surgery.

Limitations

The retrospective single-center design is vulnerable to selection bias and changing surgical practice over 14 years. Matching addressed only measured variables and could not balance all anatomical features. The abstract does not provide adjusted effect sizes for every comparison, and the broad category of anterior skull-base meningioma combines distinct origins and operative challenges.

Clinical takeaway

Use the least disruptive exposure that still provides safe control of the tumor, neurovascular structures and dural attachment. Reserve a bifrontal route for anatomy that genuinely requires bilateral access, and counsel those patients about its higher observed medical, surgical and cosmetic complication burden.

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Maximum safe resection of insular gliomas: update on surgical outcomes from 500 cases

Journal of Neurosurgery. 2026;145(2):347–361

Objective
To evaluate the safety and oncological value of maximum resection in a large contemporary series of insular gliomas.

Methods
Single-center retrospective study of 502 resections performed in 394 patients between 1997 and 2022. The series included newly diagnosed and recurrent low- and high-grade gliomas treated using a transcortical approach with cortical and subcortical mapping.

Main results
Among newly diagnosed grade 2 gliomas, persistent motor or language deficits occurred in fewer than 4% of patients. Transient motor and language deficits occurred in 9.5% and 20%, respectively. A residual tumor volume below 2.7 cm³ was associated with longer overall survival in grade 2 glioma. In newly diagnosed IDH-wildtype glioblastoma, resection of more than 88.6% of the contrast-enhancing tumor was associated with improved progression-free and overall survival. Permanent limb weakness was independently associated with worse survival (HR 2.06; 95% CI 1.14–3.74).

Interpretation
Extensive insular glioma resection can be achieved with relatively low permanent morbidity when modern mapping techniques are used. Functional preservation remains essential because permanent deficits may eliminate the survival benefit of aggressive resection.

Limitations
Retrospective, single-center experience spanning 25 years, during which imaging, molecular classification and adjuvant treatments changed considerably.

Clinical takeaway
The goal should be maximum safe—not simply maximum—resection, guided by functional boundaries and postoperative residual volume.

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Factors associated with overall survival and 90-day mortality following resection of melanoma brain metastases

Operative Neurosurgery. 2026;31(2):270–284

Objective

To identify factors associated with early postoperative mortality and overall survival after surgical resection of melanoma brain metastases.

Methods

This retrospective single-center study included 103 patients who underwent resection as their initial treatment for melanoma brain metastases between 2009 and 2018. The primary outcomes were overall survival, 90-day mortality and development of leptomeningeal disease.

Main results

Nineteen patients (18%) died within 90 days of surgery. Elevated lactate dehydrogenase at diagnosis was independently associated with greater early mortality (OR 7.17).

Factors associated with lower 90-day mortality included:

  • Postoperative Karnofsky Performance Status ≥80: OR 0.13.
  • Brain metastasis already present at the diagnosis of stage IV disease: OR 0.11.

Better overall survival was associated with:

  • Preoperative Karnofsky score ≥80: HR 0.46.
  • Adjuvant stereotactic radiosurgery: HR 0.55.
  • Surgical reduction of total intracranial tumor burden by ≥95.6%: HR 0.47.
  • Synchronous diagnosis of brain metastasis and stage IV melanoma: HR 0.59.

No evaluated factor was significantly associated with subsequent leptomeningeal disease. PubMed abstract

Interpretation

Functional status remains central to surgical selection. The study also suggests that the value of surgery may depend not only on removing the symptomatic lesion but on achieving a major reduction in the patient’s total intracranial tumor burden.

The association between adjuvant stereotactic radiosurgery and longer survival supports a combined local-treatment strategy rather than surgery alone. Elevated LDH may help identify patients at particularly high risk of early postoperative death.

Limitations

The study was retrospective, conducted at a single tertiary cancer center and included patients treated between 2009 and 2018. Systemic melanoma therapy has evolved substantially since that period. The survival associations cannot establish that extensive resection or adjuvant radiosurgery directly caused better survival because healthier patients may have been more likely to receive these treatments.

Clinical takeaway

Surgery for melanoma brain metastases should be considered within a multimodal treatment strategy. Patients with good functional status are the most likely to benefit, while elevated LDH identifies a group with substantial early mortality risk. When safely achievable, a reduction of at least approximately 95% of total intracranial tumor burden may provide greater benefit than limited resection of the dominant lesion alone.

