Postoperative C5 palsy is a debilitating complication of cervical spine surgery with unclear etiology. A previous study of 12 patients proposed a three-variable model to predict postoperative C5 palsy based on MRI measurements of the anteroposterior diameter of the spinal canal (APD), foraminal diameter (FD), and cord-lamina angle (CLA). The initial paper reported an area under the receiver operating characteristic (ROC) curve (AUC) of 0.97, with a sensitivity of 91% and specificity of 100%. This study aimed to validate the three-variable model and its individual components in a larger patient cohort. Adult patients who underwent anterior or posterior cervical discectomy and fusion at C4-5 with subsequent C5 palsy were retrospectively identified (2010-2023). Postoperative C5 palsy was defined as a new or increased deltoid/biceps weakness on manual motor testing. Patients with C5 palsy were propensity score-matched 1 to 3 to a control group based on age, sex, Charlson Comorbidity Index score, procedure type, and levels fused. A biostatistician used the APD, FD, and CLA MRI measurements to calculate ROC curves, sensitivities, and specificities for single- and three-variable predictive models of postoperative C5 palsy. A total of 42 patients with C5 palsy were matched to 126 controls. There were no significant differences in preoperative APD (mean 9.20 vs 9.45 mm, p = 0.426), minimum FD (mean 1.82 vs 1.90 mm, p = 0.609), or maximum CLA (mean 38.8° vs 38.5°, p = 0.867) between the C5 palsy and control groups. The APD had an AUC of 0.455, sensitivity of 0.912, and specificity of 0.148. The minimum FD had an AUC of 0.501, sensitivity of 0.765, and specificity of 0.330. The maximum CLA had an AUC of 0.513, sensitivity of 0.765, and specificity of 0.348. When applied collectively, the three-variable predictive model performed similarly to chance, yielding an AUC of 0.519 (95% CI 0.410-0.628), sensitivity of 0.676, and specificity of 0.452. In a large, well-matched validation cohort, the preoperative MRI parameters of the APD, FD, and CLA were not predictive of postoperative C5 palsy, both individually and as a three-variable model. The etiology of C5 palsy remains poorly understood and reliable preoperative predictors have yet to be identified. The previously proposed three-variable model demonstrated inconsistent predictive utility for postoperative C5 palsy, and the model should be interpreted with caution before more rigorous external validation.
Craniofacial distraction osteogenesis (DO) is an established technique for the management of complex craniosynostosis but remains limited by the morbidity associated with external activation ports, including infection, wound breakdown, CSF leakage, and mechanical failure. The magnet-actuated craniofacial (MAC) distraction system was developed to eliminate externalized activation components by enabling fully internalized, contactless, noninvasive actuation. The authors of this study aim to evaluate the surgical feasibility, mechanical reliability, and positional stability of the MAC system in a cadaveric human cranial model. The MAC system was subjected to comprehensive preclinical biomedical and mechanical engineering validation, including finite element analysis, benchtop force-torque testing, magnetic coupling characterization, and assessment of back-drivability resistance and torque-limiting safety features. Following validation, the system was implanted in preserved cadaveric human heads. Devices were placed in a parasagittal coronal configuration. After a latency period, distraction was performed at a rate of 1 mm/day for 10 days, followed by a simulated 60-day consolidation period. CT imaging was performed at predefined intervals to assess device position, distraction distance, and positional stability. Preclinical testing demonstrated that the MAC system maintained structural integrity under loads exceeding those expected during craniofacial distraction, with a minimum factor of safety of 3 and no evidence of material yielding or mechanical instability. In the cadaveric model, device implantation was surgically feasible without anatomical conflict. An average distraction of 6-9 mm was achieved with controlled, incremental advancement. No device migration, hardware loosening, or unintended back-drivability was observed during active distraction or consolidation. The device maintained the achieved distraction distance at the end of the consolidation period. This cadaveric feasibility study demonstrates that a fully internalized MAC distraction system can achieve controlled, stable cranial vault distraction without the need for external activation ports. The MAC system exhibited reliable mechanical performance, positional stability, and resistance to back-drivability under anatomically relevant conditions. These findings support further in vivo investigation of biological responses, long-term durability, and clinical safety prior to translation to pediatric craniofacial surgery.
