搜索结果：Journal of neurosurgery. Pediatrics

In shunted pediatric hydrocephalus patients, the potential for shunt failure is a frequent cause of emergency department (ED) presentation. The assessment of papilledema through ophthalmological fundoscopic examination (OFE) is an often-utilized adjunct evaluation in clinical workup to rule out shunt failure in patients. However, its utility in this setting has not been established in the literature. The objective of the present study was to investigate the association of papilledema with eventual shunt revision in ED encounters to rule out shunt failure. The authors conducted a retrospective, single-institution, cohort study of ED encounters with concern for shunt failure prompting neurosurgical evaluation in patients who underwent OFE from January 1, 2014, to December 31, 2021. Chart encounters were reviewed for baseline demographic characteristics, clinical characteristics, presence of papilledema, and interventions. The primary endpoint was need for shunt revision and intraoperative evidence of shunt failure. A total of 594 ED encounters with concern for shunt failure were identified, and 98 encounters were included. Overall, 6 cases of papilledema were identified (6.1%), of whom only 3 were new or worsened (3.1%) compared to prior examinations. Twenty-six (26.5%) encounters resulted in shunt revision, while 72 (73.4%) encounters resulted in no revision. There was no statistically significant difference in baseline patient demographic characteristics, etiology of hydrocephalus, or clinical symptoms between encounters resulting in shunt revision or no revision. No significant difference was identified in the comparison of patients who underwent shunt revision versus those without revision with regard to the presence of papilledema (3 [12%] patients with papilledema vs 3 [4%] without, p = 0.19), performance of shunt tap (6 [23%] vs 9 [12.5%], p = 0.21), or prior shunt revisions (3.2 ± 3.9 vs 2.9 ± 3.3, p = 0.77). Among pediatric ED encounters with concern for shunt failure, ophthalmological consultation for fundoscopic examination and the presence of papilledema did not demonstrate a significant association with shunt revision. Additional prospective studies are warranted to assess the clinical utility of using OFE as part of the armamentarium of triage in acute shunt failure evaluation.

Since 2010, the Neurosurgery Research & Education Foundation (NREF) has offered a Skull Base for Senior Residents course, using didactic sessions and cadaveric dissections to teach senior neurosurgery residents the basics of skull base surgery. In this paper, the impact of this course on the careers of previous attendees was evaluated. A list of attendees between 2010 and 2023 from the NREF Skull Base for Senior Residents course was obtained and data were collected for each attendee, including demographic information, career advancement, and academic productivity. Outcomes included advancing into a skull base neurosurgery fellowship and career, clinical practice setting, academic professorship appointment, and academic productivity as measured by publication count and the h-index. A survey of participants was also collected to assess the perceived individual benefit of participation in the course. From 2010 to 2023, 203 US neurosurgery residents attended the NREF Skull Base for Senior Residents course. Of all attendees, 174 have graduated from residency, with 95 (54.6%) of these graduates pursuing careers in complex cranial surgery. Of the 174 graduates, 94 (54.0%) practice in an academic neurosurgery setting and 83 (88.3%) of the 94 have academic appointments. More past participants completed skull base fellowships (n = 59) and practice skull base neurosurgery (n = 73) than any other single neurosurgical subspecialty. The mean (± SD) number of publications after the course and total h-index by the participants were 29.4 ± 56.1 and 10.8 ± 9.4, respectively. The mean number of literature citations after the course was 434.5 ± 929.8. The majority of young neurosurgeons who attend the NREF Skull Base for Senior Residents course pursue academic neurosurgery careers across the US, with more choosing to pursue fellowships and jobs in a skull base subspecialty compared to choosing any other subspecialty. This finding highlights the career trajectory of participants and the utility of relevant subspecialty training to hone skills and foster growth in the careers of young skull base surgeons.

