Category: Surgical technique

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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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Resectability of spheno-orbital meningiomas: surgical outcome in 93 cases and a proposed clinically relevant anatomical classification

J Neurosurg 144:336–345, 2026

This clinical study evaluates surgical outcomes for 93 patients with spheno-orbital meningiomas (SOMs) treated over two decades, proposing a four-grade anatomical classification based on orbital involvement. The paper reports presentation patterns, operative techniques, extent of resection, proptosis quantification with an exophthalmos index, and postoperative visual and surgical morbidity rates.

Using retrospective imaging and clinical data, the authors validate the grading system’s predictive value for resectability, proptosis improvement, and visual risk, showing higher gross-total resection rates in lower-grade tumors and substantial vision stabilization or improvement across grades. The work offers practical guidance for surgical planning and patient counseling in complex skull-base and orbital tumor management.

Anatomical Grading System: SOMs are classified into four grades based on orbital involvement: grade 1 (orbital hyperostosis), grade 2 (periorbital involvement), grade 3a/b (intraorbital involvement without/with rectus muscle invasion), and grade 4 (involvement of the orbital apex or optic nerve).

Surgical Resectability: Gross-total resection (GTR) is most achievable in grade 1 (88.5%) and decreases with higher grades (grade 2: 50.0%, grade 3: 16.7%, grade 4: 24.1%), primarily limited by critical neurovascular structures and functional vision considerations.

Presenting Symptoms: Proptosis (74.2%) and visual decline (57.0%) are the most common symptoms, with higher-grade tumors more likely to present with proptosis, vision loss, and cranial neuropathies.

Visual Outcomes: Surgery led to stable or improved vision in nearly 95% of patients across all grades, with no significant difference in visual morbidity between low- and high-grade tumors.

Proptosis Improvement: Correction of proptosis was most significant in grades 2 and 4, with overall exophthalmos index (EI) significantly decreasing after surgery; clinically significant enophthalmos was rare.

Surgical Morbidity: Overall morbidity increased with higher tumor grade but was not statistically significant; new ophthalmological cranial nerve neuropathies occurred in 11.8% of patients.

Surgical Approach: Aggressive removal of tumor and hyperostotic bone, with selective intraorbital dissection, optimizes functional outcomes and proptosis reduction; rigid orbital reconstruction is generally not required.

Clinical Utility: The grading system aids in predicting surgical risks, visual outcomes, and in guiding patient counseling and surgical planning for SOMs.

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Customized Titanium Implants for Cranial Fibrous Dysplasia: A Personalized Surgical Approach and Single-Center Experience

Operative Neurosurgery 30:100–108, 2026

This single-center clinical series reports on 33 patients with monostotic cranial fibrous dysplasia treated with computer-assisted resection and reconstruction using patient-specific, 3D‑printed titanium cranioplasty implants. Methods detail high-resolution CT planning, surgeon‑engineer collaboration for CAD/CAM templates, intraoperative guidance, standardized perioperative care, and long-term radiological and FACE-Q patient‑reported outcome follow-up.

Results show complete tumor resections, favorable cosmetic outcomes, no postoperative complications or recurrences across extended follow-up, and high patient satisfaction; discussion addresses material selection, cost (≈$3000 per implant), production time, accessibility in low-resource settings, and the need for comparative studies.

Patient-Specific Titanium Implants: Customized, computer-aided design (CAD) and manufacturing (CAM) titanium implants enable precise resection and effective reconstruction for cranial fibrous dysplasia (CFD), resulting in excellent cosmetic outcomes and no postoperative complications or recurrences in a 33-patient series.

Surgical Process: Preoperative high-resolution CT scans and 3D modeling are used for surgical planning, including mirrored contralateral anatomy for symmetry; intraoperative templates guide tumor resection, and implants are secured with miniscrews.

Clinical Outcomes: All patients achieved complete tumor removal, satisfactory cosmetic results confirmed by postoperative CT, and no surgical site infections or cerebrospinal fluid leaks during a mean follow-up of 76–108 months.

Patient Satisfaction: High patient-reported satisfaction was observed, with FACE-Q scores indicating 84.8% of patients highly satisfied (score ≥85) and no patients dissatisfied with surgical outcomes.