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Resection and permanent intracranial brachytherapy using modular, biocompatible cesium-131 implants for recurrent aggressive meningiomas: 5-year results from a prospective phase 2 trial

J Neurosurg 145:206–213, 2026

This prospective single-center phase 2 trial evaluates maximal safe resection combined with intraoperative Cs-131 collagen tile brachytherapy (R+CTBT) for 29 recurrent, aggressive meningiomas, reporting improved local control rates at long-term follow-up compared with each tumor’s prior same-site treatment. Outcomes include Kaplan–Meier local control at 36–60 months, hazard ratios from Cox models, and detailed adverse-event reporting.

The report describes patient selection, implant technique, dosimetry metrics, statistical methods, and safety considerations, highlighting a lower symptomatic radiation necrosis rate with Cs-131 tiles and acceptable surgical complications, while noting single-center design and limited sample size as study limitations.

Objective Evaluate whether maximal safe resection plus Cs-131 collagen tile brachytherapy (R+CTBT) improves control of recurrent aggressive meningiomas versus the patient’s prior same-site treatment.

Design Prospective, nonrandomized, single-center phase 2 trial enrolling patients with recurrent aggressive meningiomas (June 2013–Jan 2018), with follow-up through August 2020.

Procedure After maximal safe resection and intraoperative pathologic confirmation, Cs-131 seeds were embedded into collagen squares (“tiles”) and placed in the resection bed; postoperative CT was used for radiation planning and MRI for extent of resection assessment.

Population 29 tumors in 27 patients (median age 66); tumors at time of R+CTBT were predominantly WHO grade 2 (90%), with 3% grade 1 and 7% grade 3.

Efficacy Local control at 48 and 60 months was 73% and 48% after R+CTBT versus 21% and 17% after prior same-site treatment (HR 0.145, p < 0.001).

Outcomes detail Local progression (≤ 1.5 cm from operative bed) occurred in 8/29 (28%) implant sites over a median radiographic follow-up of 34.8 months.

Complications Surgery-related complications requiring intervention occurred in 4/29 (14%) (1 early infection; 3 delayed wound breakdown/infection).

Radiation injury Symptomatic radiation brain injury/radiation necrosis occurred in 4/29 (14%), and all cases resolved with medical therapy.

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Resectability of White Matter Tracts in Patients With Language-Critical Gliomas

Neurosurgery 99:140–148, 2026

This study evaluates how resections of language-associated white matter tracts (WMTs) predict persistent postoperative language deficits (PLDs) in 68 glioma patients using tractography, intraoperative mapping, and outcome assessments. Results show WMT resection strongly predicts PLDs with high negative predictive value but modest positive predictive value, and temporal/parietal segments carry the greatest risk.

Anatomic clustering localized high-risk resections to the temporoparietal junction and middle temporal lobe, while frontal operculum and orbitofrontal tracts were often resectable without lasting deficits. Anatomically stratifying tracts (parietal/temporal) improved positive predictive value, supporting tractography-informed surgical planning alongside intraoperative mapping.

Goal Identify predictors of permanent postoperative language deficits (PLDs) in language-eloquent glioma surgery by analyzing which language-associated white matter tract (WMT) segments are resected.

Cohort & approach Retrospective analysis of consecutive adults undergoing awake craniotomy with intraoperative language mapping; WMT tractography reconstructed 6 language-related tracts and parcellated by anatomic location; outcomes based on formal language testing pre-op vs 1–3 months post-op (with clinical follow-up to 6 months for persistence).

Overall predictive signal Any WMT resection strongly increased odds of PLDs (odds ratio 16.0, P = .0115) with high NPV 97.4% but low PPV 29.6%.

Anatomic vulnerability Resections associated with PLDs clustered in the temporoparietal junction (TPJ) and middle temporal lobe (MTL), while resections without PLDs were more diffuse and concentrated in frontal/anterior regions.

Resectability by region Frontal tract segments showed near-complete resectability (PPV = 0 across reported frontal segments), whereas parietal/temporal segments had higher PPVs (eg, parietal AF 0.4, temporal AF 1, temporal IFOF 0.5, temporal ILF 0.5).

Stratified model Focusing only on parietal and temporal tract segment resections improved prediction of PLDs (odds ratio 29.4, P < .001) and increased PPV to 50% (NPV 96.7%).

Resection volume The volume of tract resected did not differ by functional outcome (U = 84.0, P = .70), suggesting location/segment matters more than amount.

Clinical implication WMT resections in orbitofrontal, anterior temporal, and frontal operculum regions were often tolerated, while parietal/temporal WMT injuries substantially increased PLD risk.