This study examines the recovery rates of patients who experience postoperative dysphagia within 1 month following cervical spine surgery. Data from a prospectively maintained multi-institutional quality registry were retrospectively analyzed. Eating Assessment Tool-10 (EAT-10) questionnaire scores were collected at baseline and 1, 3, and 12 months postoperatively, with total scores ≥ 3 indicating dysphagia. Patients were grouped by whether they reported baseline dysphagia to assess the impact of baseline dysphagia on recovery. Recovery was defined as resolution of postoperative dysphagia and not reporting the condition at any follow-up time point. Patients were excluded from the recovery model if they did not report dysphagia within 1 month of surgery. Recovery to baseline was defined as reporting a postoperative EAT-10 score equal to or less than the baseline score at subsequent time points. Patients were excluded from the recovery-to-baseline model if they did not report EAT-10 scores within 1 month of surgery that were worse than their baseline score. Survival curves were generated for both models. Of the 2003 patients in the registry, 627 met inclusion criteria for the recovery curve and 714 for the recovery-to-baseline curve. Of the patients without baseline dysphagia, 498 developed new postoperative dysphagia within 1 month, with cumulative recovery probabilities of 39.5% by 3 months and 59.1% by 12 months after cervical spine surgery. Furthermore, of the patients without baseline dysphagia, 73.5% (175/238) who reported no dysphagia at 3 months and 32.5% (68/209) who reported no dysphagia at 12 months experienced long-term recovery. Eighty patients with baseline dysphagia reported worse EAT-10 scores within 1 month, with cumulative probabilities of improvement to baseline or below of 37.7% by 3 months and 54.1% by 12 months. Patients with baseline dysphagia were significantly less likely to recover than patients without baseline dysphagia (hazard ratio [HR] 0.37, 95% CI 0.26-0.53; p < 0.001) but significantly more likely to recover to baseline (HR 1.45, 95% CI 1.05-2.00; p = 0.025). Patients who develop postoperative dysphagia within 1 month of cervical spine surgery generally see symptomatic improvement over time. This analysis may aid in clinical decision-making when informing patients about the risk of developing postoperative dysphagia and the recovery rate of this surgical complication.
Temporal lobe epilepsy (TLE) is the most common form of medically refractory epilepsy in adults. While patients with concordant noninvasive findings and hippocampal sclerosis (HS) might proceed directly to surgery, those with discordant data, suspected bilateral involvement, or atypical presentation often require stereoelectroencephalography (SEEG). The diagnostic and therapeutic implications of bilateral temporal sampling remain uncertain. The aim of this study was to evaluate the yield and clinical impact of bilateral SEEG in TLE. The authors retrospectively reviewed data collected from patients with medically refractory epilepsy who underwent bilateral SEEG at a single institution from March 2017 and June 2025. Inclusion criteria were a pre-SEEG hypothesis of temporal onset, nonlesional or mesial TLE, with or without HS, and bilateral hippocampal/amygdala sampling. Patients were grouped as concordant, discordant, or bilateral based on pre-SEEG noninvasive data. The diagnostic yield, number of SEEG studies required to alter 1 patient's initial hypothesis, and seizure outcomes were analyzed. Of 197 patients who underwent SEEG, 54 met inclusion criteria. Pre-SEEG hypotheses were concordant in 20 patients, discordant in 8 patients, and bilateral in 26 patients. SEEG revealed contralateral or bilateral seizure onset in 35% of concordant cases and confirmed unilateral onset in 46% of presumed bilateral cases. Overall, 21% of presumed unilateral TLE showed bilateral involvement. The number needed to treat was 2.9 for the concordant group and 2.2 for the bilateral group. Following SEEG, 38 patients underwent resection, laser ablation, or neuromodulation. At the last follow-up, 49% of patients achieved Engel class I or II outcomes, with best results for those with resection/ablation (79% Engel class I or II). Bilateral SEEG provides clinically meaningful information in both unilateral and bilateral TLE, uncovering contralateral involvement in presumed unilateral cases and confirming unilateral foci in nearly half of presumed bilateral cases. Although SEEG is not necessary for all patients with TLE-HS and concordant studies, when it is indicated, bilateral sampling might be important to avoid misclassification and guide resective/ablative versus neuromodulatory treatment planning.