Material Advantages: Titanium implants are favored for their biocompatibility, mechanical strength, and low infection rates compared to other materials like PEEK and PMMA, making them especially suitable for CFD reconstruction.

Cost and Accessibility: Average total cost per implant was $3000, with a 4-week production time; while feasible in middle-income settings, access remains limited in low-resource environments due to financial and infrastructural barriers.

Limitations: The study’s retrospective, single-center design, absence of a comparative cohort, and variable follow-up duration limit generalizability and long-term conclusions.

Future Directions: Broader adoption of CAD/CAM and patient-specific implants in craniofacial surgery may improve outcomes, but further comparative and cost-effectiveness studies are needed, especially in resource-constrained settings.

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Fully automated image updating for brain shift compensation after dural opening

J Neurosurg 144:206–216, 2026

This study presents a fully automated intraoperative image-updating system that compensates for brain shift after dural opening by assimilating intraoperative stereovision (iSV) data into a biomechanical finite element model to deform preoperative MR (pMR) images into updated MR (uMR) images. The pipeline integrates FastSAM segmentation, vessel/sulcus feature registration, and FEM-based whole-brain deformation to produce clinically usable uMRs.

In fifteen open cranial cases, automated updates reduced mean target registration error from 6.2 mm (pMR) to 1.9 mm (uMR) and completed without user intervention in 3.9 ± 0.6 minutes. Results demonstrate robust segmentation (DSC 0.93), submillimeter iSV reconstruction accuracy, and potential for broader adoption, while noting limitations in small or featureless openings and need for deeper-structure validation.

Fully automated image updating: Developed and validated a fully automated system to update preoperative MRI images for brain shift compensation after dural opening in open cranial surgery, eliminating user intervention and expertise requirements.

Intraoperative stereovision (iSV) integration: Utilized iSV images to capture high-resolution surface deformation data, which was processed by deep learning-based segmentation (FastSAM) and registered with preoperative MRI using vessel and sulcus features.

Two-step registration process: Employed translation-only cross-correlation for global alignment and Demons deformable registration for local nonrigid deformation between iSV and preoperative MRI surfaces.

Biomechanical modeling: Assimilated extracted nonrigid cortical displacements into a finite element model to estimate whole-brain deformation and generate updated MR images (uMR).

Accuracy improvement: Achieved significant reduction in target registration error (TRE) from 6.2 ± 1.2 mm (pMR) to 1.9 ± 1.0 mm (uMR), with overall mean computational time of 3.9 ± 0.6 minutes and no user intervention.

Robustness and efficiency: System was robust across a range of surgical conditions (lesion type, craniotomy size, brain shift magnitude), and performance was not significantly affected by these variables.

Limitations: Current system requires clear iSV images (free of instruments/blood), is limited to initial post-dural opening updates, and surface accuracy was primarily evaluated; further development is needed for autonomous updates during resection and deeper structure validation.

Potential for broad adoption: Elimination of user dependency and minimal workflow interruption suggest strong potential for integration into routine open cranial 

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Surgery of peritorcular meningiomas: the structural basis for preservation of torcular venous flow

J Neurosurg 143:1449–1457, 2025

This clinical and anatomical study defines the structural composition of the torcular Herophili and its implications for resection of peritorcular meningiomas, presenting histological evidence of a delaminable collagenous plane between venous endothelium and dural fibrous layers. The authors propose a four-type classification of tumor invasion based on endothelial integrity to guide operative strategy and preserve venous flow.

Clinical outcomes from 14 patients treated between 1997 and 2018 are reported, demonstrating feasibility of gross-total resection for type I–II tumors via layer-by-layer dissection with venous wall reinforcement, while types III–IV require preservation of collateral drainage and tailored reconstructive or adjunctive approaches.

• Torcular Anatomy: The torcular wall consists of two main compartments—an inner venous structure lined by endothelium and supported by elastic and smooth muscle fibers, and an outer fibrous dural layer, separated by a collagenous cleavage plane that enables surgical delamination.

• Meningioma Classification: Peritorcular meningiomas are classified into four types based on anatomical invasion: Type I (dural involvement only), Type II (dural involvement with sinus compression/displacement), Type III (endothelial layer disrupted, tumor penetrates lumen), and Type IV (complete sinus occlusion).

