Month: August 2025

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AtlasGPT: a language model grounded in neurosurgery with domain-specific data and document retrieval

J Neurosurg 143:560–567, 2025

AtlasGPT, a neurosurgery-specific large language model grounded in expert-verified sources and retrieval-augmented generation, outperformed GPT-4 and Gemini Advanced on a neurosurgery board exam, showed greater resistance to medical misinformation, and generated more comprehensive, relevant, and well-referenced answer explanations than standard preparation materials.

• AtlasGPT is a neurosurgery-specific large language model (LLM) built on GPT-4 with retrieval-augmented generation (RAG) from trusted neurosurgical sources.

• AtlasGPT outperformed GPT-4 and Gemini Advanced on a 149-question neurosurgery board exam (accuracy: 90.6% vs 80.5%).

• AtlasGPT showed the highest accuracy on spine and imaging-based questions, even without access to image data.

• In adversarial testing, AtlasGPT was more robust to misinformation, being fooled only 14% of the time, compared to 44% for GPT-4 and 68% for Gemini Advanced.

• Expert neurosurgeons rated AtlasGPT’s explanations as more comprehensive, relevant, and better referenced than official board prep materials.

• AtlasGPT did not produce hallucinations or harmful content in its responses.

• The study suggests domain-specific LLMs like AtlasGPT can enhance medical education, decision-making, and exam preparation in complex fields.

• Limitations include use of a single question bank and need for broader source material in future work.

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Perioperative Evaluation and Monitoring of Percutaneous Balloon Compression in Treatment of Trigeminal Neuralgia

Operative Neurosurgery 29:263–270, 2025

This prospective study found that higher intraluminal balloon pressure during percutaneous balloon compression for trigeminal neuralgia reduces long-term pain recurrence without increasing persistent facial numbness. Preoperative MRI-based Meckel’s cave assessment and intraoperative pressure monitoring help optimize outcomes and balance pain relief with sensory side effects.

• Percutaneous balloon compression (PBC) is used to treat trigeminal neuralgia (TN), with outcomes influenced by intraluminal balloon pressure, balloon volume, and Meckel’s cave volume.

• Preoperative high-resolution MRI enables 3D reconstruction of Meckel’s cave, aiding in predicting intraoperative balloon volume.

• Intraoperative monitoring of balloon pressure and volume was performed in 37 patients; primary outcomes were facial numbness and pain recurrence up to 24 months.

• Facial numbness was common in the first month (38%), but typically resolved by 24 months; numbness was not linked to balloon pressure.

• TN recurrence rate was about 25% at 24 months and was significantly associated with lower intraluminal balloon pressure.

• No significant differences in Meckel’s cave or balloon volume were observed between subgroups, but Meckel’s cave volume correlated positively with balloon volume.

• Authors recommend maintaining intraluminal balloon pressure around 135.7 ± 27.1 kPa (with 120 seconds compression) to minimize recurrence without increasing sensory deficits.

• Perioperative assessment of balloon compression (including MRI and pressure monitoring) is feasible and may help balance TN recurrence risk and sensory complications.

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Predictors of dural venous sinus pressure gradient in patients with idiopathic intracranial hypertension

J Neurosurg 143:543–549, 2025

• Venous sinus stenosis (VSS) may cause raised intracranial pressure (ICP) in idiopathic intracranial hypertension (IIH) via impaired venous outflow.

• This study identified predictors of elevated cerebral venous pressure gradient (CVPG) in IIH patients using venous manometry (VM).

• Key predictors of elevated CVPG include: childbearing age, African American race, obesity (BMI ≥ 30), papilledema, pulsatile tinnitus, focal VSS with unilateral dominance on MRV, and opening pressure on lumbar puncture (LP) ≥ 25 cm H₂O.

• Papilledema and pulsatile tinnitus showed the highest sensitivity and specificity among symptoms for predicting elevated CVPG.

• MRV is a useful noninvasive screening tool for VSS, but confirmation by VM is needed.

• An LP opening pressure ≥ 25 cm H₂O is an optimal threshold to refer IIH patients for VM.

• Obesity and younger age are strongly associated with elevated CVPG.

• Venous sinus stenting is a promising therapy for medically refractory IIH with elevated CVPG.

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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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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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Does Transforaminal Endoscopic Lumbar Discectomy Provide More Value than Microdiscectomy?

Operative Neurosurgery 29:209–218, 2025

Microdiscectomy (MD) provided greater value than transforaminal endoscopic discectomy (TED) for lumbar disc herniations at this institution, with higher improvement in patient-reported outcomes per dollar spent and shorter operative times. TED had higher costs and a steeper learning curve, but similar reoperation rates.