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Speech mapping in awake high-grade glioma resection: subcortical tract proximity as a predictor of language outcomes

J Neurosurg 145:179–189, 2026

This clinical study evaluates intraoperative predictors of postoperative language decline in awake resections of language-eloquent high-grade gliomas using diffusion tractography, 5-ALA, and subcortical stimulation with standardized language testing. It reports rates of transient and permanent deficits, correlates specific white matter tracts (IFOF, ILF, AF/SLF) with domain-specific impairments, and presents stimulation thresholds predictive of decline.

The paper emphasizes that preoperative deficits and positive stimulation of multiple tracts increase risk of lasting language impairment, while most single-tract-related declines tend to recover by three months; proposed SCS amplitude cutoffs are offered as practical guidance to balance maximal resection and language preservation.

Objective Identify intraoperative predictors of postoperative language decline and predictors of temporal language recovery after awake resection of language-eloquent high-grade glioma (HGG).

Methods Single-center cohort (Jan 2017–Nov 2024) undergoing awake craniotomy with diffusion tractography, 5-ALA, subcortical stimulation (SCS), and intraoperative language testing; language outcomes assessed at 48 hours, 2 weeks, and 3 months.

Outcomes New or worsened postoperative language deficit occurred in 53.1% (69/130) and was permanent (>3 months) in 9.2% (12/130).

Key intraoperative predictor (domain-specific) Clinical deterioration during awake testing predicted short-term decline in semantic processing (IFOF) (RR 3.47), reading (ILF) (RR 21.4), and auditory naming/repetition (AF/SLF) (RR 6.98).

Permanent-deficit risk factors Higher risk of persistent language decline was associated with preoperative speech deficit (RR 2.65), intraoperative ILF-related reading deterioration (RR 8.92), and positive SCS of multiple language tracts.

Tract sensitivity & recovery Posterior ILF–related reading function showed the greatest sensitivity to decline and the lowest propensity for recovery; all observed reading deficits were linked to tumors near the posterior ILF.

SCS threshold cutoffs ROC/Youden-derived SCS amplitudes predictive of postoperative deficits were reported per tract: IFOF 5.5 mA (48h/2w), 4.5 mA (3m); ILF (reading) 7.0 mA (48h/2w), 4.5 mA (3m); AF/SLF 5.5 mA (48h/2w), 2.5 mA (3m).

Multiple-tract involvement At 3 months, deficits occurred in 7.4% (5/68) with single-tract positive SCS versus 75.0% (9/12) with two tracts; both patients with all three tracts stimulated had persistent deficits beyond 3 months.

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Corticosteroid Use Before Stereotactic Brain Biopsy for Suspected Lymphoma

Neurosurgery 99:30–39, 2026

This retrospective cohort study evaluates whether preoperative corticosteroid therapy (CST) affects the diagnostic yield of stereotactic brain biopsy (SBB) in 104 patients with pathologically confirmed primary central nervous system lymphoma (PCNSL). The analysis stratifies patients by steroid timing, duration, and cumulative dexamethasone-equivalent dose, reporting diagnostic rates, radiographic features, and complications.

Results show a 92.3% overall diagnostic yield that remained high regardless of CST exposure, dose, or timing, with comparable postoperative complication rates. The authors conclude short-course CST for symptom control appears safe before SBB, while emphasizing multidisciplinary coordination and need for prospective standardized protocols.

Clinical question Whether preoperative corticosteroid therapy (CST) (timing, dose, duration) reduces stereotactic brain biopsy (SBB) diagnostic yield in suspected primary CNS lymphoma (PCNSL), and whether it affects postoperative complications

Cohort & design Retrospective review of 725 SBBs (2014–2025) identifying 104 pathologically confirmed PCNSL cases; CST-naive vs CST-exposed with stratification by last-dose timing, cumulative dexamethasone-equivalent dose, and duration

Overall yield Initial SBB diagnostic yield for PCNSL was 92.3% (96/104), with 8 nondiagnostic initial biopsies

CST vs no CST yield Diagnostic yield was 95.3% with CST (41/43) vs 90.2% without CST (55/61), not significant (P = .46)

Timing of last CST dose Yield remained high across intervals: ≤48 h 96.4%, 48–72 h 91.7%, >72 h 100% (P = .66)

Cumulative dose & duration Yield did not differ by cumulative dexamethasone dose (≤20 mg 95.5%, 21–40 mg 100%, >40 mg 100%, P = 1.0) or by duration (≤5 days 94.6% vs >5 days 100%, P = 1.0)