The rates of thromboembolic events are highest within the first few days of intracranial stent placement and before complete endothelialization has occurred. Accelerating the rate of neointima formation may be a strategy to reduce thromboembolic events. This study was performed to evaluate the efficacy of vascular endothelial growth factor (VEGF) embedded in a poly(lactic-co-glycolic acid) (PLGA) coating in conjunction with mesenchymal stem cells (MSCs) to improve neointima formation after stent placement. Endovascular stents were coated with VEGF/PLGA or PLGA alone (control 1) or left uncoated (control 2), and protein quantification was performed both before and after a mock endovascular deployment process. A total of 23 New Zealand White rabbits then underwent endovascular implantation of stents coated with VEGF/PLGA, followed by an intra-arterial microcatheter injection of MSCs; stents coated with VEGF/PLGA without MSC injection (vehicle alone); stents coated with PLGA alone without MSC injection (vehicle alone); or uncoated stents without MSC injection (vehicle alone). After stent deployment on day 0 and prior to euthanasia on day 3, animals underwent optical coherence tomography (OCT), so that the degree of neointima formation over the stent struts as well as thrombus formation could be evaluated. Scanning electron microscopy (SEM) was also performed after euthanasia. OCT and SEM images were both scored by observers blinded to treatment group. Stents coated with VEGF/PLGA contained a significantly larger amount of protein than the stents coated with PLGA alone or uncoated stents, and there was no significant loss of protein after the mock delivery process. In vivo, VEGF/PLGA-coated stents with MSC injection demonstrated superior measurements of the neointimal area, neointimal ratio, stent-strut neointimal coverage ratio, and maximum neointimal thickness on OCT compared to those for the uncoated stent at 3 days. VEGF/PLGA-coated stents with MSCs also showed significantly improved scores on SEM and a large, though not statistically significant, reduction in the variability of thrombus formation compared to that with uncoated stents at 3 days (p = 0.06). This short-term study demonstrates that coating stents with VEGF embedded in PLGA, along with an intra-arterial injection of MSCs, improves neointimal coverage and may reduce thrombus formation. Follow-up studies are required to assess the long-term consequences of VEGF and MSC administration, as well as to elucidate the potential mechanism of their effect.

The aim of this study was to evaluate the long-term efficacy and safety of Gamma Knife surgery (GKS) for sporadic vestibular schwannoma (VS), focusing on the durability of tumor control and the necessity of extended posttreatment imaging surveillance. This retrospective study included patients with sporadic VS treated with single-session GKS between May 1991 and January 2020 at a single center. Tumors were classified into the following anatomical types using a modified Koos-based system: type A (intracanalicular), type B (cerebellopontine angle), type C (mild brainstem compression), and type D (severe brainstem compression with fourth ventricle deviation). A subgroup analysis in patients without salvage treatment within the first 5 years after GKS and with ≥ 5 years of follow-up was performed to assess long-term stability. Salvage treatment rates, functional outcomes, and adverse events were evaluated. Overall, 878 patients (488 female, median age 57 years) with sporadic VS treated with single-session GKS were included in the analysis. A subgroup of 793 patients (438 female, median age 58 years) remained free of salvage treatment during the first 5 years after GKS and had ≥ 5 years of follow-up. The median clinical follow-up duration was 154.5 months. Salvage treatment was required in 7.5% of the patients, with a significantly higher incidence in patients with type D tumors (24.7% at 5 years) compared with type A-C tumors (3.6%) (subdistribution hazard ratio 2.319, p = 0.036). In the subgroup of patients with stable disease, the cumulative incidence of salvage treatment at 15 years was 2.1%, and true tumor progression was identified in only 2 patients (0.3%). Notably, tumor type at the time of GKS did not significantly influence the risk of salvage treatment beyond 5 years in the subgroup. Serviceable hearing preservation improved in more recent treatment periods: patients with pre-GKS Gardner-Robertson class 1 hearing had a 10-year preservation rate of 63% in the late treatment period (2005-2023) compared with 48% in the early period (1991-2004). Among late adverse events, cyst-related complications were the most common (3.1%), whereas trigeminal neuralgia (1.6%), persistent facial palsy (0.1%), and malignant transformation (0.2%) were infrequent. GKS provided durable long-term tumor control and functional preservation in patients with small- to medium-sized VS. True tumor progression beyond 10 years was not observed in this cohort, suggesting that the intensity or frequency of routine imaging surveillance can be reduced or individualized after 10 years in patients with stable disease during the first 5 years after GKS. However, because delayed adverse events (e.g., cyst formation, trigeminal neuralgia, and malignant transformation) can still occur, follow-up strategies should be tailored according to initial tumor characteristics and the posttreatment clinical course.

