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Technique and outcomes of the trans-superior articular process approach for endoscopic thoracic discectomy

J Neurosurg Spine 42:775–783, 2025

The trans-superior articular process (SAP) approach for endoscopic thoracic discectomy enables safe, minimally invasive treatment of symptomatic thoracic disc herniation, particularly in challenging upper/mid-thoracic regions, with significant improvements in pain and disability, short operative time, and low complication rates in a 38-patient series.

• Trans-superior articular process (trans-SAP) approach for endoscopic thoracic discectomy is described for symptomatic thoracic disc herniation (TDH).

• This technique creates a controlled corridor through the SAP using a Jamshidi needle and manual bone drills, minimizing facet removal and neural injury.

• Study included 38 patients (mean age 48.9), mostly with central or middle thoracic herniations.

• Mean operative time was 42 minutes, hospital stay 1.3 days, and follow-up 11.5 months.

• Significant improvements in pain (VAS) and disability (ODI) scores were observed at all follow-up points.

• Only one complication (2.6%, recurrent herniation) was reported.

• Trans-SAP approach is safe, effective, and minimally invasive, but has a steep learning curve and is not suitable for hard disc, severe myelopathy, or ossified ligament cases.

• Technique enables treatment of central and paramedian TDH and can be performed under local anesthesia.

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Factors associated with cervical instability in cervical myelopathy patients

J Neurosurg Spine 42:673–678, 2025

This study found a high prevalence (43.1%) of cervical instability in patients with cervical spondylotic myelopathy (CSM). Key factors associated with instability included cervical facet joint degeneration, increased T1 slope minus cervical lordosis (T1S−CL), and higher neck pain scores.

• Cervical instability is common in patients with cervical spondylotic myelopathy (CSM), with a prevalence of 43.1%.

• Instability was defined as ≥3-mm translational motion between adjacent vertebrae on flexion-extension radiographs.

• Key factors independently associated with cervical instability are higher cervical facet joint degeneration (FJD) scores, increased T1 slope minus cervical lordosis (T1S−CL), and higher visual analog scale (VAS) scores for neck pain.

• Age, sex, BMI, JOA score, and cervical range of motion were not significantly associated with instability.

• Facet joint degeneration plays a critical role in cervical instability, creating a cycle of degeneration and abnormal motion.

• Proper assessment of T1S−CL and FJD is essential for surgical decision-making in CSM patients.

• Study limitations include single-center design, moderate sample size, and exclusion of certain patient groups.

• Spine surgeons should pay special attention to these factors when determining treatment strategies for CSM.

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Evaluating the impact of a hand-crafted 3D-Printed head Model and virtual reality in skull base surgery training

Brain and Spine 5 (2025) 104163

A multimodal neurosurgical training course integrating hand-crafted 3D-printed head models, virtual reality, and cadaveric dissections significantly improved trainees’ anatomical understanding and surgical skills in skull base surgery. While offering a cost-effective, accessible alternative to cadaveric training, further refinement in soft tissue realism is needed.

• A hand-crafted 3D-printed head model and virtual reality (VR) were evaluated for skull base surgery training.

• A two-day course with 12 neurosurgical trainees and 11 faculty combined lectures, VR, cadaveric dissections, and hands-on practice with the 3D-printed model.

• The 3D model included four different skull base tumors and realistic neuroanatomy, assembled using patient imaging data and various materials.

• Trainees showed significant improvement in spatial understanding and knowledge of surgical steps after the course.

• Faculty and trainees rated the educational value and anatomical accuracy of the model highly, though soft tissue realism was rated lower.

• VR was found to enhance anatomical comprehension and surgical planning, complementing traditional methods.

• The approach offers a cost-effective, accessible alternative to cadaveric training, but further refinement in soft tissue simulation is needed.

• Study limitations include small sample size, subjective assessments, and lack of long-term outcome data.

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Advances of MR imaging in glioma: what the neurosurgeon needs to know

Acta Neurochirurgica (2025) 167:174

Advanced MRI techniques—including perfusion, diffusion, spectroscopy, and functional imaging—are critical in glioma diagnosis, surgical planning, and treatment monitoring. These modalities improve tumor characterization, guide safer resections, and help distinguish tumor progression from treatment effects, supporting precision neurosurgical oncology and personalized care.

• High-grade gliomas are aggressive brain tumors with poor prognosis, requiring advanced imaging for diagnosis and management.

• MRI is central throughout the patient journey, from initial detection and differential diagnosis to surgical planning, treatment response, and surveillance.