Spinal arachnoid webs (SAWs) are an uncommon cause of spinal cord compression, typically presenting with an insidious onset of symptoms. Their role in acute neurological deterioration is not well established, and the underlying pathophysiology remains debated. The authors describe the case of a 62-year-old male who presented with acute thoracic back pain and rapidly progressive unilateral lower limb weakness, evolving to paraplegia within hours. The initial deficit was highly atypical for a dorsally located compressive lesion, creating significant diagnostic uncertainty. Imaging revealed a T5-7 dorsal arachnoid web, which was considered an incidental finding given the atypical presentation. Subsequent imaging demonstrated web enlargement and the development of an owl's-eye T2 hyperintensity, indicative of anterior spinal cord ischemia. Emergency surgical decompression and arachnolysis were performed, leading to partial neurological recovery. This case challenges the conventional understanding of SAWs as slowly progressive lesions and highlights the diagnostic complexity introduced by atypical presentations. The location of the web in a vascular watershed zone of the midthoracic spine likely contributed to the development of cord ischemia, which was suspected to be the primary driver of the patient's fulminant course. This case underscores the importance of considering SAWs in the differential diagnosis of acute myelopathy. https://thejns.org/doi/10.3171/CASE2682.
Moyamoya disease (MMD) is a progressive arteriopathy of intracranial internal carotid arteries. The authors identified a characteristic angiographic finding associated with arterio-arterial collaterals in which ischemic brain recruits blood supply from the posterior circulation with robust splenial-to-anterior pericallosal artery anastomoses, manifesting as a characteristic "mustache" appearance on an anterior-posterior angiogram projection. In this paper, a cohort of pediatric patients with MMD is presented to assess the utility of this finding as a potential marker of disease severity and angiogenic potential and its predictive value for surgical intervention. A retrospective single-center review of pediatric patients with MMD who underwent bilateral surgical revascularization from 2014 to 2020 was performed. The presence of a mustache sign was determined and its presence or absence was correlated with Suzuki and Matsushima grades and clinical outcome. A total of 100 pediatric patients (200 total hemispheres) with MMD were identified (mean age 11 [SD 7] years). Of the total hemispheres, 12% exhibited a low Suzuki grade (I or II) with the remainder exhibiting a high Suzuki grade (III-VI), and 59% demonstrated a mustache sign. If a mustache sign was present, this demonstrated a 94% positive predictive value for the presence of a high Suzuki grade and 77% positive predictive value for a Matsushima grade A/B outcome postoperatively. As MMD severity correlated with the development of different forms of collateralization, a unique angiographic finding of a mustache sign is highlighted, which is seen in advanced MMD and indicates robust arterio-arterial collateralization with anticipated benefit from surgical revascularization.
Stereotactic body radiotherapy (SBRT) for metastatic spinal disease provides effective local control (LC). However, there are limited data evaluating how the pretreatment volume or number of affected vertebral levels impacts treatment effect. Therefore, this study compared the efficacy of spine SBRT treatment on LC, distant progression (DP), and overall survival (OS) between patients with limited spinal disease (≤ 2 vertebral segments or < 50 cm3 pretreatment volume) to those with more widespread spine metastases. All patients with metastatic spinal disease treated with SBRT over a 7-year interval at a single institution were retrospectively reviewed. Baseline demographic characteristics, primary tumor histology, anatomical distribution of metastases, and radiation dosing parameters and toxicity were recorded. LC (absence of recurrent disease at an SBRT-treated segment), DP (progressive disease in a new/untreated segment), and OS were measured. Cox proportional hazards models were used to identify patient and lesion characteristics associated with LC, DP, and OS. In total, 375 patients were treated with spine SBRT (465 isocenters). Median minimum and maximum target doses were 9.98 and 17.73 Gy, respectively. Overall, 10.1% of patients developed distant DP, while 11.2% of lesions recurred. New or worsening compression fracture occurred in 5.6% of lesions following SBRT, with 1.9% of radiated lesions requiring surgical management of a postradiation compression fracture. Neither radioresistant pathologies nor dose above or below 14 Gy were associated with differences in LC, DP, or OS. Multivariate regression revealed that OS was significantly worse with baseline Karnofsky Performance Status < 80 (HR 1.33, p = 0.030), lesion volume ≥ 50 cm3 (HR 1.37, p = 0.011), or treatment at ≥ 3 vertebral levels (HR 1.42, p = 0.013). DP was significantly worse with lesion volume ≥ 50 cm3 (HR 2.14, p = 0.0229) but was unaffected by number of vertebral segments treated. Notably, however, LC was not significantly associated with high lesion volume or the number of vertebral segments affected. Lesion size did not impact the recurrence rates following SBRT for spine metastases in this series, with similar excellent local disease control (> 88%) for patients with ≥ 3 vertebral segments involved or ≥ 50 cm3 pretreatment tumor volume compared to patients with less disease burden. Shorter time to DP and worse OS were both associated with high index lesion volume.