• This study compares the value of transforaminal endoscopic lumbar discectomy (TED) and microdiscectomy (MD) for lumbar disc herniation using a novel Operative Value Index (OVI).

• OVI measures percent change in Oswestry Disability Index (ODI) per $1000 spent intraoperatively, integrating patient outcomes and time-driven activity-based costing.

• MD had a significantly higher OVI, lower operative times, and lower intraoperative costs than TED; no significant difference in length of stay or reoperation rates was found.

• Only 43.5% of TED cases achieved clinically important improvement (MCID), compared to 66.3% for MD.

• TED was mainly used for foraminal herniations and had a higher proportion of older patients and comorbidities.

• Longer OR setup times and higher costs for TED may relate to the learning curve and surgeon experience.

• Authors suggest OVI is a practical, real-time value metric but note limitations including small TED sample size and retrospective design.

• Future studies should assess long-term outcomes, total episode costs, and track OVI as surgeons gain TED experience.

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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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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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The role of XLIF in spinal revision surgery involving failed interbody implants

Acta Neurochirurgica (2025) 167:221

This review evaluates the use of Extreme Lateral Interbody Fusion (XLIF) for removing failed spinal implants. XLIF offers advantages over traditional approaches, including reduced operative risk, blood loss, and hospital stay, but requires surgical expertise due to potential nerve and vascular complications.

• XLIF (Extreme Lateral Interbody Fusion) is increasingly used for spinal revision surgery to remove failed interbody implants and other foreign bodies.

• A systematic literature review identified only a few published cases (seven documented, four included) using XLIF for this purpose.

• XLIF offers advantages over anterior and posterior approaches, including reduced operative time, less blood loss, shorter hospital stays, and safer navigation around scar tissue and neurovascular structures.

• The technique allows for insertion of larger interbody cages, improving spinal stability and fusion outcomes.

• Most reported complications are minor and transient, such as temporary nerve injury, but careful patient selection and surgical expertise are required.

• XLIF is especially valuable in complex revision cases where traditional approaches pose higher risks due to scar tissue or anatomical challenges.

• Current evidence is limited to case reports and small series; more robust studies are needed to validate safety and efficacy.

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Laser interstitial thermal therapy for high-grade glioma: a systematic review, meta-analysis, and meta-regression

Neurosurg Focus 59(2):E10, 2025

Laser interstitial thermal therapy (LITT) is a minimally invasive treatment for high-grade glioma (HGG) showing mean overall survival of 11.7 months and progression-free survival of 5.3 months. LITT offers acceptable safety, especially for deep or unresectable tumors, but further randomized studies are needed to confirm long-term efficacy.

• Laser interstitial thermal therapy (LITT) is a minimally invasive treatment for high-grade glioma (HGG), especially in deep-seated or unresectable tumors.

• A systematic review and meta-analysis of 21 studies including 602 patients found mean overall survival (OS) after LITT was 11.74 months and mean progression-free survival (PFS) was 5.3 months.

• 6-, 12-, and 24-month OS rates were 77.0%, 48.9%, and 16.1%; PFS rates were 37.1%, 12.8%, and 4.3%, respectively.

• Permanent postoperative deficits occurred in 5.7% of patients, with higher rates in newly diagnosed HGG than recurrent cases (4.15% vs 0.02%).

• Tumor progression after LITT was observed in about 80% of patients, and overall mortality was 67.7%.

• Deep/unresectable tumors and IDH-wildtype mutations were associated with worse outcomes; smaller tumor size and higher baseline KPS predicted better survival.

• LITT showed acceptable safety and feasibility, but randomized prospective studies are needed to confirm long-term efficacy.

• Common complications included hemiparesis, weakness, and temporary neurological deficits.

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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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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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High-grade glioma: combined use of 5-aminolevulinic acid and intraoperative ultrasound for resection and a predictor algorithm for detection

J Neurosurg 143:323–331, 2025

Combining 5-aminolevulinic acid (5-ALA) fluorescence and intraoperative ultrasound (ioUS) significantly improved the sensitivity and specificity for detecting high-grade glioma during surgery, compared to either technique alone. A machine learning algorithm (HGGPredictor) further enhanced intraoperative tumor margin prediction, suggesting a new standard for safer, more effective resections.

• Combining 5-ALA fluorescence and intraoperative ultrasound (ioUS) improves the accuracy of high-grade glioma (HGG) resection compared to using either method alone.

• 5-ALA shows higher sensitivity (84.9%), while ioUS provides higher specificity (84.5%); combined, they reach sensitivity of 91% and specificity of 86%.

• The combined approach is especially valuable for maximizing tumor removal while minimizing neurological damage, particularly near eloquent brain regions.