Pediatric patients with low-grade CNS tumors can experience an array of physical, cognitive, and psychosocial late effects, even in the absence of adjuvant therapy. It is unclear to what extent these late effects impact long-term quality of life (QOL). The aim of this study was to evaluate QOL and mental health in children with low-grade CNS tumors treated with surgery alone compared with healthy children and children with chronic illness. Medical records were retrospectively reviewed to identify children (age ≤ 18 years) who underwent surgical treatment of a low-grade CNS tumor (WHO grades I or II) without adjuvant therapy. Caregivers of enrolled patients (1-8 years after resection) completed a demographic questionnaire, the PedsQL Generic Core Scales, and the BASC-3 Parent Rating Scales. Scores were compared with published levels of QOL and mental health in healthy children and children with chronic illness. Sixty-six patients and their caregivers enrolled in the study; the mean patient age at enrollment was 13.47 years, with a mean time from surgery to enrollment of 4.26 years. These patients demonstrated significantly lower patient-reported QOL scores compared with their healthy peers for all scales. The mean PedsQL scores showed that 58% of children experienced difficulty with school-related functioning, 49% fell at or below the age-appropriate cutoff for emotional QOL, 42% experienced decreased physical QOL, and 30% experienced social challenges. The proportion of patients with BASC-3 scores (n = 51) that met or exceeded the cutoff for at-risk or clinically relevant difficulties ranged from 8% (depression) to 14% (anxiety and attention, each). Children treated for low-grade CNS tumors with surgery alone can face challenges that impact their long-term QOL and mental health. Psychosocial functioning of these children should be routinely assessed at follow-up visits in neurosurgery clinics. Other providers and families should be made aware of the potential long-term consequences associated with low-grade CNS tumors treated with surgery alone. Similar to the psychosocial care recommendations for children with chronic illness, interventions should be developed for patients with low-grade CNS tumors to mitigate risk of impaired long-term QOL and mental health.

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) has decreased rates of shunt dependence in infants with hydrocephalus. The ETV Success Score (ETVSS) is the standard for predicting the 6-month success rate for ETV in children based on age, hydrocephalus etiology, and shunt history. However, the ETVSS does not account for the impact of CPC or preoperative ventricular volume. It also relies on the independence of each contributing variable and does not predict success beyond 6 months. In this study, the authors used a machine learning approach to create a tool specifically for ETV/CPC to predict the likelihood of success at 1 year. The records of 206 pediatric patients younger than 2 years of age who received ETV/CPC as a primary, definitive treatment for hydrocephalus at a single institution between 2009 and 2021 were reviewed for patient demographics, presenting characteristics, and medical history. Data on corrected age at surgery, frontal occipital horn ratio (FOHR), hydrocephalus etiology, and whether there was prior CSF diversion were used in developing logistic regression, XGBoost, random forest, and gradient boosting algorithms to predict the percentage likelihood of ETV/CPC failure within postoperative year 1. Unlike the ETVSS, etiology of hydrocephalus did not substantially influence any model's predictions and was removed. A logistic regression model produced the best area under the receiver operating characteristic curve (AUROC) and was used as the final model. Three features selected for the final model (corrected age, prior CSF diversion, and FOHR) proved relevant. The logistic regression predictor had an AUROC of 0.85 (compared to 0.66 for the ETVSS) and an outcome classification accuracy of 76%. The model correctly classified its predictions for success slightly more accurately than its predictions for failure (sensitivity 78%, specificity 75%). This model can reliably predict the likelihood of ETV/CPC failure at 1 year. Its outperformance of the ETVSS is likely due to the impact of CPC, the novel use of preoperative ventricle size as a predictive parameter, and accounting for variable interdependence. Further validation in additional patient populations is needed.

