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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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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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Anatomy of the superior hypogastric plexus and its relevance to anterior lumbar interbody fusion

J Neurosurg Spine 43:19–25, 2025

This cadaveric study details the anatomy of the superior hypogastric plexus (SHP) at L5–S1, its variations, and implications for anterior lumbar interbody fusion (ALIF). The authors recommend left-sided SHP retraction to minimize nerve injury and retrograde ejaculation; if unfeasible, midline splitting and lateral mobilization are advised.

• The study examined the anatomy of the superior hypogastric plexus (SHP) at the L5–S1 level and its relevance to anterior lumbar interbody fusion (ALIF) surgery.

• Injury to the SHP during ALIF can cause retrograde ejaculation (RE) in males and sexual dysfunction in females.

• The SHP typically overlays the midline at L5–S1 with a slight leftward shift and is covered by connective tissue beneath the peritoneum.

• Three morphological types of SHP were found: single cord, plexiform, and fiber; the plexus divides into hypogastric nerves below the aortic bifurcation.

• Retraction of the SHP to the left side is generally more feasible (up to 15.3 mm) than to the right (up to 5.3 mm); left-sided retraction is recommended.

• If left retraction is not possible, splitting the SHP at the midline and retracting both components laterally is advised.

• Careful SHP mobilization and avoidance of electrocautery are crucial to reduce risk of RE and sexual dysfunction in ALIF patients.

• The findings highlight the importance of detailed SHP anatomy knowledge for safer ALIF, especially with minimally invasive approaches.

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A survival analysis for predictors of implant subsidence following 1- or 2-level transforaminal lumbar interbody fusion

J Neurosurg Spine 43:42–51, 2025

This study found that after 1- or 2-level TLIF, aggressive disc height restoration and taller interbody implants significantly increase the risk of implant subsidence, especially in patients with poor bone quality. Surgeons should balance correction goals with subsidence risk, particularly in those with low Hounsfield unit measurements.

• This study analyzed predictors of interbody implant subsidence after 1- or 2-level transforaminal lumbar interbody fusion (TLIF) using a time-to-event (survival) analysis.

• Aggressive disc height restoration and use of taller interbody implants significantly increased the risk of subsidence.

• Poor baseline bone quality, measured by lower Hounsfield units (HU) on CT, was a strong independent predictor for significant (≥4 mm) subsidence.

• Longer fusion constructs (more instrumented levels) also increased the risk of significant subsidence.

• No significant association was found between cage material (titanium vs PEEK), device geometry, or lumbopelvic parameters and subsidence risk.

• Subsidence occurred in 38.2% of levels (≥2 mm) and significant subsidence in 10.4% (≥4 mm) by last follow-up.

• Clinical implications suggest balancing correction goals with subsidence risk, especially in patients with poor bone quality.

• Further multicenter and prospective studies are recommended to validate these findings.

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Segmental and overall lumbar lordosis after single-level minimally invasive transforaminal lumbar interbody fusion: a systematic review and meta-analysis

J Neurosurg Spine 43:70–82, 2025

This systematic review and meta-analysis found that single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves segmental and overall lumbar lordosis, with preoperative alignment and use of expandable cages predicting postoperative lordosis. Greater segmental lordosis improvement was associated with reduced leg pain, but clinical outcome correlations were otherwise limited.

• Single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves or slightly increases segmental and overall lumbar lordosis.

• Meta-analysis of 35 studies (1935 patients) showed significant but modest increases in segmental lordosis (mean +2.2°) and lumbar lordosis (mean +2.8°) postoperatively.

• Preoperative alignment and use of expandable cages are significant predictors of postoperative lordosis change.

• Greater improvement in segmental lordosis was associated with larger reductions in postoperative leg pain, but no strong correlation with other clinical outcomes was found.

• Most included studies were retrospective case series, with high heterogeneity in surgical technique and reporting.

• No significant association was found between facetectomy type, operative bed, or fixation technique and changes in lordosis.

• The main goal of MI-TLIF is neural decompression and fusion, not alignment correction; alternative approaches may be needed for major lordosis restoration.

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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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