• Surgical Technique: For Type I and II tumors, gross-total resection is feasible by dissecting the tumor away from the inner venous wall at the cleavage plane, preserving venous integrity and flow; in Types III and IV, focus shifts to preserving venous collaterals due to disrupted or occluded flow.

• Preoperative Planning: Detailed imaging and identification of venous collaterals are critical for operative planning, especially when sinus flow is compromised or occluded.

• Outcomes: Gross-total resection was achieved in all patients with Type I and II tumors, with lower recurrence rates; subtotal resection and higher recurrence were associated with Types III and IV and higher-grade meningiomas.

• Complications and Mortality: No surgical mortality was reported; complications included wound infections and, rarely, recurrence or death related to aggressive tumor biology rather than surgery itself.

• Role of Radiotherapy: Radiation therapy was reserved for high-grade, residual, or recurrent tumors, particularly when total resection was not possible or in cases of sinus wall involvement.

• Clinical Significance: Preservation of the torcular venous wall and flow is paramount for favorable outcomes; anatomical understanding of the torcula enables safer, more effective resections and reduces recurrence in benign cases.

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The Far-Lateral Approach and Its Variants

Operative Neurosurgery 29:740–745, 2025

This technical report details the far‑lateral craniotomy and its variants for accessing ventral and ventrolateral craniovertebral pathologies, emphasizing indications, anatomical considerations, and operative steps. It outlines positioning, incision choices, bone work including condylar modifications, dural handling, and strategies to protect the vertebral artery and lower cranial nerves.

The article highlights advantages, limitations, and common pitfalls—such as occipitocervical instability with extensive condylectomy, hypoglossal canal risk, and CSF leak prevention—and supplements the text with high‑quality dissections and a 4K instructional video aimed at trainees and early‑career neurosurgeons.

 

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Avoidance of Major Vascular Injury in Transcranial Brain Tumor Surgery Using Real-Time Doppler Navigation

Operative Neurosurgery 29:633–638, 2025

This clinical technical note and case series evaluates real-time Doppler probe navigation during transcranial craniotomy for brain tumor resection, describing technique, operative workflow, and outcomes from 501 operations where the Doppler was used. The authors report a low rate of major vessel injury (<1%) and discuss how Doppler guidance complements neuronavigation and ultrasound as tumor resection progresses and brain shift reduces image accuracy.

The paper details patient selection, surgical approaches, probe specifications and intraoperative use, illustrates three case examples with video, and analyzes stroke and infarction rates attributable to vasospasm or small-vessel injury. Limitations include retrospective design and variable probe penetrance; the authors recommend routine Doppler adjunctive use for tumors encasing or adherent to major arteries.

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The Case Series of Contralateral Interhemispheric Transfalcine Approach to Medial Parietooccipital Pathologies: Surgical Technique and Results

Operative Neurosurgery 29:495–504, 2025

This retrospective case series evaluates the contralateral interhemispheric transfalcine approach (PITTA) for medial parietooccipital and peritrigonal brain lesions. The technique offers improved visualization and minimized brain manipulation, with acceptable complication rates, but requires careful venous management and is best suited for experienced neurosurgeons.

The contralateral interhemispheric transfalcine (PITTA) approach is used for challenging medial parietooccipital and peritrigonal brain lesions.

• A retrospective study of 19 cases showed PITTA was applied to vascular lesions (AVMs) and tumors (glioblastomas, meningiomas, metastases, pilocytic astrocytoma).

• The approach improves visualization and reduces manipulation of eloquent cortex and white matter compared to traditional ipsilateral approaches.

• Mean surgery time was about 4 hours 15 minutes, and most patients had temporary neurological deficits that resolved within days.

• Superior sagittal sinus injury and small vein sacrifice occurred in a few cases but were managed without lasting complications.

• No new visual deficits or permanent ipsilateral parietal lobe injuries were observed; most complications were minor and transient.

• PITTA is technically demanding and best suited for experienced neurosurgeons; careful preoperative planning and venous anatomy assessment are critical.

• The study concludes PITTA is a valuable option for selected cases, but larger prospective studies are needed to compare it with standard approaches.