To conduct the initial development and validation of a Chinese readiness for hospital discharge instrument for patients after initial invasive percutaneous transhepatic biliary drainage (PTBD). The Readiness for Hospital Discharge Scale (RHDS) is a generic measure and may not fully capture PTBD-specific readiness, particularly catheter-related self-management (e.g., tube securement, bile output monitoring, skin care and early recognition of catheter-related complications) in Chinese-speaking populations. A PTBD-specific instrument may support more targeted discharge preparation and follow-up. A methodological study. The instrument was developed using a five-stage process. An initial pool of 33 items was generated from the literature review and existing instruments. After two rounds of expert consultation, two items were deleted, six items were added and several items were revised or merged, resulting in a 35-item pool. Item analysis and exploratory factor analysis were then conducted to reduce items and examine preliminary construct validity. A total of 224 patients completed the instrument and were included for further analysis. Item analysis led to the deletion of one item, resulting in a 34-item instrument. Exploratory factor analysis revealed that 22 items remained in four factors (personal status, knowledge, coping ability and expected support), which accounted for 77.84% of the variance. The Cronbach's α coefficient of the instrument was 0.962, and the split-half reliability was 0.912. The Chinese version of the readiness for hospital discharge instrument after invasive PTBD consists of 22 items across four subscales and provides preliminary evidence of content validity, preliminary construct validity, internal consistency and split-half reliability. This instrument may help healthcare professionals assess discharge readiness before discharge among patients with PTBD catheters and identify areas requiring targeted discharge preparation, catheter-related education and follow-up support. Scholars in Chinese-speaking regions may find this culturally compatible instrument useful when conducting studies related to readiness for hospital discharge. Two hundred twenty-four participants provided their perspectives on readiness for hospital discharge.
Spinal nerve sheath tumors (SNSTs) are most commonly benign tumors that present with pain. The aim of the study was to assess factors associated with new neurological deficits and recurrence in surgically treated SNSTs. All surgically treated SNSTs at a single institution over a 10-year period (2014-2023) were identified by searching the institution's histopathological database and neuro-oncology multidisciplinary team conference. Patient demographics, presenting symptoms, tumor characteristics, surgical procedures, use of intraoperative monitoring, neurofibromatosis (NF) status, neurological outcomes, and complications were recorded. There were 169 tumors in 165 patients (52.7% female, mean age 48.6 years) included in this analysis. The median duration of symptoms was 8.5 months (range 0.5-120 months). Presenting symptoms were pain (71.6%), motor deficit (26.6%), sensory deficit (22.5%), and bladder incontinence (5.9%), with incidental findings in 7.7% of cases. The median tumor diameter was 2.5 cm (range 0.6-21 cm). The gross-total resection rate was 63.9% and subtotal resection (STR) rate was 36.1%. Intraoperative neurophysiological monitoring (IONM) was used in 21.9% of cases. NF (NF type 1, NF type 2, or schwannomatosis) was present in 18.9%. Schwannoma was the most common diagnosis (82.8%, 140/169), followed by neurofibroma (13.6%, 23/169) and malignant peripheral nerve sheath tumor (MPNST) (3.6%, 6/169). Four of 6 cases (66.6%) of MPNST were concurrent with NF. The overall complication rate was 22.5% (38/169). New motor weaknesses were seen in 5.3% of cases and were associated with larger tumors (p = 0.007). Nerve root sacrifice of motor nerves produced new motor deficit in 14.3% of cases that were intact preoperatively. The rate of new sensory deficit was 3.6% (6/169). Tumor recurrence occurred in 7.1% (12/169) of cases and was associated with female sex, STR, MPNST, and NF. The median time to recurrence was 22 months (range 1-48 months). IONM use was not associated with fewer complications. These findings suggest that surgical treatment of SNST is a safe and effective procedure. There was low risk of new motor weakness, with or without nerve root sacrifice, following surgery. Recurrence rates were low; however, the risk was increased for patients with STR, NF, MPNST, or neurofibroma. MPNST and SNST in NF are complex and difficult to manage, behaving differently than benign and sporadic nerve sheath tumors.