The aim of the study was to evaluate the predictive value of postoperative day 1 (POD1) prolactin on long-term hyperprolactinemia normalization following prolactinoma resection. The authors retrospectively reviewed 260 prolactinomas that were resected from 1998 to 2020. Patients were classified on the basis of preoperative dopamine agonist (DA) use: the DA-positive group (n = 112 [43.1%]) used DAs < 3 weeks prior to surgery, while the DA-negative group (n = 148 [56.9%]) did not. The prolactin level (ng/ml) was categorized as follows: low normal (0-10 ng/ml for men, 0-12.5 ng/ml for women), high normal (10-20 ng/ml for men, 12.5-25 ng/ml for women), and mildly hyperprolactinemic (20-40 ng/ml for men, 25-50 ng/ml for women). Prolactins were analyzed at 6 time points: POD1, 1 day to 6 weeks, 6-12 weeks, 12 weeks to 6 months, 6 months to 1 year, and > 1 year. The authors identified cases with POD1 normalization, followed by hyperprolactinemia requiring treatment, multiple elevated prolactins, or hyperprolactinemia at latest follow-up, defining rebound hyperprolactinemia as these events that occurred < 1 year of surgery and recurrent hyperprolactinemia as these events that occurred &#x2265; 1 year after surgery. Remission was defined as persistent normalization during the 1st year. The mean (SD) age was 35.4 (11.4) years. In total, 78.1% (n = 203) of patients were female. In the DA-negative group, 78.9% of mildly hyperprolactinemic patients had persistent elevation, while 90.2% and 37.0% of low- and high-normal patients achieved remission, respectively. For the DA-positive group, 81.8% of mildly hyperprolactinemic DA-positive patients remained with elevated prolactin levels, whereas 72.6% and 50.0% of low- and high-normal patients experienced remission, respectively. Rebound rates were 2.0% versus 33.3% in low-normal versus high-normal DA-negative patients and 12.6% versus 33.3% in low-normal versus high-normal DA-positive patients. Recurrence rates were 7.8% versus 25.9% in low-normal versus high-normal DA-negative patients and 11.6% versus 16.7% in low-normal versus high-normal DA-positive patients. The cumulative incidence rates of rebound (p < 0.001) and recurrent (p < 0.001) hyperprolactinemia varied by group, with low-normal DA-negative patients being the least likely to experience either outcome. For DA-positive (p < 0.001) and DA-negative (p < 0.001) patients, retreatment during the 1st year after surgery was more often required in mildly hyperprolactinemic (47.4% of DA-negative patients vs 81.8% of DA-positive patients) and high-normal (18.5% DA-negative vs 33.3% DA-positive) patients than low-normal patients (1.0% DA-negative vs 18.1% DA-positive). POD1 prolactin is associated with long-term normalization following prolactinoma resection. However, patients should not be considered cured solely on the basis of the POD1 prolactin level, as rebound hyperprolactinemia can occur, particularly with recent DA use or a high-normal POD1 prolactin level.

Dysembryoplastic neuroepithelial tumors (DNETs) are usually described as benign, but long-term data clearly show that progression is not rare. Molecular diagnostic techniques have revealed that FGFR1 alterations sit at the core of DNET biology. Importantly, FGFR1 point mutations are known to drive more aggressive behavior in several pediatric gliomas. Likewise, younger children often demonstrate poorer tumor control across multiple low-grade glioma subtypes. These parallels raise the question of whether similar risk patterns exist within DNETs. The aim of this study was to identify reliable predictors of progression in pediatric DNETs by analyzing FGFR1 alteration subtypes, patient age, and extent of resection in order to refine risk stratification. This retrospective study examined 37 pediatric DNET cases that were confirmed according to the 2021 WHO classification. FGFR1 and BRAF alterations were assessed using droplet digital PCR (ddPCR), and methylation profiling was applied in selected cases. FGFR1 alterations were found in nearly 70% of tumors. The most striking finding was the markedly poor prognosis of FGFR1 point mutant cases, with progression rates exceeding 70%, whereas FGFR1 tandem duplications showed a much more indolent course. Age also emerged as a key factor: 45% of patients aged &#x2264; 10 years progressed, compared with only 5.9% of older children. Gross-total resection remained the strongest surgical determinant of long-term tumor control. DNETs are biologically heterogeneous. Subtotal resection, FGFR1 point mutations, and younger age clearly identify a higher risk subgroup with shorter progression-free survival. Considering the molecular profile, age, and surgical extent together provides a more accurate framework for clinical decision-making and follow-up planning.

Kocher's point serves as the most common entry site for accessing the ventricles of the brain. Named after Nobel laureate Theodor Kocher, a prominent Swiss surgeon of the late 19th and early 20th centuries, the discovery of the anatomical landmark highlights the power of progressive refinement and collaboration across generations. Utilizing his well-acclaimed craniometer, Kocher described a safe trajectory to the lateral ventricle, navigating around eloquent regions of the brain and resolving the issue of ventricular collapse, a concern during his time with the use of Keen's point. To perform ventricular drainage, Theodor Kocher employed an approach resembling the modern craniotomy with bone flap replacement, which he deemed provided greater visibility of the target region anterior to the precentral gyrus. Despite achieving excellent ventricular drainage through his point, the open approach failed to address the risk of blood loss and infection and the requirement for high levels of anesthesia. Were it not for the forgotten contributions of Theodor's son, Albert Kocher, the present method of external ventricular drainage would have remained far more complicated. Albert simplified the approach, using cocaine for local anesthesia and directly drilling through the skin and bone at Kocher's point followed by insertion of a syringe.

