Category: Outcome

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The Timing of Diskectomy as a Predictor of Outcomes in Patients With Lumbar Disk Herniation

Neurosurgery 98:1051–1062, 2026

This prospective cohort study evaluates how the duration of preoperative symptoms influences outcomes after microdiskectomy for lumbar disk herniation. Outcomes measured include radicular pain, low back pain, disability (ODI), and motor and sensory deficits, with follow-up at 6 weeks, 6, 12, and 24 months in 1,120 analyzed patients.

Key finding: surgical intervention within one month of symptom onset yields faster, more pronounced pain relief and neurological recovery, whereas symptoms persisting beyond two years associate with the highest rates of residual motor and sensory deficits at 24 months.

Objective Evaluate how the preoperative duration of low back pain, disability, radicular leg pain, and motor/sensory deficits relates to postoperative outcomes after microdiskectomy for lumbar disk herniation (LDH).

Design/setting Prospective cohort (April 2015–October 2022) of adults undergoing microdiskectomy for symptomatic LDH with imaging-confirmed herniation consistent with symptoms.

Assessments & follow-up Pain measured by NRS, disability by ODI, motor deficit by MRC grading, sensory deficit as present/absent; assessed pre-op and at 6 weeks, 6, 12, and 24 months post-op.

Cohort size 1222 patients enrolled; 69 recurrences and 33 lost to follow-up excluded, leaving 1120 for statistical analyses.

Symptom-duration grouping Patients categorized by symptom duration thresholds ≤1, ≤6, ≤24, and ≥25 months for LDH-related symptoms (pain/disability/neurologic symptomatology).

Key outcome (timing) Surgery performed within 1 month of symptom onset was associated with more favorable outcomes than longer symptom duration, including faster improvement in neurological deficit and more significant radicular pain relief.

Residual deficits at 2 years Residual motor and sensory deficits at 24 months were least common when preoperative neurological symptoms lasted ≤1 month, and more common when symptoms exceeded 1 month.

Worst outcomes with long duration LDH symptoms persisting beyond 2 years were associated with the least favorable postoperative outcomes, including the highest residual motor and sensory deficits at 2 years.

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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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The effect of paraspinal sarcopenia on postoperative sagittal balance: a multivariate analysis following multilevel lumbar fusion surgery

The Spine Journal 26 (2026) 709−719

This clinical study examines how paraspinal sarcopenia influences long-term sagittal alignment and functional outcomes after multilevel posterior lumbar interbody fusion. Using preoperative MRI/CT and serial radiographs, muscle cross-sectional area, fat infiltration, and spinopelvic parameters were measured to compare sarcopenic and nonsarcopenic patients over at least two years.

Results show multifidus atrophy and fatty infiltration, plus inadequate preoperative lumbar and segmental lordosis, independently predict postoperative sagittal imbalance and worse pain and disability. The authors recommend preoperative paraspinal muscle assessment, nutritional and rehabilitation optimization, and tissue-sparing techniques to improve long-term outcomes.

Study aim: Assessed how paraspinal sarcopenia affects long-term sagittal alignment and persistent pain/disability after multilevel posterior lumbar interbody fusion (PLIF), and identified risk factors for postoperative sagittal imbalance.

Design & cohort: Retrospective single-institution study of 213 multilevel PLIF patients with imaging follow-up through ≥2 years; sarcopenic (n=69) vs nonsarcopenic (n=143/144) groups were compared.

Sarcopenia definition: Grouping based on psoas muscle index (MI) at L3 with thresholds <6.36 cm²/m² (men) and <3.92 cm²/m² (women).

Key measurements: Quantified L3 psoas/erector spinae/multifidus muscle MI, fat infiltration (Goutallier grading), and muscle density (CT HU); tracked spinopelvic parameters including LL, SL, PT, PI-LL, SVA plus VAS and ODI outcomes.

Muscle differences by group: Sarcopenic patients had lower muscle indices and higher fat infiltration (especially erector spinae and multifidus), with no significant difference in muscle density reported.

