Category: Vascular

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Microsurgical management of 883 previously coiled intracranial aneurysms

J Neurosurg 143:654–667, 2025

This systematic review and meta-analysis found that microsurgical management of previously coiled intracranial aneurysms is effective and safe in well-selected patients, achieving high complete occlusion and good functional outcomes, especially with delayed direct clipping, small aneurysm size, and anterior location.

• Microsurgical management of previously coiled intracranial aneurysms (IAs) is effective and safe in well-selected patients.

• Meta-analysis included 874 patients with 883 previously coiled IAs; most underwent direct clipping.

• Complete occlusion rate was 97.2%, good functional outcome 82.9%, and perioperative mortality 3.7%.

• Direct clipping had the best safety and efficacy, with the lowest rates of complications and highest rates of good outcomes.

• Smaller, anteriorly located, and unruptured aneurysms were associated with the most favorable outcomes.

• Early microsurgery (within 1 month of coiling) and Gurian group C IAs had higher perioperative death rates.

• Key management factors: IA size, location, rupture status, indication, and timing/type of microsurgery.

• Most studies were retrospective case series, limiting subgroup analysis and introducing some heterogeneity.

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Predictive models for assessing the risk of brain aneurysm rupture

J Neurosurg 143:607–614, 2025

This study evaluated predictive models for brain aneurysm rupture risk using clinical, morphological, and advanced MRI radiomics data. Models combining these factors, especially radiomics, significantly improved accuracy in identifying symptomatic aneurysms, supporting a comprehensive, personalized approach for aneurysm risk stratification and treatment decisions.

• The study evaluated predictive models for assessing the risk of brain aneurysm rupture using high-resolution MRI, clinical, morphological, and radiomic data.

• 129 intracranial aneurysms were analyzed; 26% were symptomatic (ruptured or with warning symptoms).

• The PHASES score alone had low predictive ability (AUC 0.61–0.62) for symptomatic aneurysms.

• Adding morphological metrics (especially size ratio) and smoking status improved prediction (AUC up to 0.79).

• Incorporating aneurysm wall enhancement (AWE) metrics further increased model performance (AUC 0.82).

• The best model included age and radiomics features, achieving the highest predictive accuracy (AUC 0.87, 88% sensitivity).

• Younger age, current smoking, larger size ratio, and higher wall enhancement were associated with symptomatic aneurysms.

• A comprehensive approach using clinical, morphological, and advanced imaging/radiomics data improves aneurysm risk stratification.

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Conservative management of 661 patients with unruptured intracranial aneurysms: an observational study over 4 decades

J Neurosurg 143:641–653, 2025

This retrospective study of 661 patients with unruptured intracranial aneurysms found a 4.4% aneurysm-related mortality and 0.6% annual rupture rate. No ruptures occurred with PHASES <8 or ELAPSS <15, highlighting these thresholds for risk stratification and the importance of close follow-up, especially in the first 10 years.

• A retrospective study analyzed 661 patients with 767 unruptured intracranial aneurysms (UIAs) managed conservatively over 4 decades.

• The overall aneurysm-related mortality rate was 4.4%, with 3.5% of patients experiencing rupture; annual hemorrhage rate was 0.6%.

• Most ruptures (87%) occurred within the first 5 years after diagnosis; no ruptures were observed after 10 years.

• No ruptures or aneurysm-related deaths occurred in patients with PHASES score <8 or ELAPSS score <15.

• Independent predictors of rupture included aneurysm size, PHASES and ELAPSS scores, posterior circulation location, and age ≥70 years.

• Aneurysms <7 mm in diameter did not rupture in this cohort, but this may reflect selection bias.

• Lifelong regular follow-up is recommended for conservatively managed UIAs, especially in the first 10 years.

• PHASES and ELAPSS score thresholds can help identify high-risk patients who may benefit from treatment.