Fetal myelomeningocele repair (FMMR) has shown significant promise in decreasing the incidence of myelomeningocele (MMC)-associated hydrocephalus. In this study, the authors report on the reversal of hindbrain herniation via FMMR. They also describe biometric changes in third ventricle anatomy, which influences the outcome of endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC). At the Arnold Palmer Hospital for Children and Winnie Palmer Hospital for Women & Babies, the maternal and fetal inclusion and exclusion criteria developed by the Management of Myelomeningocele Study (MOMS) were applied to determine eligibility for prenatal MMC repair. Patient charts, prenatal fetal MRI, ultrasonography studies, and postnatal brain MRI for the first 50 FMMRs performed between 2019 and 2024 were retrospectively reviewed for this study. Ventricle size was measured prior to fetal surgery, as was the clivus-supraocciput angle (CSO) on fetal and postnatal images. Neonates were stratified into hydrocephalic and nonhydrocephalic groups for comparative analysis. The hydrocephalic group included patients who had undergone ETV/CPC or insertion of a ventriculoperitoneal shunt (VPS). A total of 50 women underwent FMMR. One woman did not consent to inclusion in the study, 8 patients remained in utero at the time of analysis, and 3 patients died. Of the 38 patients included in the analysis, 21 (55%) underwent treatment for their symptomatic hydrocephalus; 4 received a VPS, and 17 underwent ETV/CPC. Four ETV/CPC cases did not respond to the treatment and were scheduled for VPS insertion, resulting in an overall ETV/CPC success rate of 70.6% (12/17) in the study. A statistically significant difference in the mean prenatal ventricle size was observed between the nonhydrocephalic (9.61 mm) and hydrocephalic (12.1 mm, p = 0.023) groups. Additionally, a significant difference in the CSO angle in the first month after birth was noted between the groups (67.2&#xb0; vs 76.7&#xb0;, p = 0.01). There is strong evidence that FMMR decreases MMC-related hydrocephalus by reversing hindbrain herniation and altering the developmental anatomy of the third ventricle. This makes ETV/CPC a safe alternative to CSF shunting because of the newly altered anatomy of the third ventricle and posterior fossa. Larger studies are recommended to further evaluate fetal brain development after FMMR.

The middle meningeal artery (MMA) often traverses a bony canal, rendering it vulnerable during craniotomy. In moyamoya disease (MMD), it serves as a collateral pathway for cerebral perfusion, making vessel preservation essential during bypass surgery. This study examined the anatomy of MMA bony canals in dry skulls and compared findings in patients with MMD and atherosclerotic cerebrovascular disease (ACVD). A total of 175 adult and pediatric dry skulls and cranial CT scans of MMD (n = 100) and ACVD (n = 100) patients were analyzed retrospectively. The relationship of bony canals to the convergence of the coronal, sphenofrontal, and sphenoparietal sutures, serving as an anatomical landmark, was assessed. Bony canals containing the frontal MMA branch were present in 91.2% of adult skulls (&#x2265; 18 years). Before fontanelle closure (< 2 years), the incidence was 1.8%, increasing to 47.7% in skulls &#x2265; 2 years (p < 0.0001). The mean canal length was 12.0 &#xb1; 5.9 mm in adult skulls, 10.1 &#xb1; 4.5 mm in skulls &#x2265; 2 years, and 7.5 &#xb1; 3.5 mm in skulls < 2 years (p = 0.212). In adult skulls, the mean distances of the canal entry and exit points posterior to the landmark were 11.6 &#xb1; 4.8 mm and 13.8 &#xb1; 6.4 mm, respectively. Parietal branch canals were rare (&#x2264; 12.9%) and typically located below the squamous suture. Clinically, MMD patients were younger than ACVD patients (41.6 &#xb1; 12.2 vs 55.0 &#xb1; 11.6 years, p < 0.0001) and had a similar prevalence of frontal branch canals (80.0% vs 84.0%, p = 0.36). Bony canals were longer (15.9 &#xb1; 9.7 mm vs 13.3 &#xb1; 6.2 mm, p = 0.02) and wider (1.6 &#xb1; 0.4 mm vs 1.3 &#xb1; 0.5 mm, p < 0.0001) in MMD patients. After fontanelle closure, the likelihood of the MMA traversing a bony canal located within one thumb's width posterior to the pterion increases with age. Comprehensive knowledge of MMA anatomy is crucial for its preservation during bypass surgery.