Alignment & outcomes: Sarcopenic patients showed worse long-term sagittal alignment at final follow-up (differences in LL, SL, PT, PI-LL, SVA) and worse long-term VAS and ODI scores, despite similar preoperative clinical scores.

Independent risk factors: Multifidus atrophy (lower MMI) and multifidus fat infiltration plus insufficient preoperative LL and SL were independent predictors of long-term postoperative sagittal imbalance; psoas, erector spinae, and other balance parameters were not independently associated.

Practical implication: Better sagittal-balance maintenance was associated with larger paraspinal MI, reduced fat infiltration, and favorable preoperative LL/SL, supporting preoperative evaluation of muscle health, nutritional status, and alignment.

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Risk Factors and Reoperation Rate in Revision Lumbar Disc Herniation Surgery: A Systematic Review and Meta-Analysis of 1,031,348 Patients

Global Spine Journal 2026, Vol. 16(3) 1633-1647

This systematic review and meta-analysis examines reoperation rates and associated risk factors following primary lumbar disc herniation surgery across 25 studies totaling 1,031,348 patients. Pooled reoperation rate was 8.5% overall (adjusted to 10.3% for publication bias), with rates varying by follow-up: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% beyond 5 years.

Key risk factors identified include smoking, older age, diabetes, and large annular defects, while sex was not significant. The review highlights heterogeneity across study designs and follow-up durations, recommends careful patient selection, extended conservative management or closer surveillance for high-risk patients, and calls for trials comparing revision techniques.

Objective Estimate the reoperation rate after lumbar disc herniation surgery and identify associated risk factors.

Evidence base 25 studies (including observational studies and 3 RCTs) totaling 1,031,348 patients were included.

Overall reoperation rate Pooled reoperation rate was 8.5% (95% CI 6.2%–11.6%); after trim-and-fill adjustment for publication bias it was 10.3% (95% CI 7.6%–14.0%).

Follow-up pattern Reoperation rates differed by follow-up duration: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% at >5 years (significant subgroup differences).

Smoking risk Smoking was associated with higher odds of reoperation (OR 1.39, 95% CI 1.09–1.78).

Age risk Older age was associated with higher odds of reoperation (OR 1.52, 95% CI 1.25–1.85).

Annular defect risk Larger annular defect size was associated with higher odds of reoperation (OR 2.19, 95% CI 1.07–4.48).

Other factors Diabetes and certain surgical techniques were linked to higher reoperation risk in individual studies; sex was not a significant predictor (OR 1.22, 95% CI 0.96–1.55).

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Neuropsychological profile and risk factors for poor cognitive outcomes in survivors of aneurysmal subarachnoid hemorrhage

J Neurosurg 144:517–525, 2026

This clinical study characterizes long-term neuropsychological outcomes in 156 survivors of aneurysmal subarachnoid hemorrhage (aSAH), using MoCA-22, digit span, and verbal fluency tests. Findings show that 34% scored below the 25th percentile despite largely favorable functional recovery, with deficits concentrated in executive function, working memory, and language.

Multivariable analysis identified modified Fisher grade 4 on admission and new radiological infarction during hospitalization as independent predictors of poor cognitive outcomes. Secondary assessments revealed frequent depressive symptoms and acquired personality disturbances, implicating impacts on work productivity and social relationships.

Objective Characterize neuropsychological deficits in aneurysmal subarachnoid hemorrhage (aSAH) survivors and identify clinical variables linked to poor cognitive outcomes.

Design/assessments Retrospective cohort (2009–2024) with cognitive testing ≥6 months post-aSAH using MoCA-22, Digit Span Forward/Backward, and Verbal Fluency; poor outcome defined as MoCA-22 <25th percentile (norm-adjusted).

Prevalence 34% (53/156) had MoCA-22 <25th percentile despite most having good functional recovery at discharge (mRS ≤2 in 79% of those with poor MoCA-22).