• Advanced MRI techniques—perfusion, diffusion, spectroscopy, fMRI, and DTI—improve tumor characterization, surgical planning, and assessment of infiltration and eloquent cortex involvement.

• Perfusion MRI (DSC, DCE, ASL) and DWI help distinguish high-grade gliomas from mimics and guide biopsy or surgery.

• MR spectroscopy provides metabolic information, aiding in differentiating gliomas from metastases and guiding surgical margins.

• Postoperative MRI is crucial for assessing residual tumor, complications, and radiotherapy planning.

• MRI during treatment surveillance helps differentiate true progression from pseudoprogression or radiation necrosis.

• Future advances include higher field strengths, molecular imaging, and AI integration for precision neuro-oncology.

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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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Comparative Analysis of Efficacy and Safety of Frame-Based, Frameless, and Robot-Assisted Stereotactic Brain Biopsies: A Systematic Review and Meta-Analysis

Operative Neurosurgery 28:749–761, 2025

This systematic review and meta-analysis compares frame-based, frameless, and robot-assisted stereotactic brain biopsies. Robot-assisted biopsies demonstrated non-inferior diagnostic yield and safety compared to traditional methods, with shorter operative times. Complication and mortality rates were similar across all techniques, supporting robot-assisted biopsy as an effective alternative.

• Frame-based stereotactic brain biopsy has been the gold standard for high diagnostic yield and safety, especially for complex or deep-seated lesions.

• Frameless neuronavigation and robot-assisted techniques have emerged as alternatives over the past decade.

• Meta-analysis included 92 studies: 9801 frame-based, 2665 robot-assisted, and 1862 frameless cases.

• Pooled diagnostic yields: robot-assisted 97%, frame-based 95%, frameless 94%; robot-assisted was not inferior.

• Complication and mortality rates were low and similar across all methods.

• Robot-assisted procedures had significantly shorter total operative times (mean 76.6 min) compared to frame-based (132.7 min) and frameless (97.3 min).

• Diagnostic yield for brainstem lesions was comparable between robot-assisted and frame-based approaches.

• Robot-assisted biopsy may offer workflow, comfort, and efficiency advantages, especially for certain patient groups.

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3D‑exoscopic extradural Hakuba‑Dolenc approach with manipulation of pneumatized anterior clinoid process for the prevention of cerebrospinal fluid leakage

Acta Neurochirurgica (2025) 167:165

This study describes a 3D-exoscopic extradural Hakuba-Dolenc approach with a hybrid technique for anterior clinoidectomy in cases with pneumatized anterior clinoid process, aiming to prevent cerebrospinal fluid leakage during skull base surgery. The technique was effective, with no postoperative CSF leakage observed.

• Describes a modified 3D-exoscopic extradural Hakuba-Dolenc approach to anterior clinoidectomy, focusing on preventing cerebrospinal fluid (CSF) leakage, especially in cases with pneumatized anterior clinoid process (ACP).

• The hybrid technique combines drilling and biting for safe removal of the ACP, minimizing mucosal injury and CSF leak risk.

• Preoperative thin-slice bone CT is essential to identify anatomical variations of ACP and avoid complications.

• Careful interdural dissection of the lateral cavernous wall is performed, with hemostasis for venous bleeding.

• Gelfoam is placed in the sphenoid sinus to isolate mucosa and prevent CSF leakage.

• The approach was effective, with no CSF leakage or neurological deficits postoperatively and at 3-month follow-up.

• Key risks include CSF rhinorrhea and potential optic nerve injury; patients should be informed preoperatively.

• Technique is indicated for paraclinoid aneurysm and certain skull base tumors.

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Comparison of outcomes between cervical disc arthroplasty and anterior cervical discectomy and fusion for the treatment of cervical spondylotic myelopathy