Adamantinomatous craniopharyngioma (ACP) is a rare type of brain tumor that affects a wide age range, from children to older adults. Due to the rarity of the disease, existing studies are predominantly limited to single-center or single-surgeon experiences, often lacking statistical power and generalizability. The aim of this study was to address this gap by providing a comprehensive analysis of ACP outcomes based on a large multicenter cohort from the Registry of Adenomas of the Pituitary and Related Disorders (RAPID). This multicenter retrospective cohort study was conducted via the RAPID consortium and assessed patients with histologically confirmed ACP treated surgically between August 2000 and November 2024 at high-volume pituitary centers across the United States. Among the 359 patients (206 male, median age at primary surgery of 47 years) included in the analysis, 76% underwent endoscopic transsphenoidal surgery and 22% underwent craniotomy. Gross-total resection was achieved in 45% and subtotal resection in 47%. Notably, 120 of 311 patients (39%) presented with preoperative hypothalamic-pituitary axis dysfunction. Following all treatments, permanent hypothyroidism was reported in 40% of patients, adrenal insufficiency in 33%, and arginine vasopressin deficiency in 19%. Of 263 patients who underwent primary surgery, radiation therapy was administered in 84 (32%). Progression-free survival (PFS) declined from 66% at 1 year to 31% at 6 years. In the multivariable analysis, independent predictors of worse PFS included subtotal resection (HR 0.22, 95% CI 0.11-0.42; p = 0.001), partial resection (HR 0.11, 95% CI 0.04-0.28, p = 0.001), larger tumor size (HR 0.77, 95% CI 0.64-0.94; p = 0.009), and tumor extension beyond the sella and suprasellar regions (HR 0.21, 95% CI 0.06-0.74; p = 0.016). Primary surgery and salvage surgery groups showed comparable PFS. In this large multicenter cohort study, gross-total resection was achieved in fewer than half of patients and was independently associated with improved PFS. Approximately one-third of patients underwent radiation therapy after primary surgery. These findings provide robust evidence supporting the prognostic value of extent of resection and inform contemporary treatment algorithms for ACP. The high incidence of postoperative endocrinopathy underscores the need for individualized multidisciplinary long-term care. While the retrospective design is a limitation, the multicenter approach enhances the generalizability of these results.

Despite growing national consensus on the importance of cognitive evaluation and structured, graduated return-to-play protocols in sports-related concussion care in children and adolescents, it remains unclear how consistently these practices are reflected in state-level legislation. The authors aimed to evaluate the extent to which current state concussion laws in the United States incorporate evidence-based practices, particularly regarding cognitive testing and specification of qualified medical professionals for return-to-play clearance in these athletes. A cross-sectional review of concussion laws across all 50 states and the District of Columbia as of September 2025 was conducted. Statutory texts were abstracted for provisions addressing immediate removal from play, same-day return to play, use of baseline and postinjury cognitive assessments, implementation of graduated return-to-play protocols, and medical clearance requirements with specification of provider type. All 51 jurisdictions have available state-level statutes regarding concussion care in children and adolescents. All require immediate removal of athletes with suspected concussion, with 74.5% basing removal on suspicion and 25.5% requiring signs or symptoms. Fourteen states (27.5%) explicitly prohibit same-day return to play, 2 (3.9%) allow it after concussion is ruled out by sideline evaluation, and the remainder do not address it. Medical clearance is universally required for return to play; however, only 6 states (11.8%) restrict clearance authority to physicians, while most permit broader categories of healthcare providers. Eight states (15.7%) mandate a graduated return-to-play progression, although protocols vary. Only Hawaii requires baseline cognitive testing, and Rhode Island recommends but does not mandate it. State concussion laws now universally mandate education, removal, and clearance before return, yet variability in coach training, return-to-play protocols, and cognitive testing exists. Aligning legislation with evidence-based standards is needed to ensure consistent protection for young athletes across the country.