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Surgery for mesial temporal pathology: a 26-year experience

J Neurosurg 143:738–747, 2025

Over 26 years, keyhole craniotomy via the inferior temporal gyrus for mesial temporal lobe surgery showed a low complication rate (5.3%), with only 0.3% permanent neurological deficits. Technique refinement and perioperative strategies minimized risks, supporting this approach as safe and effective for temporal lobe pathology.

A 26-year, single-surgeon study reviewed 717 mesial temporal lobe (MTL) surgeries using a keyhole inferior temporal gyrus (ITG) approach for epilepsy and other pathologies.

• Overall complication rate was low (5.3%), with only 0.3% of patients experiencing permanent neurological deficits and no perioperative deaths.

• Most common complications were hemorrhage (1.5%), postoperative seizure (1.3%), and cosmetic defects (0.6%).

• Neurological complications included transient cranial nerve deficits, visual field deficits, and speech difficulty, all rare.

• No significant correlation found between complications and age, sex, pathology type, operative time, or blood loss.

• Technical strategies such as meticulous closure, careful muscle reapproximation, and limiting brain retraction reduced complications over time.

• The ITG keyhole approach provided safe, effective, and cosmetically favorable access to the MTL, with complication rates improving as technique and teaching matured.

• Long-term follow-up (97% at 36 months) confirmed sustained safety and efficacy of this approach.

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How to deal with the superior petrosal vein in microvascular decompression for trigeminal neuralgia?

Neurosurg Focus 59(3):E12, 2025

Sectioning the superior petrosal vein at its main trunk while maintaining venous crossflow is a safe and effective strategy during microvascular decompression for trigeminal neuralgia, improving surgical access without significantly increasing venous-related complications, according to a large retrospective study.

• Management of the superior petrosal vein (SPV) during microvascular decompression (MVD) for trigeminal neuralgia (TN) is controversial, with concerns about operative field access and potential complications.

• A retrospective study evaluated a technique of SPV division at its main trunk near the superior petrosal sinus, maintaining venous crossflow through contributories, in 171 out of 217 patients (79%).

• No statistically significant increase in venous-related complications was observed in the SPV division group compared to the preservation group.

• Only 3 possibly venous-related complications occurred in the SPV division group, all of which were mild and transient.

• Anatomical variations of the SPV require careful intraoperative assessment and preservation of collateral venous drainage for safety.

• Preoperative imaging and intraoperative techniques (e.g., indocyanine green angiography) are recommended to assess collateral flow before SPV division.

• The study concludes that SPV division at the main trunk with preservation of crossflow is a safe strategy that improves surgical exposure during MVD for TN.

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Neuroapraxia of Trigeminal Nerve Controlled by Neuromonitoring During Microvascular Decompression in Multiple Sclerosis Patients Affected by Drug-Resistant Trigeminal Neuralgia Recurrent After Previous Operations

Operative Neurosurgery 29:295–300, 2025

This case series reports the first use of intraoperative neuromonitoring-controlled neuroapraxia of the trigeminal nerve with a temporary aneurysm clip during microvascular decompression for drug-resistant, recurrent trigeminal neuralgia in multiple sclerosis patients, showing immediate pain relief and no complications at up to 10 months’ follow-up.

• Trigeminal neuralgia (TN) in multiple sclerosis (MS) patients is difficult to treat and often recurs after surgery.

• This report describes the first 3 cases of recurrent, drug-resistant MS-related TN treated with intraoperative neuromonitoring (IONM)-controlled neuroapraxia during microvascular decompression (MVD).

• Neuroapraxia was induced by applying a temporary titanium aneurysm clip to the trigeminal nerve for up to 30 seconds, with real-time IONM to avoid nerve damage.

• All patients achieved immediate pain relief and maintained Barrow Neurological Institute pain score I at 9–10 months follow-up, with no major complications.

• Compared to previous techniques, this approach minimized complications by reducing clip time and using neuromonitoring.

• This technique may offer a safe, promising option for MS patients with recurrent TN, but larger studies with longer follow-up are needed.

• The study’s main limitation is the small patient number and short follow-up period.

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Open Microsurgical Versus Endovascular Management of Unruptured and Ruptured Brain Aneurysms

Operative Neurosurgery 29:171–180, 2025

This review compares open microsurgical clipping and endovascular techniques for treating unruptured and ruptured brain aneurysms, discussing their respective risks, benefits, and outcomes. It emphasizes individualized treatment decisions based on aneurysm characteristics, patient factors, and advances in both surgical and endovascular modalities.