J Neurosurg Spine 42:705–717, 2025

This systematic review and meta-analysis evaluates the outcomes of cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) in treating cervical spondylotic myelopathy (CSM). Based on 12 randomized controlled trials including 2,612 patients, the study found that CDA shows superior clinical effectiveness and a more favorable safety profile than ACDF. Neck pain improvement (VAS) with CDA was clinically meaningful within the first postoperative year. CDA also had lower reoperation rates and reduced incidence of adjacent segment disease (ASD), although with slightly longer operative times. Further high-quality, large-scale trials are needed to confirm these findings.
Key Points
• • Objective: Compare the efficacy and safety of CDA vs. ACDF in CSM patients through meta-analysis.
• • Methods: 12 RCTs with 2,612 patients (1,464 CDA, 1,148 ACDF); outcomes included NDI, VAS, ROM, SF-36, complications, and reoperations.
• • Overall success: Higher in CDA group (RR 1.21; p = 0.004).
• • Neck pain (VAS): Significantly improved in CDA up to 12 months post-op; clinically meaningful.
• • Arm pain (VAS): Slight improvement at 3 and 12 months; not clinically significant.
• • NDI scores: Statistically better in CDA, though often below MCID thresholds.
• • ROM: Better preserved in CDA; data limited and heterogeneous.
• • Quality of life (SF-36): No significant differences between groups.
• • Operative time: Longer in CDA (MD 18.75 min; p < 0.00001).
• • Complications: Similar blood loss and adverse event rates; lower ASD and reoperation rates in CDA.
• • Limitations: Limited CSM-specific data, inconsistent surgical protocols, and risk of bias in several trials.
• • Conclusion: CDA offers better early clinical outcomes and fewer mechanical complications than ACDF, but broader validation is needed.

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Dynamic Craniotomy With Khanna NuCrani Plates as an Alternative to Craniotomy With Fixed Plates in Traumatic Brain Injury

Neurosurgery 96:1353–1363, 2025

Dynamic craniotomy using Khanna NuCrani expandable plates allows reversible outward bone flap movement, accommodating postoperative brain swelling in traumatic brain injury. This technique reduced intracranial pressure, avoided repeat surgeries, and improved outcomes compared to fixed plate craniotomy or decompressive craniectomy.

• Dynamic craniotomy with Khanna NuCrani plates allows reversible outward movement of the bone flap, accommodating postoperative brain swelling and hemorrhage in traumatic brain injury patients.

• In a series of 25 patients, 84% experienced postoperative swelling, all compensated by outward bone flap migration, with no need for reoperation, cranioplasty, or wound healing complications.

• All patients had normal postoperative intracranial pressures, and 84% achieved good outcomes; mortality was 16%, related to injury severity and age, not surgical failure.

• Dynamic craniotomy reduced the need for repeat surgeries compared to fixed plate craniotomy and decompressive craniectomy, and avoided complications like bone flap failure and syndrome of the trephined.

• Bone flaps retracted to anatomic positions after swelling resolved, with no cosmetic complaints reported.

• Dynamic plates prevent the bone flap from sinking and tolerate significant increases in intracranial volume while maintaining normal ICP.

• The technique may offer substantial cost savings by reducing repeat surgeries and complications, with estimated savings of $68,000 to $85,000 per patient.

• Dynamic craniotomy is proposed as a hybrid alternative to fixed plate craniotomy and decompressive craniectomy, offering immediate intracranial volume expansion and fewer complications.

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Comprehensive Morphometric Analysis to Identify Key Neuroimaging Biomarkers for the Diagnosis of Adult Hydrocephalus Using Artificial Intelligence

Neurosurgery 96:1386–1396, 2025

This study used AI and SHAP analysis to identify five key, easily measurable 1-D neuroimaging biomarkers—FTHR, MEI, MCMI, SMLH, and CPCA—for accurately diagnosing adult non-normal pressure hydrocephalus, offering a practical, standardized, and interpretable approach to improve early detection and clinical decision-making.

• Hydrocephalus diagnosis is often inconsistent due to reliance on clinical and qualitative radiological assessments.

• This study used artificial intelligence (AI) and SHAP analysis to identify key, easily measurable neuroimaging biomarkers for adult non-normal pressure hydrocephalus (non-NPH).

• A comprehensive set of 21 morphometric features was analyzed from MRI images of 42 adult non-NPH patients and 40 healthy controls.

• Gradient Boosting was the best-performing AI classifier, achieving 0.94 accuracy and 0.97 AUC.

• Ventricular volume is the most important biomarker, but measurement is complex for clinicians.

• Five key 1-D biomarkers identified are: frontal-temporal horn ratio (FTHR), modified Evans index (MEI), modified cella media index (MCMI), sagittal maximum lateral ventricle height (SMLH), and coronal posterior callosal angle (CPCA).

• These five markers are easily measurable and provide high diagnostic accuracy, supporting practical clinical use.

• The approach addresses multicollinearity and improves diagnostic standardization, but further validation with larger datasets is needed.

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Spinal Anesthesia for Multilevel Awake Minimally Invasive Transforaminal Lumbar Interbody Fusion

Operative Neurosurgery 28:855–861, 2025

This retrospective study found that multilevel awake minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anesthesia is safe and effective, with minimal blood loss, good pain control, and short hospital stays, supporting its use even in complex cases for improved patient outcomes.