Cognitive profile Moderate/severe deficits (z-score >1 SD below norms) occurred in 11% on DST-F, 27% on DST-B, and 9% on VFT, highlighting prominent working-memory/executive-function vulnerability.

Key risk factors Modified Fisher grade 4 on admission and new radiological infarction during hospitalization were independently associated with poor MoCA-22 outcomes (aOR 2.43 and 2.71, respectively).

Quality of life impact Radiological infarction was associated with worse work productivity (OR 0.69) and social relationships (OR 0.72).

Behavioral sequelae Among those assessed, 27% reported at least mild depressive symptoms and 64% showed acquired personality disturbance.

Bottom line Cognitive/behavioral deficits can persist long after aSAH even with favorable mRS; higher hemorrhage burden (modified Fisher 4) and in-hospital infarction signal higher risk.

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The Helsinki Unruptured Intracranial Aneurysm Quality of Care study: a prospective observational study

J Neurosurg 144:507–516, 2026

This prospective single-center study evaluates the safety of unruptured intracranial aneurysm (UIA) treatments by prospectively measuring postprocedural diffusion-weighted MRI (DWI) lesions and correlating them with clinical outcomes at 3 months. Among 169 consecutive patients, 63% developed new DWI lesions, with endovascular cases showing more multiple lesions and surgical cases showing larger lesions.

Despite excellent functional outcomes by modified Rankin Scale (98% mRS 0–1) and high return-to-work rates, DWI lesions were associated with increased neurological symptoms, longer hospital stays, and worse outcomes when ≥10 mm. The authors argue that routine DWI should complement mRS to better capture ischemic burden and guide quality assessment and follow-up.

Objective Evaluate safety of unruptured intracranial aneurysm (UIA) treatment by measuring postprocedural ischemic lesions on MRI diffusion-weighted imaging (DWI) and correlating them with clinical outcomes.

Design Prospective, investigator-initiated, single-center observational cohort of consecutive UIA patients treated at Helsinki University Hospital (Dec 2022–Aug 2024) with brain MRI within 3 days and 3-month follow-up (mRS, neurological symptoms, return to work).

Cohort 169 patients: 120 (71%) endovascular and 49 (29%) surgical; aneurysm location distribution differed (most surgical cases were MCA aneurysms).

DWI incidence New DWI lesions occurred in 63% overall, with no difference between endovascular and surgical treatment (63% vs 63%).

Lesion patterns by modality Endovascular treatment more often produced high lesion counts (≥6 lesions: 14% vs 0%), while surgery more often produced larger lesions (≥10 mm: 20% vs 8%).

Symptoms association Most DWI lesions were asymptomatic (85%), but having any DWI lesion increased risk of new neurological symptoms (15% vs 2%), with 59% of symptoms transient.

mRS association Any DWI lesion was not associated with mRS outcomes, but lesions ≥10 mm were linked to poorer mRS status (mRS 0–1: 84% vs 99%) and higher risk of mRS worsening (21% vs 1%).

Return to work & conclusion 97% of previously working patients returned to work within 3 months; DWI lesions are common despite excellent mRS outcomes, and DWI may add information that mRS alone misses when assessing quality of care.

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Hurting More Than Helping? Decompressive Craniectomy in Patients With Symptomatic Intracerebral Hemorrhage After Mechanical Thrombectomy in Acute Ischemic Stroke

Neurosurgery 98:345–357, 2026

This multicentre registry study evaluates whether decompressive craniectomy (DC) improves 90-day functional outcomes in patients who developed symptomatic intracerebral haemorrhage (sICH) following mechanical thrombectomy for anterior-circulation acute ischaemic stroke. Using multivariable regression and propensity-score matching from 464 STAR registry patients, the authors compare clinical characteristics, procedural variables and mRS outcomes between DC and non-DC groups.

Findings indicate poor overall recovery (14% mRS 0–3; 56% mortality). After adjustment and matching, DC was associated with a lower odds of acceptable functional outcome and no consistent mortality benefit with similar results in low-ASPECTS subgroups. This suggests limited functional gains from DC in this population.