Complications Postoperative complications occurred in 4.8% of PCNSL cases, with no significant difference between CST-exposed and CST-naive patients (P = .84)

Nondiagnostic biopsies & next steps Only 2/8 initially nondiagnostic cases had prebiopsy CST; all 8 were ultimately confirmed PCNSL via repeat SBB, CSF cytology, or postmortem, supporting repeat/alternative diagnostic approaches when initial biopsy is nondiagnostic

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Multi-Institutional Assessment of Circulating Cell-Free DNA in Cerebrospinal Fluid Facilitates Central Nervous System Lymphoma Diagnosis and Treatment Initiation

Neurosurgery 99:40–49, 2026

This multi-institutional clinical study evaluates a CLIA-certified rapid PCR assay detecting the MYD88 L265P variant in cell-free DNA from cerebrospinal fluid to diagnose central nervous system (CNS) lymphoma. The assay demonstrated 100% specificity, 40% sensitivity, and facilitated earlier treatment initiation, sometimes obviating the need for risky CNS tissue biopsy.

The report details prospective implementation across 19 hospitals, methods for CSF processing and qPCR, diagnostic performance metrics, clinical trajectories of MYD88-positive patients, and implications for using CSF liquid biopsy to accelerate safe, targeted CNS lymphoma therapy.

Clinical need CNS lymphoma diagnosis has historically relied on CNS tissue biopsy, which can delay treatment and carries neurological morbidity risk.

Assay approach A CLIA-certified rapid PCR test was implemented to detect the MYD88 L265P variant in cell-free DNA (cfDNA) from CSF as a minimally invasive diagnostic method.

Deployment scale Prospective testing was conducted over 16 months across 19 hospitals: 201 samples from 184 patients; 19 samples (18 patients) were MYD88 L265P positive, with 2 test failures from inadequate DNA.

Performance characteristics In patients with available records, the assay showed specificity 100%, sensitivity 40%, PPV 100%, NPV 83% (positive LR ∞; negative LR 0.6).

Clinical utility Positive MYD88 results enabled CNS lymphoma–directed treatment initiation, including cases treated without CNS tissue confirmation, with 100% concordance between CSF and CNS tissue biopsy among contemporaneous paired cases (N=8).

Time impact MYD88-positive results often returned before biopsy (median 5.5 vs 10.5 days from admission), and time to treatment was shorter when LP/CSF testing avoided CNS biopsy (7 vs 9 days, P=.048).

Predictors/limitations Detection was more likely with leptomeningeal disease (multivariable P=.017) and DLBCL histology (multivariable P=.027); sensitivity remained modest, implying negative tests still require further workup such as biopsy.

Practice caveat (annotation) Because of modest sensitivity and concerns about spectrum bias/loss to follow-up, MYD88 CSF testing can supplement or obviate biopsy in selected cases, but generally does not replace the need for tissue-based molecular profiling.

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Isocitrate Dehydrogenase Wild-type Glioblastoma Resection Under Fluorescein Sodium and White Light Guidance Based on Response Assessment in Neuro-Oncology Resect Criteria

Operative Neurosurgery 30:861–869, 2026

This study evaluates sodium fluorescein–guided resection versus white‑light surgery in isocitrate dehydrogenase wild‑type glioblastoma, using RANO resection classes and quantitative MRI volumes to compare residual contrast‑enhanced tumor burden. The retrospective analysis of 162 patients shows significantly lower postoperative CE residual volume and higher complete CE resection rates with fluorescein guidance.

The paper also correlates molecular markers with resection outcomes, finding MGMT promoter methylation associated with higher complete CE resection rates and suggesting fluorescein guidance may particularly improve CE resection across molecular subgroups, while survival differences require longer follow‑up and larger cohorts.

Objective Increase extent of resection of the contrast-enhanced (CE) portion of IDH–wild-type glioblastoma, using the RANO absolute residual-volume resection classes to quantify what sodium fluorescein guidance achieves vs white light (WL) surgery.

Design/measurement Retrospective comparative study of 162 patients (fluorescein 82 vs WL 80), with pre/post-op MRI volumetrics outlined in Brainlab and categorized by RANO EOR classes.

Key EOR result Residual CE tumor volume was lower with fluorescein guidance than WL (median 0.0 cm³ vs 0.5 cm³, P = .023).

Complete CE resection rate Proportion with 0 cm³ residual CE (RANO I + IIA) was higher with fluorescein (62.2%) than WL (42.5%), P = .012.