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An Algorithm for the Microsurgical Resection of Cerebellar Cavernomas

Operative Neurosurgery 29:238–246, 2025

This study retrospectively analyzes cerebellar cavernous malformations (cCMs), presenting a tailored microsurgical treatment algorithm. Nearly half of cCM patients required surgery, with individualized approaches improving outcomes. The study highlights the rarity, management challenges, and need for further research into optimal surgical strategies for cCMs.

• Cerebellar cavernous malformations (cCMs) are rare vascular brain lesions, representing 6.5% of all CMs in a large cohort.

• Almost half (49%) of cCM patients underwent surgical treatment, with approaches tailored to lesion location using a specific algorithm.

• Surgical strategies included supracerebellar-infratentorial, telovelar, suboccipital transcortical, and retrosigmoid approaches.

• Surgically treated patients showed significant improvement in functional outcomes, with no mortality and a 27.5% morbidity rate.

• No significant risk factors for postoperative morbidity were identified, including lesion location or associated developmental venous anomalies.

• Conservative management was chosen for asymptomatic or mildly symptomatic patients; about half of cCM patients were managed this way.

• The study provides an individualized surgical algorithm and highlights the need for further research and minimally invasive techniques.

• Main limitations include retrospective single-center design, small surgical sample size, and lack of pediatric or radiation therapy cases.

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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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Relationship of blood flow, angioarchitecture, and rupture in cerebral arteriovenous malformations

J Neurosurg 143:499–504, 2025

Patients with ruptured cerebral AVMs were more likely to have deep location, deep venous drainage, lower flow, smaller nidal volume, smaller arterial feeders, and fewer draining veins than unruptured AVMs. These findings highlight the complex interplay between angioarchitecture, hemodynamics, and rupture risk.

• Lower AVM flow, smaller nidus volume, deep location, deep venous drainage, smaller arterial feeders, and fewer draining veins are associated with ruptured AVMs compared to unruptured ones.

• Male sex and deep AVM location significantly increase the risk of hemorrhagic presentation.

• AVM size and flow are not independent predictors when other variables are considered.

• Fewer draining veins, but not venous stenosis, are linked to rupture, suggesting venous outflow restriction may play a role.

• Findings support previous smaller QMRA-based studies showing lower flow is associated with rupture, despite some conflicting literature.

• Prerupture flow data are lacking; rupture itself may alter measured hemodynamics.

• Further research is needed to clarify the role of hemodynamics and venous occlusion in AVM rupture risk.

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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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Predicting the natural history of unruptured brain arteriovenous malformations: external validation of rupture risk scores

J Neurosurg 143:490–498, 2025

This retrospective study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs) and found their predictive performance ranged from nondiscriminatory to poor. The R2eD AVM scale performed best but still showed limited accuracy, highlighting the need for improved predictive models.

• The study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs): Nataf, R2eD AVM, ARI, and VALE.

• Current rupture risk scores showed nondiscriminatory to poor performance in predicting ruptured presentation in a Peruvian single-center population.

• The R2eD AVM scale had the best performance among evaluated scores, but its discrimination was still poor (AUROC 0.664).

• A logistic regression model using size, location, venous tortuosity, and ventricular involvement showed only fair discrimination (AUROC 0.709).

• Key risk factors for rupture included smaller size, periventricular/infratentorial location, absence of venous tortuosity, and ventricular involvement.

• Some variables in published scores, such as venous tortuosity and venous drainage features, were not predictive in this cohort.

• Further research and better predictive factors are needed to improve rupture risk assessment in bAVMs.

• The R2eD AVM score can be used preferentially in clinical practice, but with caution due to its limited performance.

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Quantitative Volumetric Computed Tomography Density Predicts Basal Ganglia Hemorrhage Expansion and Enhances Spot Sign Diagnostic Accuracy

Neurosurgery 97:481–488, 2025

Automated quantitative CT analysis using normalized volumetric CT density (nv-CTD) enhances prediction of basal ganglia hematoma expansion, especially when combined with the spot sign. nv-CTD offers high sensitivity for ruling out expansion and enables improved risk stratification for early intervention in intracerebral hemorrhage.

• Automated quantitative CT analysis (nv-CTD) predicts hematoma expansion (HE) in basal ganglia intracerebral hemorrhage (ICH), improving risk stratification for early surgical intervention.