Telesurgery has emerged as a transformative approach to address geographic disparities in surgical care, particularly in urology. However, robust real-world evidence specifically focused on renal procedures remains limited. We conducted this systematic review and single-arm meta-analysis to evaluate the safety, feasibility, and perioperative outcomes of remote robot-assisted renal surgery. We systematically searched PubMed, Embase, Cochrane Library, and Web of Science from inception to July 1, 2026. Studies reporting robot-assisted telesurgery for renal procedures (partial nephrectomy, radical nephrectomy, or renal cyst decortication) were included. The Joanna Briggs Institute (JBI) Case Series Checklist was used for quality assessment. A single-arm meta-analysis with random-effects models was performed to pool surgical success rates, operative time, estimated blood loss (EBL), length of hospital stay (LOS), warm ischemia time (WIT), and network parameters. Subgroup analyses were conducted by sample size, study design, and robotic platform. Sensitivity analyses using the leave-one-out method were performed to test the robustness of the pooled estimates. Eight studies comprising 98 patients were included. All studies were of moderate-to-high methodological quality (JBI scores: 8-10/10). The pooled surgical success rate was 100%, with a local surgeon take-over rate of 2.1% (2/98). No Clavien-Dindo grade III or IV complications were reported. The pooled estimates were: operative time 99.52 min (95% CI: 77.10-121.94; I² = 92.5%), EBL 28.30 mL (95% CI: 18.18-38.41; I² = 87.9%), LOS 5.31 days (95% CI: 3.29-7.33; I² = 98.0%), and WIT (for partial nephrectomy) 21.14 min (95% CI: 17.76-24.53; I² = 0.6%). Network parameters remained below the 200-300 ms safety threshold, with a mean round-trip time of 51.79 ms (95% CI: 1.25-102.34) and maximum latency of 128.26 ms (95% CI: 95.38-161.13). Subgroup analyses by robotic platform revealed significant between-group differences for operative time (p = 0.000) and EBL (p = 0.000), but not for LOS (p = 0.703). Sensitivity analyses confirmed the robustness of the pooled estimates for operative time and EBL, whereas the LOS estimate was sensitive to the inclusion of studies reporting extreme values. Remote robot-assisted renal surgery demonstrates high technical success rates, low complication rates, and favorable perioperative outcomes, with network parameters well within established safety thresholds. These findings support the clinical implementation of telesurgery for appropriately selected renal surgery patients, particularly in underserved regions. However, the substantial heterogeneity observed highlights the need for large-scale, prospective comparative studies with standardized outcome definitions and longer follow-up.
Vestibular schwannomas (VSs) are common benign tumors of the cerebellopontine angle, often treated with surgery or stereotactic radiosurgery to preserve nerve function. Malignant transformation of VS (MTVS) is exceedingly rare and has been primarily associated with neurofibromatosis type 1 (NF1), neurofibromatosis type 2-related schwannomatosis (NF2-SWN), or prior radiation exposure. However, cases of MTVS occurring without these risk factors are rare and remain poorly understood. A 58-year-old woman without neurofibromatosis underwent subtotal VS resection in 2019, with stable residual tumor and no adjuvant treatment. In 2023, she developed acute neurological decline, and imaging suggested malignant transformation or a new tumor. Surgery confirmed a high-grade neoplasm, likely leiomyosarcoma or malignant peripheral nerve sheath tumor, with genetic analysis revealing no NF1 or NF2-SWN mutations. She received adjuvant stereotactic radiation therapy, and at the 3-month follow-up, imaging showed stable residual disease. However, she continued to experience persistent neurological deficits, including facial weakness, ataxia, and intention tremor, with a Karnofsky Performance Scale score of 60%. MTVS is extremely rare without neurofibromatosis or prior radiation therapy, potentially driven by surgical inflammation or unidentified genetic alterations. While increased surveillance after subtotal resection may be considered, more research is needed to identify predictive markers and guide clinical management. https://thejns.org/doi/10.3171/CASE251003.
Ovarian cancer stem cells (OvCSCs) are one of the main factors contributing to post-treatment recurrence and the poor prognosis of patients with ovarian cancer. Therefore, the development of therapeutic strategies targeting OvCSCs is needed to improve patient survival. We previously reported the high expression of survivin/BIRC5 in OvCSCs and also that targeting pathways regulating survivin expression effectively suppressed OvCSC survival. In the present study, we tested a panel of agents consisting of FDA-approved drugs and compounds under clinical studies for their ability to suppress survivin expression in OvCSCs and identified clotrimazole (CTZ) as a potent candidate. The effects of CTZ on survivin expression were examined by RT-PCR and Western blot analyses. The effects of CTZ alone or in combination with anticancer agents on OvCSCs were evaluated using WST-8, PI uptake, and colony formation assays. CTZ preferentially impaired OvCSC survival by suppressing the c-myc-survivin axis without affecting normal fibroblasts and enhanced the efficacy of platinum- and taxane-based chemotherapeutic agents. These results suggest that CTZ suppresses survivin expression in OvCSCs and enhances the effects of conventional ovarian cancer chemotherapeutic agents, supporting further investigations of this approach as a potential strategy for ovarian cancer treatment.