Decompressive craniectomy (DC) after symptomatic intracerebral hemorrhage (sICH) following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is not associated with improved functional outcomes at 90 days; only 11% of DC patients achieved a modified Rankin Scale (mRS) of 0-3, compared to 15% without DC (adjusted odds ratio [OR] 0.2, 95% CI 0.02-0.9, P = .045).

Mortality rates at 90 days were similar between DC and non-DC groups after multivariable adjustment and propensity score matching, despite a lower crude mortality in the DC group in univariable analysis (DC: 43%, non-DC: 59%; adjusted P = .5).

Propensity score–matched analysis confirmed that patients undergoing DC had significantly lower odds of achieving an acceptable functional outcome (8% vs 24%, P = .045), with no significant mortality difference (P = .10).

Patients selected for DC were generally younger, more likely to be female, and had higher-grade hemorrhages (parenchymal hematoma type 2) compared to those not undergoing DC.

Subgroup analysis of patients with large infarct cores (ASPECTS <6) showed that DC was not associated with improved functional outcome or mortality, suggesting limited benefit in this population.

Overall prognosis for sICH after AIS treated with MT is poor, with only 14% of all patients achieving mRS 0-3 at 90 days and 56% mortality, regardless of DC.

Findings challenge previous smaller studies and recent guidelines suggesting benefit of DC in malignant MCA infarction or spontaneous sICH, highlighting the unique poor prognosis in post-MT sICH.

Study limitations include retrospective design, lack of standardization in DC decision-making, missing imaging data, and potential selection bias, which could influence the observed associations.

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Long-Term Mortality of Patients With Head Injuries—A 10-Year Follow-up Study With Population Controls Study Performed at Tampere University Hospital

Neurosurgery 98:105–114, 2026

This study reports a 10-year follow-up comparing survival and causes of death between 1,930 patients treated for head injuries at a Finnish university hospital and 9,605 matched population controls. After excluding deaths within the first year, patients had a hazard ratio of 1.84 for mortality, with excess deaths concentrated in the first five years and elevated unintentional/traumatic and alcohol-related causes.

Multivariable analysis found age, male sex, pre-existing conditions, chronic alcohol use, and substance abuse—rather than injury severity or CT-positivity—were independently associated with reduced survival, though greater TBI severity remained linked to additional mortality risk when comparing patient severity subgroups to their matched controls.

Long-term Mortality: Patients with head injuries have significantly reduced long-term survival compared to matched population controls, with a hazard ratio (HR) for death of 1.84 after excluding those who died in the first year post-injury.

Acute vs. Long-term Risk: Death rates are notably higher among patients with head injuries for up to 5 years after injury, then approach control levels thereafter.

Causes of Death: Unintentional and traumatic causes (9.6% vs 4.4%) and alcohol-related causes (8.4% vs 1.9%) are significantly more common among head injury patients than controls.

Patient Characteristics: Age, male sex, pre-existing conditions, chronic alcohol use, and regular substance abuse are independently associated with decreased survival, whereas injury severity and CT findings are not significant predictors in multivariate analysis.

TBI Severity: Even patients with no documented traumatic brain injury (TBI) have reduced survival compared to controls; increasing TBI severity is associated with additional mortality risk.

Lifestyle and Pre-existing Factors: Much of the reduced survival is linked to patient characteristics and lifestyle factors (such as substance abuse), not solely to injury-related factors.

Immediate Causes of Death: Aspiration pneumonia and epileptic causes are significantly overrepresented as immediate causes of death in head injury patients who survive more than one year.

Control Group Limitations: Use of population controls and lack of detailed control data may overestimate associations between head injury and mortality due to unmeasured confounders.