• Multilevel awake minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anesthesia is safe and effective for complex lumbar spine cases.

• A retrospective review of 16 patients (mostly two-level procedures) showed no new neurological deficits and all were discharged home without complications.

• Median age was 69.5 years; common comorbidities included hypertension, obesity, and sleep apnea.

• Median operative time was 156 minutes, with low median blood loss (50 mL) and a median hospital stay of 2 days.

• Postoperative pain was well controlled, most commonly using methocarbamol and short-duration opioids.

• 93.75% of patients reported significant symptomatic improvement at follow-up.

• Awake MIS-TLIF offers benefits over general anesthesia, such as faster recovery, shorter hospital stays, and fewer side effects.

• Study limitations include small sample size and retrospective design; further research is needed.

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Historical evolution, management, and outcome of surgical treatment for high-grade spondylolisthesis

J Neurosurg Spine 42:784–796, 2025

This systematic review analyzes the evolution and outcomes of surgical techniques for high-grade spondylolisthesis (HGSL). Both reduction and in situ fusion are effective, but reduction carries higher neurological risk and in situ fusion higher nonunion risk. Larger, high-quality studies are needed to guide optimal patient-specific treatment.

• High-grade spondylolisthesis (HGSL) is defined as vertebral slippage >50% (Meyerding grade 3–5) and is rare, with no consensus on optimal surgical management.

• Surgical approaches are divided into reduction and fusion versus in situ fusion, with no gold-standard technique established.

• Reduction techniques are linked to more neurological complications, while in situ fusion (especially older techniques like Bohlman’s) has higher rates of nonunion and graft failure.

• Modifications using transsacral transvertebral screws and titanium cages have reduced nonunion and graft failure rates in in situ fusion.

• Most patients, regardless of technique, report good postoperative outcomes in pain and function.

• Choice of technique should be individualized, considering factors like sacropelvic orientation, pelvic balance, slip angle, and dysplastic features.

• Current evidence is limited to small, heterogeneous case series and reports; no prospective studies exist.

• Larger, well-designed prospective studies are strongly recommended before widespread recommendations can be made.

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High-Accuracy Augmented Reality Guidance for Intracranial Drain Placement Using a Standalone Head-Worn Navigation System

Neurosurgery 96:1217–1226, 2025

A standalone augmented reality (AR) headset navigation system was clinically validated for external ventricular drain (EVD) placement, demonstrating improved accuracy, higher first-attempt success, and reduced complications compared to freehand technique, supporting AR as a safe, effective, and ergonomic alternative for neurosurgical procedures.

• A standalone head-worn augmented reality (AR) navigation system was developed for external ventricular drain (EVD) placement.

• A prospective clinical pilot study compared AR-guided EVD placement to freehand technique in emergency/ICU settings.

• AR guidance achieved 100% functional first-attempt placements, significantly higher optimal placement rates, and lower complication and revision rates than freehand.

• Placement quality was evaluated with an extended modified Kakarla scale and all AR placements were functional on the first attempt.

• The AR system used high-accuracy inside-out infrared tracking and real-time 3D anatomical overlays for planning and guidance.

• Complications in the AR group were fewer and less severe, with errors attributed to hardware misuse rather than the AR guidance itself.

• Surgeons reported good acceptance and ease of use of the AR system, with minimal workflow disruption.

• A multicenter randomized controlled trial is planned to further validate these findings.

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Cost and operating room time savings with single-position prone lateral lumbar interbody circumferential fusion

J Neurosurg Spine 42:768–774, 2025

Single-position prone lateral lumbar interbody fusion (LLIF+PPS) reduces operating room time and costs compared to dual-position surgery, especially for 2-level fusions, while maintaining similar hospital stays and clinical outcomes. Cost savings are most significant in complex, multilevel cases due to eliminated patient repositioning.

• Single-position (SP) prone lateral lumbar interbody fusion (LLIF) eliminates patient repositioning compared to dual-position (DP) LLIF+PPS.

• Study compared costs, operating room (OR) time, and hospital stay between SP and DP LLIF+PPS for 1- and 2-level fusions.

• For 2-level fusions, SP surgery had significantly shorter OR time, lower OR and anesthesiology costs than DP surgery.

• For 1-level fusions, differences in OR time and costs between SP and DP were not statistically significant.

• Hospital length of stay was similar between SP and DP groups for both 1- and 2-level fusions.

• Both approaches showed similar safety, fusion rates, and patient-reported outcomes after at least 1 year.