RANO distribution shift RANO class distribution differed between groups (P = .015), with more IIA and fewer IIB resections under fluorescein guidance.

Non-CE resection No significant between-group differences were found in preoperative CE/NCE volumes or postoperative NCE residual volumes, consistent with fluorescein primarily highlighting BBB-disrupted (enhancing) tissue.

MGMT association MGMT promoter methylation was associated with higher likelihood of achieving nonresidual CE (complete CE resection), P = .005; fluorescein guidance and MGMT status were significant predictors of nonresidual CE.

Survival Overall survival did not significantly differ between fluorescein-guided and WL groups (log-rank P = .15), while MGMT-methylated patients had significantly better survival than unmethylated (P = .019; HR = 0.52).

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Relationships Between Surgical Approach, Tumor Classification Scheme, and Early Neurocognitive Outcome After Awake Craniotomy for Resection of Insular Glioma

Operative Neurosurgery 30:880–889, 2026

This study evaluates early postoperative neurocognitive outcomes after awake craniotomy for insular glioma resection, comparing transcortical and transsylvian approaches and examining tumor classification schemes. It reports frequent, domain-specific declines—most notably in memory and verbal fluency—and analyzes relationships with tumor hemisphere, insular zone, and extension.

The authors found similar overall neurocognitive change across surgical corridors but identified higher verbal fluency decline with transcortical approaches and greater domain-specific risk linked to left-sided tumors, extra-insular extension, and anterior or inferior insular involvement.

Study aim: Assessed how surgical approach (transsylvian vs transcortical) and tumor classification/location relate to early postoperative neurocognitive function (NCF) after awake resection of insular glioma.

Cohort & design: Retrospective series of 53 newly diagnosed insular glioma patients (47% high-grade; 75% left hemisphere) treated with awake craniotomy, with neuropsychological testing pre-op and within 60 days post-op.

Classification schemes: Tumors were categorized by Berger–Sanai zones (collapsed to anterior/posterior/superior/inferior) and Pitskhelauri extension groups (insula only; insula + extension; predominantly extra-insular).

Overall NCF change: Postoperative decline occurred across multiple domains, with the largest effects most often in memory and verbal fluency (executive function).

Frequency of clinically meaningful decline: 85% declined on ≥1 test (Δz ≤ −1.0), 52% on ≥2 tests, and 22% on ≥5 tests; decline was most frequent/severe in memory and also common in executive function, attention, and processing speed.

Surgical approach comparison: Mean NCF change generally did not differ by approach, but the transcortical approach showed a higher rate of verbal fluency decline than transsylvian (61% vs 26%).

Tumor hemisphere & localization effects: Left-hemisphere tumors were linked to poorer outcomes on multiple tests (notably memory, verbal fluency, naming, and token comprehension), while anterior tumors had worse executive function (mental flexibility) than posterior, and inferior lesions had worse recognition memory than superior.

Tumor extent/size associations: Predominantly extra-insular tumors had greater fluency reduction than insula-only; more Berger–Sanai quadrants involved correlated with worse executive function change; larger tumor volume and higher postoperative FLAIR volume related to worse processing speed and comprehension outcomes.

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Early Initiation of Radiation Therapy Improves Survival in Elderly Patients With Glioblastoma

Neurosurgery 98:1402–1412, 2026

This clinical study evaluates the effect of early postoperative radiation therapy (RT) initiation on survival in patients aged 65 and older with IDH‑wildtype glioblastoma, analyzing outcomes from a prospective registry of 56 patients treated between 2020–2024. Survival analyses, including Kaplan‑Meier curves and Cox regression, compare outcomes for RT started <20 days versus ≥20 days after surgery and examine RT fractionation and temozolomide use.

Results show that initiating RT within 20 days post‑surgery is associated with improved overall survival and progression‑free survival on univariate analysis, while multivariate models indicate confounding by performance status and adjuvant temozolomide; adjuvant TMZ remains a strong positive predictor of survival. The authors conclude early RT may benefit elderly GBM patients and call for prospective randomized trials to confirm timing effects.

Study aim: Evaluate whether earlier start of postoperative radiation therapy (RT) improves survival in elderly (≥65) patients with newly diagnosed IDH-wildtype glioblastoma.

Cohort & design: Retrospective cohort using a prospective registry (2020–2024), 56 patients, comparing RT start <20 days vs ≥20 days after surgery; endpoints were overall survival (OS) and progression-free survival (PFS).