• nv-CTD is calculated as mean ICH CT density divided by surrounding parenchyma density, providing a normalized measure of hemorrhage acuity.

• Lower nv-CTD (<2.3) is highly sensitive (96%) for predicting HE, while the spot sign is highly specific (95%); using both improves diagnostic accuracy (AUC 0.80 vs 0.68 for spot sign alone).

• nv-CTD alone performs similarly to the spot sign for HE prediction and can be used when CTA is unavailable, especially to rule out HE.

• Automated computer vision segmentation enables consistent, rapid, and reproducible feature extraction, overcoming limitations of manual CT interpretation.

• The study included 108 patients and used a custom-trained neural network for image analysis, excluding those with thalamic ICH, high IVH burden, or small hemorrhages.

• Limitations include retrospective design, modest sample size, and narrow inclusion criteria, which may limit generalizability.

• Volumetric and quantitative imaging analysis can augment clinical decision-making for basal ganglia ICH management.

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Imaging efficacy and safety of low dose intraventricular tissue plasminogen activator in aneurysmal subarachnoid hemorrhage

Acta Neurochirurgica (2025) 167:202

Low-dose intraventricular tPA (1 mg every 8 hours for up to 3 doses) via EVD after aneurysmal subarachnoid hemorrhage significantly accelerated subarachnoid blood clearance without hemorrhagic or infectious complications, but did not reduce shunt dependency. Larger studies are needed to assess effects on delayed cerebral ischemia.

• Low-dose intrathecal tPA (1 mg every 8 hours for up to 3 doses via EVD) was administered to 8 aSAH patients after aneurysm coiling to enhance subarachnoid blood clearance.

• Significant blood clearance was achieved: mean Hijdra Sum Score (HSS) reduction was 81.1% within 3 days, compared to 41.3% in a prior natural history cohort (p = 0.001).

• No patients experienced hemorrhagic complications or ventriculitis following IT-tPA treatment.

• Two patients (25%) developed delayed cerebral ischemia (DCI) and radiographic vasospasm, which is lower than historical rates (47.9%).

• Most patients (75%) required ventriculoperitoneal shunt placement, a higher rate than institutional averages.

• IT-tPA was well tolerated and effective for rapid clot clearance, but the impact on clinical outcomes like DCI prevention and shunt dependency remains unclear due to small sample size.

• Further randomized controlled trials are needed to determine optimal dosing, timing, and clinical benefits of IT-tPA for aSAH patients.

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Multicentre study of the role of lumbar puncture in the diagnosis of spontaneous subarachnoid haemorrhage

Acta Neurochirurgica (2025) 167:193

A multicentre UK and Ireland study found that 1% of aneurysmal subarachnoid haemorrhage (SAH) cases were diagnosed by lumbar puncture (LP) after a negative CT within 6 hours. LP remains crucial in diagnosing SAH missed by early CT, suggesting NICE guidelines may need reconsideration.

• A multicentre UK and Ireland study assessed the role of lumbar puncture (LP) in diagnosing spontaneous subarachnoid haemorrhage (SAH), especially after negative CT scans.

• Out of 10,187 spontaneous SAH cases, 7% were diagnosed by LP, with 3% of aneurysmal SAH confirmed by LP after a non-diagnostic CT.

• 1% of aneurysmal SAH cases were detected by LP following a negative CT scan performed within 6 hours of symptom onset.

• There was no significant change in diagnostic practice following the introduction of the 2022 NICE guidelines, which recommend not routinely offering LP after a negative CT within 6 hours.

• Concerns remain that relying solely on CT, especially when reported by non-expert radiologists, risks missing SAH cases.

• LP remains important for diagnosing SAH in patients with strong clinical suspicion and negative early CT, potentially impacting future NICE guidance.

• Study limitations include retrospective design, possible under-reporting, and focus on neurosurgical referrals only.

• The findings support continued use of LP in select patients despite new guidelines.