• A machine learning algorithm (HGGPredictor) was developed to predict tumor presence during surgery based on 5-ALA and ioUS results.

• The study included 72 patients and 301 biopsies, with histological analysis as the reference standard.

• The benefit of combination is greatest for strong fluorescence or hyperechogenicity; ioUS is particularly helpful when 5-ALA fluorescence is weak.

• The combined method is accessible and can be integrated into existing surgical protocols without major additional costs.

• Limitations include single-center design and lack of a control group, but results suggest a new standard for HGG resection.

 

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Intraoperative brain tumor classification via laser-induced fluorescence spectroscopy and machine learning

J Neurosurg 143:313–322, 2025

A laser-based device, TumorID, combined with machine learning, rapidly and nondestructively classifies brain tumor tissue intraoperatively. Tested on 46 patients, it distinguished glioma, meningioma, pituitary adenoma, and normal tissue with high accuracy, offering potential to improve neurosurgical decision-making and outcomes

• TumorID is a laser-induced endogenous fluorescence spectroscopy device paired with machine learning for rapid intraoperative brain tumor classification.

• It distinguishes glioma, meningioma, pituitary adenoma, and nonneoplastic tissue in near real time using a 405-nm laser and support vector machine (SVM) algorithm.

• The device requires only 0.5 seconds per scan and does not damage tissue.

• In a study of 46 patients and 761 scans, TumorID achieved a multiclass AUROC of 0.809, demonstrating high classification accuracy.

• Neutral porphyrin emission regions were most significant for tissue differentiation.

• TumorID offers objective, fast, and nondestructive tissue diagnostics, potentially improving surgical decision-making and resection outcomes.

• Future directions include in vivo use, prediction of tumor subtypes and genetics, and integration with other data sources for improved accuracy.

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Is FLAIRectomy Directly Correlated with Prolonged Survival in Glioblastoma? A Prospective National Multicenter Study on Correlation Between Extent of Tumor Resection and Clinical Outcome

Neurosurgery 97:489–500, 2025

This multicenter prospective study shows that the extent of FLAIRectomy (resection of FLAIR-positive areas) in glioblastoma is a stronger predictor of survival than traditional resection, with higher EOFR significantly improving progression-free and overall survival, especially in IDH-mutant tumors, without increasing neurological complications.

• FLAIRectomy, or resection of FLAIR-MRI hyperintense regions beyond the contrast-enhancing tumor, was studied in a prospective multicenter cohort of 150 glioblastoma patients.

• A higher extent of FLAIR resection (EOFR) was associated with significantly improved overall survival (OS) and progression-free survival (PFS), more so than resection of contrast-enhancing tumor alone.

• Each 1% increase in EOFR correlated with a 6.8% reduction in mortality risk for IDH-wildtype and 12.1% for IDH-mutant tumors.

• Mean OS was 28.4 months and mean PFS was 16.3 months in the study cohort.

• IDH1 mutation status was also associated with longer survival, but EOFR remained an independent predictor after adjustment.

• AI analysis confirmed that patients with higher EOFR clustered with longer survival.

• Neurological safety was addressed with intraoperative neuromonitoring and careful planning; permanent deficits occurred in 9/150 patients.

• The study concludes that FLAIR-based supramarginal resection may be a more reliable predictor of survival in glioblastoma than conventional imaging-guided resection.

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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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Feasibility, Safety, and Impact of Awake Resection for Recurrent Insular Diffuse Gliomas in Adults

Neurosurgery 97:399–409, 2025

Function-based transopercular awake resection for recurrent insular diffuse gliomas in adults is feasible and safe, with similar resection rates, complications, and outcomes as first-time surgery, though prior combined treatments may increase intraoperative cooperation difficulties and sick leave, especially in high-grade gliomas.

• Transopercular awake resection for recurrent insular diffuse gliomas is feasible and safe, showing similar resection rates and outcomes to first-time surgery.

• No significant increase in intraoperative adverse events or surgery-related complications was observed for recurrent cases compared to first-line surgeries.

• Patients with previous combined oncological treatments had a higher risk of insufficient intraoperative cooperation, but this did not lead to mapping failure.

• Extent of resection and 6-month postoperative outcomes (Karnofsky Performance Status, seizure control, sick leave) were similar between recurrent and first-line groups.

• Longer sick leave was associated with high-grade gliomas and adjuvant treatments, not with surgery type.

• Shorter awake phase duration was observed in recurrent cases, likely due to easier access from prior surgeries and smaller tumor volumes.

• Study supports careful preoperative counseling and patient selection, especially for those with previous combined treatments.

• Results are specific to adult insular glioma patients treated with transopercular awake surgery and may not generalize to other populations or techniques.

 

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