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Functional status in long-term survivors after mapping-guided surgery for diffuse low-grade glioma

J Neurosurg 144:139–150, 2026

This clinical study reports long-term functional outcomes in 103 consecutive patients with diffuse low-grade glioma who underwent mapping-guided resections and were followed for at least 15 years. Key findings include high overall survival (83.5%), mean postoperative KPS of 94.8, and 90% return-to-work rate, with low permanent neurological morbidity across 205 resections.

Comparative analysis shows patients who sustained employment had smaller pre/postoperative tumor volumes, greater extent of resection (including more supratotal resections), and less exposure to radiotherapy. The data support early maximal safe resection and postponement of radiotherapy to preserve long-term functional status and professional activity.

Functional Preservation: Long-term survivors of diffuse low-grade glioma (LGG) surgery had high rates of preserved functional status, with 90.7% of surviving patients maintaining a Karnofsky Performance Scale (KPS) score ≥ 80 after an average of 18.2 years follow-up.

Return to Work: 90% of patients were able to return to work after mapping-guided resection, and maintaining professional activity was strongly associated with higher preoperative KPS and greater extent of resection (EOR).

Extent of Resection (EOR): Greater EOR, particularly supratotal or total resections, correlated with better long-term functional outcomes and higher rates of continued employment.

Radiation Therapy Impact: Early or any radiotherapy (RT) was linked to lower rates of return to work and a reduced proportion of patients with KPS ≥ 80 at last follow-up, while chemotherapy did not show this negative association.

Timing of Surgery: Early surgery at diagnosis, especially in patients with higher KPS and smaller tumor volume, increased the chance for maximal resection and long-term preservation of functional status.

Low Neurological Morbidity: Permanent postoperative neurological deficits were rare (1.5% after 205 resections), supporting the safety of maximal resection with intraoperative mapping.

Malignant Transformation: The risk of malignant transformation was lower in patients with greater EOR and those who continued to work, suggesting oncological benefit from radical resection.

Adjuvant Therapy Strategy: A wait-and-watch strategy after maximal safe resection, postponing adjuvant treatments unless necessary, helped preserve long-term quality of life and autonomy.

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The Association of Area Deprivation Index and Spine Surgery Outcomes: A Systematic and Narrative Review

Operative Neurosurgery 29:775–784, 2025

This systematic review examines the relationship between neighborhood-level socioeconomic disadvantage, measured by the Area Deprivation Index (ADI), and outcomes after various spine surgeries. Ten North American observational studies (56,925 patients) indicate higher ADI is associated with increased readmissions, emergency visits, longer lengths of stay, higher costs, and worse patient-reported outcomes for cervical and lumbar procedures.

The review outlines potential mechanisms—limited health literacy, barriers to follow-up, comorbidity control, and access deficits—and proposes targeted interventions across education, income/employment, housing, and household support to mitigate disparities and improve perioperative optimization and outcomes.

Area Deprivation Index (ADI): ADI is a validated, neighborhood-level measure of socioeconomic disadvantage, incorporating 17 variables across education, income/employment, housing, and household characteristics, with scores ranked from 0 (least disadvantaged) to 100 (most disadvantaged).

Association with Spine Surgery Outcomes: High ADI is linked to worse outcomes after spine surgery, including higher rates of postoperative readmissions, complications, emergency room visits, longer hospital stays, and poorer patient-reported outcomes (PROs).

Cervical Spine Surgery: Increased ADI is associated with higher costs of care, increased surgical utilization, and longer hospital length of stay after anterior cervical discectomy and fusion (ACDF); some studies also report increased likelihood of 30-day readmission, though not always statistically significant.

Lumbar Spine Surgery: High ADI predicts worse preoperative pain, function, depression, and anxiety scores; patients with high ADI experience greater rates of complications (e.g., respiratory failure), longer hospital stays, increased emergency visits, higher costs, and are less likely to achieve clinically meaningful improvements postoperatively.

Mechanisms of Disparity: Poor health literacy, reduced access to primary and follow-up care, barriers to transportation, and poor control of comorbidities are key mechanisms by which high ADI leads to worse surgical outcomes.