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Incidence, Management, and Outcomes of Pediatric Infectious Aneurysms

Operative Neurosurgery 29:27–33, 2025

This retrospective study reviews five pediatric cases of infectious intracranial aneurysms (IIAs) secondary to infective endocarditis. IIAs in children are rare but have high morbidity and mortality, with early surgical or endovascular intervention recommended due to frequent failure of medical management and high rerupture rates.

• Pediatric infectious intracranial aneurysms (IIAs) are rare complications, most often secondary to infective endocarditis (IE), and account for 2–14% of pediatric intracranial aneurysms.

• This retrospective study identified 5 pediatric cases of IIA among 151 children treated for IE (3%), with most patients having congenital or acquired heart disease.

• The majority (80%) presented with ruptured aneurysms causing subarachnoid hemorrhage (SAH); one was found incidentally.

• All patients were started on antibiotics, but 80% failed medical management and required surgical or endovascular intervention.

• Mortality was high: 2 of 5 patients (40%) died within a year, and only 2 survivors had good neurological outcomes (mRS <2).

• Early intervention (surgical or endovascular) is recommended for ruptured IIAs due to high rates of rerupture and medical management failure.

• A multidisciplinary approach is essential for optimal outcomes in these complex cases.

• Further studies with larger cohorts are needed to determine the best management strategies.

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Microsurgical clipping for intracranial aneurysms in elderly patients: outcomes comparable to those in younger cohorts

J Neurosurg 143:214–219, 2025

Microsurgical clipping for intracranial aneurysms in patients aged 70 and older showed complication, mortality, and functional dependence rates comparable to younger patients, supporting its safety and efficacy in selected elderly individuals. Careful patient selection remains crucial; further studies are encouraged to confirm these findings.

• Microsurgical clipping for intracranial aneurysms in elderly patients (≥70 years) shows outcomes comparable to those in younger patients (<70 years).

• A retrospective single-center study (2016–2022) matched 50 elderly with 100 younger patients using propensity score matching.

• No significant differences were found between age groups for complications, extended length of stay, nonhome discharge, functional dependence, or mortality.

• Aneurysm characteristics (location, morphology, rupture status) were similar between groups.

• Frailty and comorbidities, rather than age alone, are important predictors of outcomes after clipping.

• Study highlights the safety of microsurgical clipping in well-selected elderly patients, but emphasizes careful patient selection.

• Limitations include single-center design, possible selection bias, and influence of unmeasured confounders.

• Further research is needed to validate findings and guide patient selection for clipping in the elderly.

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Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

Operative Neurosurgery 28:808–816, 2025

This retrospective case series describes six patients with acute iatrogenic intracranial pseudoaneurysms treated with flow diverter stents. The study demonstrates that, with appropriate antiplatelet regimens and repeat angiography, flow diverters are a safe and effective treatment for these complex vascular injuries.

• Flow diverter stents (FDs) were used to treat six cases of acute iatrogenic intracranial pseudoaneurysms at a single institution.

• Most injuries occurred during tumor resection or other neurosurgical procedures, affecting various intracranial arteries.

• All injuries resulted in pseudoaneurysm formation and were treated endovascularly, mainly with pipeline embolization devices (PEDs).

• No pseudoaneurysm recurrence, rebleeding, parent artery occlusion, or stenosis was observed in patients with available follow-up imaging.

• Complications were minimal; one transient ischemic attack and one case of epistaxis occurred, with no major adverse outcomes.

• Some pseudoaneurysms were not detected on initial angiography; repeated imaging within days was critical for diagnosis.

• Proper antiplatelet regimens (aspirin and ticagrelor or clopidogrel) were essential for safe FD use.

• The study supports FDs as a safe and effective option for managing complex acute iatrogenic intracranial pseudoaneurysms, highlighting the need for early repeat angiography when suspicion is high.

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Factors affecting outcomes following burr hole drainage of chronic subdural hematoma

J Neurosurg 142:1606–1615, 2025

This large single-center retrospective study of 1226 patients found that preoperative factors—age under 80, independence, higher GCS motor score, fewer medications, and lower ASA grade—predict better outcomes after burr hole drainage for chronic subdural hematoma. Surgical drain use and shorter bed rest improved discharge outcomes, but recurrence was not linked to modifiable factors.

• Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially in elderly patients, and burr hole craniostomy (BHC) is the main surgical treatment.

• This large single-center retrospective study (n=1226) analyzed predictors of outcomes, complications, recurrence, and hospital length of stay (LOS) after BHC for CSDH.

• Favorable short-term outcomes were associated with age <80, preadmission independence, preoperative GCS motor score of 6, fewer than 5 regular medications, and ASA grades I–II.

• Use of a subdural drain and shorter postoperative bed rest (1 day vs 2 days) were linked to better outcomes and higher odds of discharge home.

• No modifiable or nonmodifiable factors, including surgical technique, were significantly associated with CSDH recurrence.

• Polypharmacy (>4 medications) and older age were associated with higher risk of complications and longer hospital LOS.

• Antithrombotic use was not significantly associated with clinical outcomes, recurrence, complications, or LOS.

• Long-term survival was mainly influenced by baseline patient factors (age, independence, GCS-M, ASA grade), not surgical variables.

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Competing pathways of intracranial aneurysm growth: linking regional growth distribution and hemodynamics

J Neurosurg 142:1741–1750, 2025

This study analyzes intracranial aneurysm growth, revealing two main mechanisms: high-flow impingement causing wall thinning (mainly in ACom aneurysms) and slow, oscillatory flow leading to wall thickening (mainly in MCA aneurysms). Findings support personalized monitoring and interventions based on regional hemodynamic environments.

• Intracranial aneurysm growth is driven by complex interactions of hemodynamic forces and wall remodeling mechanisms.

• Growth most commonly occurs in the aneurysm body and central flow regions, with patterns varying by location and morphology.

• Two main growth pathways are identified: high-flow impingement (causing wall thinning/degeneration, mainly in ACom aneurysms) and low-flow oscillatory conditions (causing wall thickening/remodeling, mainly in MCA aneurysms).

• High-flow impingement regions (neck, body, inflow) show higher wall shear stress (WSS) and are linked to wall degeneration and rupture risk.

• Low-flow regions (dome, central) have low WSS, high oscillatory shear index, and promote wall remodeling and thickening.

• Distinct growth patterns by aneurysm type suggest targeted monitoring and interventions could reduce rupture risk.

• Findings challenge the simplistic view that only one flow condition drives growth or rupture, emphasizing the need for personalized treatment strategies.

• Study limitations include model assumptions (rigid walls, Newtonian blood), subjective region labeling, and exclusion of nonhemodynamic factors.

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Clinical and radiological presentation of cavernomas according to the Zabramski classification

J Neurosurg 142:1751–1762, 2025

Most cerebral cavernous malformations (CCMs) are asymptomatic, especially Zabramski type IV. Symptoms, mainly seizures or neurological deficits, are primarily linked to Zabramski type I. Type I CCMs often regress to types II/III, but up to one-quarter develop new symptoms over time.

• Most cerebral cavernous malformations (CCMs) are asymptomatic and found incidentally on MRI.

• Zabramski classification is widely used to describe CCMs’ radiological features, but its correlation with clinical symptoms was not well established before this study.

• Zabramski type I CCMs are mostly symptomatic and associated with an unstable clinical course; types II and III are usually asymptomatic or have mild symptoms; type IV CCMs are always asymptomatic.

• Epileptic seizures are the most common presenting symptom, especially for supratentorial CCMs; infratentorial CCMs more often cause balance problems and cranial nerve deficits.

• Most Zabramski type I CCMs regress over time to type II or III; very few type II or III CCMs change to type I.

• Age is associated with Zabramski type: type I CCMs occur in younger patients, type III in older.

• Nearly all Zabramski type IV CCMs appear in patients with multiple CCMs and remain stable and asymptomatic over time.

• The Zabramski type at diagnosis can help predict the future clinical course of CCMs.