• Microsurgical clipping and endovascular techniques are the main treatments for intracranial aneurysms, each with distinct risks and benefits.

• Clipping offers more durable repairs and lower retreatment rates but is more invasive and has higher short-term morbidity, especially in ruptured aneurysms.

• Endovascular treatments (coiling, stenting, flow diverters) are less invasive, have shorter recovery, and are preferred for older patients or those with comorbidities, but have higher recurrence and retreatment rates.

• Aneurysm characteristics such as size, location, morphology, and patient age/comorbidities are critical in selecting the optimal treatment.

• Posterior circulation aneurysms and wide-necked or complex aneurysms often favor endovascular approaches due to surgical risks.

• Clipping is particularly advantageous for younger patients, anterior circulation, and when hematoma evacuation or fenestration is needed.

• New endovascular devices (flow diverters, WEB) expand treatment options but require further study for long-term outcomes.

• Treatment decisions should be individualized, ideally at centers with expertise in both techniques, considering rupture status, anatomy, and patient factors.

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Comparison of suboccipital craniectomy versus suboccipital cranioplasty in foramen magnum decompression for adult Chiari malformation

J Neurosurg Spine 43:237–245, 2025

This retrospective study compared suboccipital craniectomy and cranioplasty for foramen magnum decompression in adult Chiari malformation. Both techniques improved symptoms and syrinx size, but cranioplasty incurred higher costs without significant clinical or radiological advantages. Cost considerations should be discussed during shared decision-making.

• Suboccipital craniectomy and suboccipital cranioplasty are two surgical techniques for foramen magnum decompression (FMD) in adult Chiari malformation.

• Both procedures significantly improve preoperative symptoms and reduce syrinx size, with no significant difference in clinical outcomes.

• Suboccipital craniectomy results in a greater increase in subarachnoid space compared to cranioplasty.

• No significant differences were found in surgical time, estimated blood loss, or cervical alignment between the two groups.

• Suboccipital cranioplasty incurs higher daily medical costs due to the use of plates and screws for bony reconstruction.

• Both techniques have similar rates of complications and secondary surgeries.

• The additional costs of cranioplasty should be discussed with patients during shared decision-making.

• Study limitations include retrospective design, small sample size, surgeon preference, and shorter follow-up for cranioplasty.

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Microsurgical pineal cyst fenestration: A safe and effective treatment strategy in patients with symptomatic pineal cyst syndrome

Acta Neurochirurgica (2025) 167:179

Microsurgical fenestration of pineal cysts significantly improved symptoms in 94% of non-hydrocephalic patients with nonspecific symptoms, with no mortality or severe adverse events. Cyst size and radiological features did not predict outcomes. The study supports fenestration as a safe, effective treatment, but optimal indications remain unclear.

• Microsurgical fenestration of pineal cysts (PC) was studied as a treatment for symptomatic patients without hydrocephalus.

• Most patients had nonspecific symptoms like headache, dizziness, and sleep disturbances; nearly all saw surgery as a last resort.

• 47 patients were analyzed, with an average follow-up of about 7 years post-surgery.

• Significant symptom improvement was observed: mean pain score (VAS) dropped from 7 to 1, with 96% reporting relief.

• No mortality or severe complications occurred; minor complications included CSF leaks (10%) and one surgical site infection.

• No clinical or radiological factors predicted better outcomes; even small cysts could benefit from surgery.

• Fenestration of both anterior and posterior cyst walls was seen as key to success, potentially safer than full resection.

• Further research is needed to define indications, optimal technique, and pathophysiology of symptomatic pineal cysts.

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Minimally Invasive and Cost-Effective Access to Deep-Seated Intracranial Lesions Using 19F Peel-Away Sheath Introducer and “Dynamic” Retraction

Operative Neurosurgery 29:118–124, 2025

This study introduces a minimally invasive, cost-effective technique for resecting deep-seated brain lesions using a 19F peel-away sheath introducer and dynamic retraction. In 13 patients, the method proved safe and effective, achieving high rates of gross total resection with minimal complications and reduced costs.