Ganglioneuromas (GNs) are rare benign tumors arising from sympathetic neural crest derivatives, with limited large-scale data guiding management. The objective of this study was to characterize the clinical presentation, imaging features, surgical management, and long-term outcomes of patients with GN treated at a single institution over a 30-year period. The authors conducted a retrospective review of all patients diagnosed with GN between 1995 and 2025 at a single institution. Clinical data, imaging characteristics, operative details, perioperative complications, and long-term outcomes were abstracted. A total of 101 patients (62.3% female, mean age 26.9 ± 15.9 years) were identified. Tumors most commonly arose in the retroperitoneum (n = 46, 45.5%), thoracic paraspinal/mediastinal region (n = 33, 32.7%), presacral space (n = 18, 17.8%), and cervical region (n = 4, 4%). The mean tumor dimensions on MRI were 8.5 ± 3.8 × 6.6 ± 3.2 × 5.8 ± 3.7 cm. Most lesions (72%) were incidental findings. Seventy patients underwent 72 surgeries, of which 69.4% had preoperative biopsy confirmation. Gross-total resection (GTR) was achieved in 73.6% of cases (53/72) and subtotal resection (STR) was performed in 26.4% (19/72). Short-term postoperative complications occurred in 43.1% of cases, most commonly neurological deficits (22.2%). The mean hospital length of stay was 4.6 ± 3.7 days. At the final follow-up (mean duration 33.8 ± 42.6 months), 46.5% of patients were stable, 42.3% had improved, and 11.3% had worsened from baseline. Two patients experienced recurrence (2.9%, 2/70). No malignant transformations were observed. Thirty-one patients were managed with observation (mean age 32.3 ± 17.7 years; mean follow-up duration 90.9 ± 151 months). Observation was chosen primarily due to proximity to major vascular or neural structures (74.2%). No patient in the observation group developed new symptoms, and 2 tumors exhibited minimal interval growth (0.08-0.17 cm/year). GNs demonstrate indolent behavior, low recurrence rates, and no observed malignant transformation in this large cohort. GTR is achievable in most cases, but STR provides excellent long-term control when required to avoid morbidity. Observation is safe for asymptomatic tumors, particularly when adjacent to critical structures, with no growth observed on long-term follow-up, except for minimal growth in few cases. These findings support an individualized, risk-based approach to management.
Lesions in or around the atrium pose a surgical challenge due to their deep location and proximity to eloquent cortical and subcortical structures. Hence, a handful of approaches have been proposed aiming to minimize parenchymal transgression while providing adequate surgical maneuverability and dexterity. To this end, the authors sought to evaluate, for the first time in the pertinent literature, the feasibility of the intraoccipital sulcus (IOS) as a natural corridor to access the atrium safely and effectively. Twenty formalin-fixed adult cerebral hemispheres treated with the Klingler's technique were investigated. The morphology of the IOS was recorded, and the subcortical anatomy lining the corridor from the sulcal fundus to the atrium was explored through focused lateromedial white matter dissections. Additionally, 20 T2-weighted multiplanar reconstructions (MPRs) from the HCP Young Adult dataset were analyzed to quantify the "angle of attack" toward the atrium. Then the respective distances of the IOS and intraparietal sulcus (IPS) from the midline were compared to evaluate whether an IOS-based trajectory permits access to the atrial roof rather than the lateral wall. T2-weighted MR images from a cohort of 25 healthy individuals were also included to record the IOS surface anatomy, sulcal length, and fundus-to-atrium depth. The IOS was consistently recorded and found to be continuous with the IPS in most cases. Its mean length and depth were approximately 2.2 cm and 1.1 cm, respectively, and the mean sulcal fundus-to-atrium distance was 1.90 cm. MPR analysis showed that the anterior IOS segment offers an almost perpendicular trajectory to the atrium and lies medial to the IPS, thus allowing entrance to the atrial roof. The white matter transgression en route to the ventricle disrupts the fibers of the vertical occipital fasciculus while causing minimal injury to the posterior part of the sagittal stratum. The approach avoids the optic pathway since it allows entering the atrium through its roof. An IOS transsulcal corridor provides a practical, safe, and effective pathway to the roof of the atrium as it minimizes transgression of eloquent fiber tracts and respects the optic radiations. Combined cadaveric and MRI evidence supports the IOS as a reliable planning landmark for selected atrial and periatrial lesions; however, prospective clinical validation is still needed.