Potential Interventions: Targeted interventions addressing education (health literacy outreach, transitional care), income/employment (public assistance, nutrition programs), housing (medical-legal partnerships, transitional housing), and household resources (home health, internet access, transportation assistance) may help mitigate disparities for high ADI patients.

Limitations: Evidence is limited by heterogeneity of included studies, moderate risk of bias, small sample sizes for some subgroups, and lack of generalizability across all spine surgery types.

Future Directions: ADI can serve as a prognostic tool for identifying at-risk patients; further research should validate these associations and evaluate the effectiveness of targeted interventions to improve spine surgery outcomes in disadvantaged populations.

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Masseter Sarcopenia and Mortality After Type II Odontoid Fractures in the Elderly: A 5-Year Follow-Up Study

Neurosurgery 97:1297–1307, 2025

This clinical retrospective study evaluates whether masseter sarcopenia, measured on routine head CT scans, predicts mortality after Type II odontoid fractures in elderly patients. Using masseter cross-sectional area (MCSA) thresholds, the authors found that lower MCSA is independently associated with increased 1-year mortality, while frailty indices and age drive longer-term risk.

The paper details methods, cohort characteristics (n=72, mean age 80.9), imaging measurement technique, multivariate Cox models, and Kaplan-Meier analyses. Results support MCSA as a practical prognostic marker to inform postinjury management and targeted interventions in high-risk geriatric trauma patients.

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Factors associated with poor prognosis in elderly biopsy‑only glioblastoma patients

Acta Neurochirurgica (2025) 167:273

In elderly glioblastoma patients undergoing biopsy only, poor preoperative performance status, central tumor location, and larger tumor volume were associated with reduced three-month survival and lower treatment completion rates, highlighting the need for careful preoperative assessment and personalized counseling in this vulnerable group.

Study investigated elderly patients (>65 years) with glioblastoma (GBM) who underwent biopsy only, not surgical resection.

• Median overall survival (OS) was 4.6 months; only half completed oncological treatment.

• Poor preoperative performance status (PS), central tumor location, and larger tumor volume were independently associated with reduced three-month survival.

• Poor PS was the only independent predictor for not completing oncological treatment; these patients had very poor survival (median OS 1.6 months).

• Completion of treatment was linked to longer survival (median OS 8.3 months for completers vs. 3.5 months for non-completers).

• Findings suggest limited benefit of biopsy and oncological treatment in elderly GBM patients with poor PS.

• Results can help guide preoperative counseling and decision-making for this vulnerable patient group.

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Symptomatic Progression, Recurrence, and Long-Term Follow-Up of Patients With Intracranial Epidermoid Cysts

Neurosurgery 97:351–360, 2025

This retrospective study of 146 patients with intracranial epidermoid cysts found that recurrence is common after subtotal resection, but most patients experience significant symptomatic improvement post-surgery. Intraoperative lumbar drain placement increased 30-day readmission risk, and malignant transformation was exceedingly rare. Mortality was not observed.

• Intracranial epidermoid cysts are rare, slow-growing tumors, often presenting with cranial nerve dysfunction, headaches, vertigo, and seizures.

• Surgical resection is standard, but complete removal is often limited by adherence to critical neurovascular structures, leading to frequent residual tumor.

• Recurrence is common, especially after subtotal resection; radiologic evidence of residual tumor predicts shorter recurrence-free survival.

• Most patients show significant symptomatic improvement after surgery, with over half asymptomatic at latest follow-up, even if reoperations are needed.

• 30-day readmission rate is over 10%, mainly due to CSF leaks and aseptic meningitis; intraoperative lumbar drain placement increases readmission risk.

• Malignant transformation to squamous cell carcinoma is exceedingly rare (less than 0.05%).

• No deaths related to tumor or treatment were observed in this large cohort.

• Maximal safe resection is recommended to minimize recurrence, but complete capsule removal is often not feasible.