A novel, cost-effective minimally invasive technique for deep-seated intracranial lesions uses a 19F peel-away sheath introducer and “dynamic” retraction.

• This approach was evaluated in 13 patients with various brain pathologies, including glioblastoma, metastases, cavernous malformations, pilocytic astrocytoma, and colloid cyst.

• Gross total resection was achieved in 11 of 13 cases, with minimal complications and most patients remaining neurologically stable or improved postoperatively.

• The technique involves a small craniotomy, insertion of the 19F introducer using image guidance, and lining the corridor with cottonoid strips after sheath removal for retractorless, dynamic retraction.

• Compared to standard tubular retractor systems, this method reduces cost (introducer: ~$252 vs. commercial systems: $695–$4000) and potentially lessens brain trauma.

• Postoperative imaging showed minimal brain damage, with only one patient exhibiting minor diffusion changes without clinical consequences.

• Limitations include small sample size and retrospective design, but the technique may be especially valuable in resource-limited settings.

• Authors conclude this method is safe, technically feasible, and a viable alternative to more expensive tubular retraction systems for deep brain lesions.

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The Transtemporal Isthmus Approach for Insular Glioma Surgery

Operative Neurosurgery 28:478–486, 2025

This study presents a transtemporal isthmus approach for insular glioma surgery, achieving maximal safe resection. This method utilizes a widened temporal isthmus to access the insular lobe, ensuring significant tumor removal while preserving neurological function. The approach is shown effective for both low- and high-grade gliomas.

• The study introduces a transtemporal isthmus approach for the resection of insular gliomas, aiming for maximal and safe tumor removal.

• This surgical method involves the use of MRI and functional neuronavigation guidance, along with intraoperative electrophysiological monitoring.

• The approach is particularly beneficial for tumors involving zones III and IV of the Berger-Sanai classification.

• Gross total resection was achieved in 64.9% of low-grade and 87.5% of high-grade gliomas.

• The temporal isthmus is widened by the tumor, providing a surgical corridor for resection.

• The median postoperative Karnofsky performance score was 90, indicating good functional preservation.

• Muscle strength and speech were nearly normal in all patients three months post-surgery.

• The study suggests this approach is effective for safe and maximal tumor resection, while preserving essential functions.

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The risk of intraoperative venous air embolism from neurosurgical procedures performed in the lounging position

J Neurosurg 142:797–807, 2025

The study investigated the risk of venous air embolism (VAE) during neurosurgery in the lounging position, finding no permanent sequelae or fatal events. Despite a 51.4% VAE detection rate, no hemodynamic instability occurred, suggesting experienced teams can safely use this position.

Study Overview

• Objective: Assess venous air embolism (VAE) risk and outcomes in lounging position neurosurgery.

• Study Design: Retrospective analysis of 1000 patients from 2010 to 2020.

• Primary Focus: VAE incidence, severity, and associated complications.

Key Findings

• VAE Detection: 51.4% of patients experienced VAE, with no grade 5 events.

• Complications: 0.3% developed acute respiratory distress syndrome (ARDS) linked to VAE grade.

• No Permanent Sequelae: No patients suffered permanent neurological deficits from VAE.

Patient Demographics

• Mean Age: 47.7 years; 56.5% female.

• Common Pathologies: 94.9% had posterior fossa tumors, mainly vestibular schwannomas.

Surgical Approach and Positioning

• Lounging Position: Feet elevated above head to improve venous return.

• Surgical Benefits: Reduced intracranial pressure and improved surgical field visibility.

Risk Factors and Outcomes

• High-Grade VAE: Associated with older age and lower BMI.

• No PFO Contraindication: PFO is not linked to paradoxical embolism in this cohort.

• Outcome Predictors: Preoperative KPS score is most relevant for clinical outcomes.

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

Operative Neurosurgery 28:165–174, 2025

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

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

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

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

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

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

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

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

Neurosurg Focus 58(2):E7, 2025

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

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

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

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

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

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

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

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Dural and cranial reconstruction techniques in retrosigmoid craniotomy: key factors associated with CSF leaks in 225 patients

Neurosurg Focus 58(2):E8, 2025

This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes.

METHODS The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated.

RESULTS CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage.

CONCLUSIONS HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.

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