Univariate survival finding: Starting RT <20 days after surgery was associated with improved OS (P=.0460) and PFS (P=.0075) versus ≥20 days.

Adjusted (multivariate) finding: After adjustment (including KPS and adjuvant temozolomide), RT timing was not statistically significant for OS (P=.2962) or PFS (P=.0670), indicating likely confounding.

Temozolomide effect: Adjuvant temozolomide was a significant predictor of better outcomes on multivariate analysis for both OS (P=.0038; HR 0.16) and PFS (P=.0133; HR 0.27).

Fractionation nuance: Among those starting RT early (<20 days), conventionally fractionated RT (60 Gy/30 fx) showed significantly improved PFS (P=.0164), while hypofractionated RT (40 Gy/15 fx) did not reach significance (P=.0509).

Baseline group differences: The <20-day RT group had better performance status (higher KPS, lower ECOG) and higher rates of receiving adjuvant temozolomide, which may influence observed survival differences.

Clinical implication noted: Timely initiation of adjuvant therapy (RT and chemotherapy) may be particularly important in elderly patients, but stronger evidence (e.g., prospective randomized trial) is needed to define optimal timing and account for confounding/logistical delays.

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Exploring the Diagnostic Test Accuracy of MicroRNAs as Potential Biomarkers for Glioblastoma

Neurosurgery 98:1221–1230, 2026

This systematic review and meta-analysis evaluates microRNA (miRNA)–based liquid biopsies for diagnosing glioblastoma (GBM), synthesizing data from 15 studies and 28 biomarker evaluations across 868 samples. Key diagnostic metrics—pooled sensitivity 0.84 and specificity 0.89—indicate strong potential, with miR-21 showing the highest accuracy among single-miRNA assays.

The report details search strategy, inclusion criteria, statistical methods, subgroup analyses (miRNA type, biofluid source, control type), and study quality assessment. Limitations include methodological heterogeneity, high risk of bias in patient selection, inconsistent reporting (CSF source, IDH status), and small cohort sizes, underscoring need for standardized clinical validation.

Aim Evaluate the diagnostic accuracy of microRNA (miRNA) liquid biopsies (blood/serum/plasma/CSF) for diagnosing glioblastoma (GBM) via systematic review and meta-analysis.

Methods PRISMA-guided searches of Ovid Medline and Embase (updated through Oct 16, 2024); included studies had histologic GBM confirmation and extractable 2×2 diagnostic data; pooled estimates generated using a random-effects bivariate model.

Evidence base 15 included articles (published 2011–2022) provided 28 miRNA evaluations, totaling 868 samples from 551 GBM patients and 811 samples from 578 controls.

Overall accuracy Pooled sensitivity 0.84 and specificity 0.89, with heterogeneity of 66% (sensitivity) and 39% (specificity); pooled AUC 0.89.

Likelihood ratios Pooled PLR 7.26, NLR 0.19, and DOR 40.17, indicating strong overall discriminatory performance.

Key biomarker miR-21 showed the highest pooled performance among assessed groupings (sensitivity 0.90, specificity 0.95).

Subgroups Single miRNAs had higher specificity than multi-miRNA panels, while diagnostic capability did not differ clearly by biofluid source (CSF vs blood) in this dataset.

Limitations All included studies had high risk of bias in patient selection, and many had bias in index test interpretation/flow-timing; limited CSF comparisons and inconsistent qPCR thresholds/normalization contributed to heterogeneity and constrain clinical translation without standardization and validation.

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The role of salvage stereotactic radiosurgery for tumor progression following incomplete microsurgical resection of vestibular schwannoma

J Neurosurg 144:1403–1409, 2026

This clinical study evaluates salvage stereotactic radiosurgery (SRS) for vestibular schwannoma (VS) that progresses after incomplete microsurgical resection, reporting long-term tumor control, freedom from additional treatment (FFAT), and complication rates in a 64-patient cohort. Key outcomes include 10- and 15-year tumor control of 87.5% and 84.4%, and FFAT of 95.3% and 92.2%, respectively.

The methods describe retrospective selection, radiosurgical dosimetry (median margin 12.5 Gy), imaging and follow-up protocols, and statistical analyses using Kaplan–Meier and Cox models; no factors significantly predicted control or FFAT, and common complications included trigeminal neuropathy and hearing worsening.

Objective Assess safety/efficacy of salvage stereotactic radiosurgery (SRS) for vestibular schwannoma (VS) that progresses after incomplete microsurgical resection, including factors affecting tumor control and freedom from additional treatment (FFAT).