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Natural history of dolichoectatic vertebrobasilar aneurysms: a multinational study

J Neurosurg 142:1376–1386, 2025

This multinational study of 382 patients reveals dolichoectatic vertebrobasilar aneurysms (DVBAs) have a high annual mortality (10.8%) and morbidity (1.6%). Advanced age (>50 years), basilar artery location, and large aneurysm size predict worse outcomes, supporting early invasive treatment when feasible to improve prognosis.

• Dolichoectatic vertebrobasilar aneurysms (DVBAs) are rare, malignant vascular lesions with high morbidity and mortality.

• Largest multinational study to date analyzed 382 patients with DVBAs from 11 centers in Europe, US, and Japan.

• Most patients were male (68.6%), median age at diagnosis was 58.8 years.

• Annual adverse event, mortality, and morbidity rates were 12.4%, 10.8%, and 1.6% respectively.

• Older age (>50 years), basilar artery location, larger aneurysm size (>25 mm), and type II (dolichoectatic) morphology were key risk factors for poor outcomes.

• Highest risk of adverse events and death occurred within the first year after diagnosis, especially in older patients and those with basilar artery involvement.

• Early invasive treatment is encouraged when feasible, based on age and radiological characteristics.

• Study highlights urgent need for new, safer therapeutic options for DVBAs.

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A comparative study of robot‑assisted and manual pore cranial drilling and drainage for spontaneous supratentorial intracerebral hemorrhage

Neurosurgical Review (2025) 48:438

The study compares robot-assisted versus manual pore cranial drilling and drainage for spontaneous supratentorial intracerebral hemorrhage. Robot assistance showed superior outcomes in hematoma clearance, operative efficiency, and complication rates, suggesting potential advantages over manual methods, though further trials are needed for confirmation.

• Study Objective: The research compares the effectiveness of robot-assisted versus manual pore cranial drilling and drainage for treating spontaneous supratentorial intracerebral hemorrhage (SSICH).

• Key Findings: Robot-assisted techniques showed superior results in hematoma clearance, operative efficiency, and complication rates compared to manual methods.

• Technological Advantage: The use of the Remebot version 4.1.0.3 robot demonstrated enhanced precision and efficiency, leading to better surgical outcomes.

• Statistical Analysis: The study used statistical tests like ANCOVA to adjust for confounders, showing significant differences favoring robot-assisted methods in key surgical outcomes.

• Results: Robot-assisted surgeries resulted in lower postoperative hematoma volumes, higher clearance rates, shorter surgical durations, and fewer complications.

• Subgroup Analysis: Notable improvements were observed in cases with a rightward mid-line shift, highlighting the benefits of robotic assistance in complex cases.

• Future Recommendations: Further prospective, multicenter, randomized controlled trials are needed to confirm the broader applicability and cost-effectiveness of robotic techniques in neurosurgery.

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Surgical Management of Acute Subdural Hematoma: A Meta-Analysis

Neurosurgery 96:922–936, 2025

The meta-analysis evaluates surgical interventions for acute subdural hematoma, comparing craniotomy and decompressive craniectomy. It finds similar mortality and functional outcomes in matched cohorts, despite worse baseline parameters in craniectomy patients. The study emphasizes the need for future trials to validate these findings.

• Acute Subdural Hematoma (ASDH) requires urgent surgical intervention, typically through craniotomy (CO) or decompressive craniectomy (DC).

• Meta-analysis included 18 studies with 8886 patients, assessing functional outcomes and mortality rates between CO and DC.

• Functional outcomes showed similar Glasgow Outcome Scale-Extended (GOSE) scores between CO and DC, but Glasgow Outcome Scale (GOS) scores favored CO.

• Mortality analysis indicated lower short-term mortality for CO, but similar long-term mortality between CO and DC in matched cohorts.

• Complications and reoperation rates were comparable between CO and DC, with cerebrospinal fluid diversion more common in DC.

• Quality of Life (QOL) was not thoroughly assessed due to differences in measurement tools and limited data.

• The study highlights the need for further clinical trials to validate findings and address gaps in existing literature

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