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Cerebellopontine Angle Meningiomas: A Multi-Institutional Cohort Study

Neurosurgery 97:105–111, 2025

This multi-institutional study of 95 cerebellopontine angle meningioma cases found that gross total resection, especially with internal auditory canal drilling for intracanalicular invasion, improves symptom control and reduces recurrence. Most patients experienced stable or improved hearing, with postoperative complications and recurrence rates detailed.

• Cerebellopontine angle (CPA) meningiomas are challenging due to their proximity to neurovascular structures and present commonly with hearing loss, ataxia, and headaches.

• Gross total resection (GTR) was achieved in 62.1% of 95 patients; smaller tumor size and drilling the internal auditory canal (IAC) for tumors with intracanalicular invasion were associated with higher GTR rates.

• Most patients had stable or improved hearing postoperatively; only a minority experienced worsening.

• Postoperative complications included cranial nerve dysfunction, CSF leak, and hydrocephalus, but there were no perioperative deaths.

• Tumor progression or recurrence occurred in 25.3% of patients, with higher rates in WHO grade 2 tumors; Simpson grade I/II resection and older age reduced recurrence risk.

• Extent of resection (EOR) is not reliably predicted by tumor size alone; other anatomical factors are important.

• Adjuvant radiation was mainly used for higher-grade tumors with subtotal resection, but most progression cases were managed with observation or salvage therapy.

• Surgical resection is effective for symptom control and reducing recurrence, especially with GTR and appropriate IAC management.

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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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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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Long-term survivors in 976 supratentorial glioblastoma, IDH-wildtype patients

J Neurosurg 142:174–186, 2025

Glioblastoma, isocitrate dehydrogenase (IDH)–wildtype is the most aggressive glioma with poor outcomes. The authors explored survival rates and factors associated with long-term survival in patients harboring a glioblastoma, IDH-wildtype.

METHODS In an observational, retrospective, single-center study, the authors examined the medical records of 976 adults newly diagnosed with supratentorial glioblastomas, IDH-wildtype between January 2000 and January 2021. They analyzed clinical-, imaging-, and treatment-related factors associated with 2-year and 5-year survival.

RESULTS The median overall survival was 11.2 months (12.2 months for patients included after 2005 and the introduction of standard combined chemoradiotherapy). The median progression-free survival was 9.4 months (10.0 months for patients included after 2005). Overall, 17.6% of patients reached a 2-year overall survival, while 2.2% of patients reached a 5-year overall survival. Furthermore, 6.6% of patients survived 2 years without progression, while 1.1% of patients survived 5 years without progression. Two factors that were consistently associated with 2-year and 5-year survival were first-line oncological treatment with standard combined chemoradiotherapy and methylated O 6 -methylguanineDNA methyltransferase promoter. Other factors that were significantly associated with 2-year or 5-year survival were age at diagnosis ≤ 60 years, headaches or signs of raised intracranial pressure at diagnosis, cortical contact of contrast enhancement, no contrast enhancement crossing the midline on initial imaging, total or subtotal tumor resection, and a second line of oncological treatment at recurrence. Within 21 cases of 5-year survival, 18 were confirmed to be glioblastomas, IDH-wildtype, and 7 of the 5-year survivors (38.9%) had additional genetic alterations: 3 cases had an FGFR mutation or fusion, 3 cases had a PIK3CA mutation, 1 case had a PTPN11 mutation, and 1 case had a PMS2 mutation in the context of constitutional mismatch repair deficiency syndrome.

CONCLUSIONS Five-year overall survival in patients with glioblastoma, IDH-wildtype is extremely low. Predictors of a longer survival are mostly treatment factors, emphasizing the importance of a complete oncological treatment plan, when achievable. Glioblastoma, IDH-wildtype 5-year survivors could be screened for actionable targets in case of recurrence.

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Laser Interstitial Thermal Therapy versus Open Surgery for Mesial Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis

World Neurosurg. (2024) 192:224-235

Epilepsy surgery offers a vital treatment option for drug-resistant mesial temporal lobe epilepsy, with temporal lobe resection (TLR) and magnetic resonanceguided laser interstitial thermal therapy (MRgLITT) being fundamental interventions.