In patients with mild traumatic brain injury (TBI; Glasgow Coma Scale scores 13-15), the presence of anticoagulant or antiplatelet therapy, collectively referred to as blood thinners (BTs), has been presumed to elevate the risk of intracranial hemorrhage (ICH) progression. Current Brain Injury Guidelines (BIG) automatically classify all patients receiving BTs as high-risk (modified BIG [mBIG] 3), requiring hospital admission and repeat imaging. The aim of this study was to evaluate whether BTs independently increase the risk of hemorrhage progression, surgical intervention, or mortality in mild TBI with ICH, and whether risk varies by specific BT agent. The authors conducted a retrospective cohort study of 2312 adult patients presenting with mild TBI and traumatic ICH at a level 1 trauma center (2016-2021). Patients were categorized by mBIG criteria and then reclassified using hemorrhage characteristics (reclassified mBIG [RmBIG]), excluding BT status. Outcomes included radiographic progression, surgical intervention, and in-hospital mortality. A subgroup analysis was performed to assess outcomes by specific BT type. Radiographic progression occurred in 14.1% of mBIG 3 patients versus 1.7% and 6.8% of mBIG 1 and 2 patients, respectively. Among reclassified patients, those receiving BTs had similar progression rates to non-BT patients within the same RmBIG category. Patients classified as mBIG 3 based only on BT use had significantly lower progression rates (11.9%) compared with those classified based on hemorrhage severity (18.1%, p < 0.001). Mortality and surgical intervention rates did not differ overall by BT status. In the BT subgroup analysis, warfarin was the only agent significantly associated with increased radiographic progression (OR 1.93, p = 0.01). Anticoagulant and antiplatelet therapy might not warrant automatic classification of all patients with mild TBI as high risk. While warfarin represents the upper end of the risk spectrum, most agents did not increase adverse outcomes. Refining BIG to incorporate hemorrhage features and agent-specific risk might improve patient care and resource utilization.
In moyamoya disease, fragile collateral networks such as periventricular anastomoses are associated with an increased risk of hemorrhage, particularly in the posterior circulation. Peripheral aneurysms arising from these vessels are rare, and those involving the artery of Percheron are exceptionally uncommon. A 55-year-old patient with a history of thalamic hemorrhage presented with headache and impaired consciousness. CT revealed a right thalamic hemorrhage with intraventricular extension and acute hydrocephalus. Emergency ventricular drainage was performed. Subsequent angiography identified a ruptured peripheral aneurysm arising from the artery of Percheron originating from the left P1 segment, along with right-dominant moyamoya vascular architecture. The aneurysm was successfully treated with N-butyl cyanoacrylate embolization to prevent rebleeding. Due to insufficient clearance of intraventricular hematoma, endoscopic evacuation was performed. The patient experienced no rebleeding, and follow-up angiography confirmed durable obliteration of the aneurysm. Peripheral aneurysms arising from the artery of Percheron in moyamoya disease are extremely rare but should be considered in cases of deep hemorrhage with intraventricular extension. Prompt endovascular embolization using liquid embolic agents, combined with endoscopic hematoma evacuation, may provide an effective and minimally invasive treatment strategy. https://thejns.org/doi/10.3171/CASE26356.