Cohort Retrospective series of 64 adults treated with salvage SRS for post-resection tumor progression; median age 51.5 years and 46.9% male.

Treatment parameters Median marginal dose 12.5 Gy (median isodose 50%); median tumor volume 1.6 cm³; median time from surgery to salvage SRS 38.8 months.

Long-term control Tumor control rates after salvage SRS were 87.5% at 10 years and 84.4% at 15 years.

Durability (FFAT) FFAT rates were 95.3% at 10 years and 92.2% at 15 years, indicating most patients avoided further intervention long term.

Predictors No evaluated factors (e.g., Koos grade, age/sex, cranial nerve neuropathies, marginal dose, extent of resection, tumor volume) were significantly associated with tumor control or FFAT in Cox modeling.

Complications Most common post-SRS issue was worsening/new trigeminal neuropathy (15.6% total); hearing worsened in 14.1% (Gardner-Robertson class), and facial nerve function worsened in 4.7% (House-Brackmann).

Conclusion Salvage SRS is a safe and effective long-term strategy for VS tumor progression after incomplete resection, supporting continued monitoring and consideration of SRS once progression is documented.

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Guidelines for the Treatment of Adults With WHO Grade II Diffuse Glioma: Update

Neurosurgery 98:984–991, 2026

These updated CNS evidence-based guidelines consolidate current literature on the management of WHO grade II diffuse gliomas, covering imaging, surgical strategies, neuropathology, radiotherapy, chemotherapy, and recurrence. They summarize evidence levels, provide topic-specific recommendations, and identify areas needing higher-quality research to inform clinical decisions.

The document details unchanged, updated, and new recommendations—ranging from MRI protocols and intraoperative mapping to molecular testing and adjuvant therapy—while describing methodology, conflict-of-interest procedures, and plans for periodic revision to ensure clinical relevance.

Scope: Updated evidence-based recommendations for adult WHO grade II diffuse glioma across imaging, surgery, neuropathology/molecular markers, radiotherapy, chemotherapy, and recurrence management.

Methods: Systematic search of MEDLINE/Embase/Cochrane covering Jan 1, 2013–Jan 31, 2020, with recommendations based on evidence rather than consensus.

Imaging (minimum MRI): Minimum evaluation includes T2-weighted and pre- and post-gadolinium T1-weighted MRI; serial imaging is used to detect new enhancement or significant growth suggesting higher-grade transformation.

Imaging (advanced/PET): Diffusion plus perfusion techniques (e.g., DSC/DCE/ASL) are suggested when standard MRI cannot distinguish grade II from higher-grade gliomas; amino-acid PET (FET or FDOPA) may be added when not evident on MRI to help with grading, prognosis (FET), or progression detection (FDOPA).

Surgery: When safe/feasible, resection (gross total or subtotal) is recommended over biopsy alone to reduce progression; extent of resection should be maximized when safely possible (including for IDH-mutant and IDH–wild-type tumors).

Pathology/molecular testing: Diagnosis relies on histopathology from representative tissue; IDH mutation testing is recommended for classification/prognosis, and 1p/19q loss-of-heterozygosity testing is recommended in oligodendroglial cases for prognosis/treatment planning.

Adjuvant therapy (high-risk): For high-risk grade II diffuse glioma (age >40 or <40 without gross total resection), adding chemotherapy to radiotherapy is recommended to improve overall survival (including procarbazine/PCV-based approaches) and is also recommended without decline in neurocognitive function.

Recurrence: At suspected recurrence, advanced imaging (MRS/perfusion/diffusion/PET) is suggested; temozolomide is suggested (often initial choice) and procarbazine may help (strongest evidence in oligodendroglioma); radiation is suggested if not previously given and reirradiation may be considered.

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Awake Versus Asleep Craniotomy for Glioma: A Comparison of Survival and Costs Using Time-Driven Activity-Based Costing

Operative Neurosurgery 30:653–667, 2026

Awake versus asleep (general anesthesia) craniotomy are two approaches for glioma resection, and this work compares their intraoperative costs and survival outcomes.

Key Insights and Themes

Clinical question centers on whether awake craniotomy (AC) differs from asleep craniotomy under general anesthesia (GA) in intraoperative cost and in survival for glioma patients.

Cohort identification included all glioma resections at one institution from 2017–2022: 298 GA cases and 67 AC cases.

Awake-craniotomy indication primarily involved tumors in eloquent brain regions to allow intraoperative monitoring of neural function, while noneloquent tumors typically started under GA.