This meta-analysis specifically examines seizure outcomes at extended follow-up periods exceeding 24 months, visual field deficits as measured by perimetry, and complication rates both overall and categorized based on duration as minor (transient <6 months) or major (persistent >6 months) to inform clinical decision-making.

For seizure freedom, TLR was superior, with 72.5% [65.6%, 78.5%] of patients achieving postoperative seizure freedom compared to 57.1% [51.2%, 62.7%] for MRgLITT (P value <0.01). Visual field deficits were observed in 79.4% [59.5%, 91.0%] of TLR patients and 49.8% [23.6%, 76.0%] of MRgLITT patients, a difference not reaching statistical significance (P value: 0.08). Overall complication rates were 11.4% [7.4%, 17.2%] for TLR and 6.5% [3.3%, 12.3%] for MRgLITT (P value 0.15). Major complications occurred in 2.0% [1.1%, 3.09%] of TLR cases and 2.7% [1.4%, 5.2%] of MRgLITT cases (P value 0.54), while minor complications were significantly more frequent with TLR at 9.9% [6.4%, 15.0%] versus MRgLITT’s 4.1% [1.9%, 8.4%] (P value 0.04). MRgLITT had a more favorable outcome regarding confrontation naming, while more studies are needed regarding verbal memory to be able to draw firm conclusions. TLR provides superior seizure freedom but comes with an increased risk of transient complications. Although there was no statistical significance in visual field deficits, the trend suggests a higher frequency with TLR.

The study’s extensive data analysis, including rigorous sensitivity checks, ensures the robustness of these conclusions, reflecting a comprehensive analysis of the available data at this time point.

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Primary Embolization of Cerebral Arteriovenous Malformations With Intention to Cure: A Systematic Review of Literature and Meta-Analysis

Neurosurgery 95:1232–1244, 2024

The treatment of brain arteriovenous malformations (AVMs) involves multiple approaches, including embolization, microsurgical resection, and radiosurgery. With the advent of new embolisates, dual-lumen balloon catheters, detachable tip microcatheters, and transvenous embolization, endovascular AVM obliteration has become more effective. Although adjuvant embolization and embolization are commonly used, the safety and effectiveness of curative embolization remain unclear.

METHODS: We conducted a systematic literature review using PubMed, Ovid Medline, and Web of Science to identify studies reporting outcomes in patients with AVMs who underwent primary embolization with the intention to cure. We collected data on patient characteristics, AVM features, complications, and radiographic and clinical outcomes for meta-analysis.

RESULTS: We identified 25 studies with a total of 1425 patients with 1427 AVMs who underwent curative embolization. Of these patients, 70% were low grade (pooled = 61% [39-82]), 67% were <3 cm (pooled = 78% [60-92]), and 75% were in superficial locations (pooled = 80% [72-86]). At last radiographic follow-up (mean, 16.7 ± 10.9 months), the full obliteration rate was 52% (pooled = 61% [43-77]) and retreatment rate was 25% (pooled = 17% [8.3-27]). At last clinical follow-up (mean, 24.2 ± 13.3 months), the poor clinical outcome rate was 7.9% (pooled = 4.4% [1.3-8.7]) and symptomatic complication rate was 13% (pooled = 13% [8-19]). There was no significant difference in the rate of radiographic cure, need for retreatment, and poor outcomes between ruptured and unruptured AVMs. Symptomatic complications were more common in the treatment of unruptured AVMs. The primary outcomes showed high heterogeneity (I ² = 72%-94%).

CONCLUSION: Curative embolization of AVM is primarily reserved for small and low-grade AVMs, with highly variable outcomes. Our findings suggest poor radiographic outcomes and increased risk of complications. Outcomes are highly dependent on patient selection and technique used. Large multicenter prospective studies are required to further guide patient selection, categorize clinical and radiographic outcomes, and identify subgroup of patients that may benefit from curative embolization.

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