Paraspinal muscle flaps have been used for complex wound reconstruction. Given the higher rates of wound complications associated with closure following posterior cervical decompression and fusion (PCDF), this study evaluated the use of paraspinal muscle flap advancement to mitigate this recognized risk. A retrospective cohort of patients who underwent PCDF with conventional closure at an academic quaternary center between 2011 and 2022 was identified. Postoperative outcomes were compared with those of a prospectively maintained cohort of patients who underwent PCDF with paraspinal muscle flap advancement performed between 2023 and 2025. Exclusion criteria included active local or systemic infection and less than 3 months of follow-up. A total of 380 patients underwent conventional closure, and 128 patients underwent closure with muscle flap advancement. Baseline characteristics were similar across cohorts, including BMI (p = 0.466) and the prevalence of diabetes mellitus (p = 0.597) and osteoporosis (p = 0.256). The muscle flap cohort was older (p = 0.004) and had higher rates of tobacco use (p = 0.002). There were no differences in preoperative prealbumin (p = 0.427) or albumin (p = 0.527). Operative indications (p = 0.568), revision surgeries (p > 0.999), estimated blood loss (p = 0.465), and number of spinal levels fused (p = 0.067) were not significantly different between the cohorts. Rates of wound complications were comparable between the conventional and muscle flap cohorts, including infection (8% vs 3%, p = 0.132), wound dehiscence (12% vs 11%, p = 0.670), hematoma (1% vs 0%, p = 0.576), and seroma (5% vs 9%, p = 0.429). Wound-related reoperation occurred less frequently following muscle flap closure (12% vs 7%, p = 0.021). On multivariable logistic regression analysis, muscle flap closure was associated with reduced odds of infection (p = 0.005; OR 0.275, 95% CI 0.085-0.702) and wound-related reoperation (p = 0.026; OR 0.445, 95% CI 0.198-0.912). Paraspinal muscle flap advancement following PCDF was associated with reduced odds of infection and wound-related reoperation after adjustment of preoperative and operative factors.
Blister aneurysms (BAs) constitute an uncommon and distinct subtype of intracranial aneurysm. Owing to their inconspicuous morphology and nonbranching location, they are often not apparent on conventional angiographic studies. The pathophysiology of BAs remains incompletely elucidated, with arterial dissection considered a principal pathogenic mechanism. A 49-year-old woman presented with a spontaneous subarachnoid hemorrhage of unknown etiology. Initial lumen-based imaging was nondiagnostic. Vessel wall MRI (VW-MRI) discerned a small hemispheric protrusion without a definable neck, arising from the left A3 segment. Postcontrast imaging demonstrated aneurysmal wall enhancement, a feature correlated with recent rupture in the context of a subarachnoid hemorrhage, implicating this lesion as the presumed hemorrhagic source. Concomitantly, eccentric mural thickening with intrinsic T1 and T2 hyperintensity was evident along the parent artery, supportive of intramural hematoma and underlying arterial dissection. This case emphasizes the adjunctive value of VW-MRI in the diagnostic workup of suspected BAs. By targeting the arterial wall beyond the luminal contour, VW-MRI enhances lesion visibility and delineates associated parent artery abnormalities. https://thejns.org/doi/10.3171/CASE26248.
Neuromodulation, including deep brain stimulation (DBS), is a treatment option for patients with medically intractable epilepsy who do not meet candidacy for resective surgery. DBS of the anterior nucleus of the thalamus (ANT) has been FDA approved for focal epilepsy, and stimulation of the centromedian nucleus of the thalamus (CMT) is increasingly being explored for generalized epilepsies including juvenile myoclonic epilepsy (JME). The authors present the case of a patient with JME and medically intractable seizures who underwent bilateral, sequential ANT and CMT DBS implantation. This case describes a 51-year-old woman with medically intractable JME in whom adequate trials of more than 10 antiseizure medications and prior vagus nerve stimulation failed. She underwent bilateral ANT DBS, which reduced her generalized tonic-clonic seizures but did not improve her myoclonic jerks. Owing to persistent disability from daily myoclonus, she later underwent bilateral CMT DBS. Following CMT stimulation, she experienced rare myoclonic jerks. At 7 months postoperatively, her status remained Engel class IIb with sustained functional improvement. This case highlights the complementary roles of ANT and CMT stimulation in modulating distinct thalamocortical pathways. Although CMT DBS has been described in patients with generalized epilepsy, this case demonstrates a meaningful reduction specifically in disabling myoclonic jerks that previously resulted in falls and dropped objects. https://thejns.org/doi/10.3171/CASE251033.
Thierry de Martel was a pioneer of French neurosurgery and a decorated World War I veteran. During World War II, he organized and modernized neurosurgical care for French soldiers at the American and Laennec Hospitals in Paris. As the German army advanced in June 1940, de Martel, aged 64, sought to join a last-ditch resistance effort. Disillusioned by France's military defeat and political collapse and burdened by the death of his only son in World War I, he took his own life on June 14, 1940, the day German troops entered Paris. This article reconstructs the final weeks of de Martel's life through archival materials, medical records, and eyewitness accounts, offering a unique historical perspective on the ethical, emotional, and professional dilemmas faced by physicians during wartime. De Martel's final act was both a protest and a legacy-a message of surgical precision, patriotic despair, and moral clarity. His story resonates today as a testament to the enduring tension between duty to life and devotion to country.