Costing method (TDABC) used process maps plus automated time-stamped extraction from the electronic medical record to capture intraoperative resources and time.

Cost components were dominated by supplies and personnel, with other elements (turnover and overhead) described as relatively minor contributors.

Baseline overall intraoperative cost had a median total of $6600 (IQR $2875), largely driven by supply cost (median $3178) and personnel cost (median $3141).

Operating-room time was longer for AC (median 5.2 hours) than GA (median 4.5 hours), and AC had about 30 additional minutes of incision-to-closure time.

Patient/tumor comparability showed GA patients were older, but there were no differences in WHO grade distribution or extent of resection between groups.

Unadjusted total cost difference showed higher median intraoperative cost for AC ($8506) versus GA ($6033).

Unadjusted subcomponent differences showed AC had higher median supply cost ($4238 vs $2928) and higher median personnel cost ($4111 vs $2962) than GA.

Adjusted total cost effect found AC associated with $2175 additional intraoperative cost versus GA after accounting for confounders.

Adjusted cost drivers attributed the added AC cost to higher supply cost (+$1272) and higher personnel cost (+$970).

Supply subcomponents were higher for AC than GA across consumables, implants, sterilization, and medications in unadjusted comparisons.

Personnel mix differed in that neurology attendings/fellows were included in AC but not GA at this institution, contributing to personnel-cost differences.

Unadjusted survival showed higher overall survival for AC on Kaplan–Meier analysis (log-rank P = .011), while progression-free survival did not significantly differ (log-rank P = .106).

Adjusted survival showed no significant differences between AC and GA in overall survival (HR 0.84, P = .48) or progression-free survival (HR 0.9, P = .66) after multivariable adjustment.

Key limitation (missing GA neuromonitoring costs) is that electrophysiological neuromonitoring personnel costs for GA were not captured due to EMR documentation limits.

Scope limitation (episode-of-care costs) is that the analysis focuses on intraoperative costs, and commenters note postoperative/inpatient costs could change conclusions about overall expense.

Conclusion

Awake craniotomy for glioma resection had higher intraoperative costs than asleep craniotomy, but after adjustment it showed no significant survival advantage in overall or progression-free survival.

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Prediction of Diffuse High-Grade Glioma Survival Outcomes Using Preoperative Whole-Brain Tractography–Based Resectability Metrics

Neurosurgery 98:836–847, 2026

This study presents novel whole-brain tractography (WBT)–derived resectability metrics—resectability index (RI) and unresectable tumor volume (UTV), plus modified versions mRI and mUTV—calculated from preoperative diffusion imaging to estimate how much of diffuse high-grade gliomas (HGG) can be safely resected. Metrics are derived by quantifying tumor overlap with critical white-matter tracts and deep structures, and compared with conventional postoperative measures.

Using retrospective data from 146 tumors (84 with WBT), mRI and mUTV strongly predicted biopsy versus resection and correlated with extent of resection, residual tumor, and overall survival. Accelerated failure time models incorporating mUTV/mRI provided accurate preoperative survival predictions, outperforming conventional metrics in postoperative models.

Problem: Extent of resection (EOR) predicts survival in diffuse high-grade glioma but is only measurable postoperatively, limiting preoperative decision-making.

Approach: Preoperative whole-brain tractography (WBT) was used to quantify tumor overlap with eloquent tracts and deep structures to estimate resectability before surgery.

Metrics: Unresectable tumor volume (UTV) = tumor overlap with eloquent tracts + deep structures; Resectability index (RI) = (preop tumor volume − UTV) / preop tumor volume.

Modified metrics: mUTV/mRI focused only on corticospinal tract and left arcuate fasciculus, and performed better than unmodified metrics in several analyses.

Surgical decision prediction: mRI (AUROC 0.953) and mUTV (AUROC 0.854) accurately predicted biopsy vs resection, with optimal cutoffs mRI 0.75 and mUTV 2.5 cm³.

Survival separation: Tumors with mRI > 0.65 vs ≤ 0.65 showed the largest median overall survival difference (not reached vs 82 days, P < .0001).

Best preop survival model: A log-logistic accelerated failure time (AFT) model using only preoperative covariates achieved validated C-index 0.788, with mUTV an independent predictor of overall survival (P = .008).

Overall conclusion: Preoperative WBT-based resectability metrics approximate postoperative EOR/residual tumor volume and can strongly predict survival outcomes after biopsy or resection.

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