• SP prone LLIF+PPS is most beneficial for complex, multi-level cases, offering efficiency and cost savings.

• Further studies with larger cohorts are needed to confirm these findings.

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Impact of patient positioning on bleeding rate in stereotactic brain biopsies: semi‑sitting versus supine position

Acta Neurochirurgica (2025) 167:159

The study found that using a semi-sitting position (30° head elevation) during stereotactic brain biopsies significantly reduced the rate of hemorrhagic complications compared to the supine position, suggesting patient positioning is a key, modifiable factor for improving safety and outcomes in these neurosurgical procedures.

• Study compared bleeding rates in stereotactic brain biopsies between semi-sitting and supine positions.

• Retrospective analysis of 78 patients: 39 semi-sitting, 39 supine.

• Hemorrhagic complications were significantly lower in the semi-sitting group (7.7%) vs supine (33.3%).

• Semi-sitting position is a potential protective factor against bleeding (OR 0.17, p=0.009).

• Groups were similar in age, sex, tumor type, and biopsy site; more samples were taken in semi-sitting group.

• No symptomatic bleedings occurred in either group.

• Semi-sitting position may reduce intracranial venous pressure, lowering bleeding risk.

• Authors recommend further prospective, multicenter studies to validate findings.

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Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines Update for the Role of Emerging Therapies in the Management of Patients With Metastatic Brain Tumors

Neurosurgery 96:1172–1177, 2025

This 2025 CNS guideline update reviews evidence for emerging therapies in adult brain metastases, providing new recommendations on targeted therapies, immunotherapy, radiosensitizers, and laser interstitial thermal therapy, while noting insufficient evidence for some modalities. Recommendations aim to guide multidisciplinary management beyond standard surgical and radiation treatments.

• This guideline is an updated systematic review on emerging therapies for adult patients with metastatic brain tumors (MBTs), focusing on evidence-based recommendations.

• Targeted therapies and immunotherapies have the strongest new evidence, especially for NSCLC, melanoma, and breast cancer brain metastases.

• Level I recommendations include the use of specific agents such as icotinib with WBRT for EGFR-mutant NSCLC, alectinib for ALK-positive NSCLC, and dabrafenib plus trametinib for BRAFV600E-positive melanoma.

• Immune checkpoint inhibitors (e.g., ipilimumab plus nivolumab for melanoma, ICIs for NSCLC) are recommended to improve survival and intracranial control in selected patients.

• Laser interstitial thermal therapy (LITT) may be considered equivalent to craniotomy or medical management in certain cases of tumor progression or radiation necrosis after SRS.

• There is insufficient evidence to recommend interstitial modalities or high-intensity focused ultrasound (HIFU) for brain metastases.

• Future research should prioritize prospective, comparative studies for modalities like LITT and HIFU, and the guideline will be updated as new evidence emerges.

• Clinical decisions should be individualized, and participation in clinical trials is encouraged to refine treatment strategies for MBTs.

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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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Decoding Glioblastoma Heterogeneity: Neuroimaging Meets Machine Learning

Neurosurgery 96:1181–1192, 2025

This review highlights how advanced neuroimaging and machine learning, especially radiomics and deep learning models, are transforming the noninvasive diagnosis, molecular characterization, and prognosis prediction in IDH-wildtype glioblastoma, offering improved patient stratification and personalized treatment strategies while emphasizing the need for further clinical integration.

• Neuroimaging and machine learning have greatly improved diagnosis, classification, and prognosis of IDH-wildtype glioblastoma, a highly heterogeneous and aggressive brain tumor.

• Advanced MRI techniques, including diffusion tensor imaging (DTI) and radiomics, provide noninvasive insights into tumor infiltration, metabolic profiles, and microstructural changes.

• Machine learning algorithms, especially CNNs, enhance glioblastoma characterization, enabling accurate prediction of genetic mutations, IDH status, tumor subtypes, and survival outcomes.

• Radiomics extracts quantitative features from neuroimages, serving as potential biomarkers for tumor classification, prognosis, and guiding treatment strategies.

• Integration of radiomics and machine learning helps differentiate pseudoprogression from true tumor progression and predicts patterns of tumor invasion and recurrence.

• Imaging biomarkers and machine learning models are promising but remain complementary to molecular diagnostics and are not yet standard in clinical practice.

• Ongoing research aims to refine models, integrate emerging imaging techniques, and better link imaging features to underlying molecular processes for personalized therapy.

• The synergy of neuroimaging and AI is expected to enable noninvasive, precision management and better outcomes for glioblastoma patients.

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