Awake resection in grade 2 glioma (G2G) improves quality of life (QOL) and overall survival (OS). Nonetheless, epilepsy occurs frequently in this context and can impair QOL, especially when the disorder is pharmacoresistant. Herein, the goal was to study patients with intractable epilepsy (IE) before and/or after surgery for a G2G. Patients who underwent awake functional mapping-based resection of an IDH-mutant G2G in the period from June 2002 to March 2024 and had IE before and/or after surgery (follow-up > 1 year) were selected for this retrospective study. Onco-functional outcomes were compared among patients with preoperative IE who were completely seizure free (Engel class IA) postoperatively (group 1), patients with preoperative and postoperative IE (group 2), and patients who experienced IE only postoperatively (group 3). In a consecutive series of 105 patients (61 males [58.1%]) with a mean age of 35.6 &#xb1; 12.2 years, 134 awake surgeries were performed. At diagnosis, 101 patients (96.2%) presented with seizures, and 82 patients (78.1%) presented with IE. The mean preoperative Karnofsky Performance Status (KPS) was 88.7 &#xb1; 7.4, and 74 patients (70.5%) were able to work preoperatively. Sixty-three gliomas (60%) were left-sided and 42 were right-sided, which consisted of 66 insula-centered/paralimbic (62.8%), 13 central (12.4%), 14 frontal (13.3%), 6 temporal (5.7%), and 6 parietal (5.7%) tumors. The mean preoperative tumor volume was 82.8 &#xb1; 47.9 cm3. Only 1 patient (0.9%) had persistent postoperative deterioration, and the mean postoperative KPS was 89.2 &#xb1; 6.4. Sixty-one patients returned to work (82.4%). The mean extent of resection (EOR) was 86.8% &#xb1; 8.3% (mean residual volume 13 &#xb1; 18.4 cm3). Histopathologically, there were 65 astrocytomas (61.9%) and 40 oligodendrogliomas (38.1%). Twenty-two patients (21.0%) had immediate adjuvant therapy, and 29 patients (27.6%) underwent reoperation(s). The mean follow-up was 8.3 &#xb1; 4.7 years with an OS rate of 70.5%. Sixty patients (57.1%) were completely seizure free after surgery (group 1), and 45 patients (42.8%) had postoperative IE (22 patients [21.0%] in group 2 and 23 patients [21.9%] in group 3). The proportion of insula-centered/paralimbic G2Gs was higher in group 1 (p = 0.002), whereas the percentage of central G2Gs was greater in groups 2 and 3 (p = 0.01). Higher preoperative tumor volume (p < 0.00001) and lower EOR (p = 0.05) were correlated to IE. The postoperative KPS (p < 0.00002) and return to work (RTW) rate (p = 0.0004) were higher in group 1. These original findings show that G2G location, tumor volume, and EOR are associated with perioperative IE, itself correlated to QOL, especially KPS and RTW. Such data may help neurosurgeons better evaluate the epilepto-onco-functional balance of surgery in G2G.

Rathke's cleft cysts (RCCs) and craniopharyngiomas (CPs) are lesions of the sellar region, both originating from remnants of Rathke's diverticulum. The presence of squamous metaplasia (SM) within RCCs often creates histological overlaps with papillary CPs (PCPs), complicating accurate diagnosis. Given the distinct treatment and clinical outcomes associated with these lesions, precise identification is essential. BRAF V600E and CTNNB1 mutations have emerged as distinguishing genetic markers for PCP and adamantinomatous CP (ACP), respectively. This study aimed to evaluate the utility of BRAF V600E and &#x3b2;-catenin immunohistochemistry in differentiating RCC from CP. The authors retrospectively reviewed the clinical, radiological, and histopathological data of 383 RCCs diagnosed between January 2015 and May 2024 at Beijing Tiantan Hospital. BRAF V600E and CTNNB1 immunohistochemistry were performed on all cases, with BRAF results confirmed via Sanger sequencing. Clinical outcomes were evaluated during follow-up. Sixty-nine RCC cases met the inclusion criteria (61 primary and 8 recurrent). Of these, 52 cases were in intrasellar region (75.4%), with 9 cases (13.0%) in the suprasellar region and 8 cases (11.6%) involving both regions. Histologically, 39 cases (56.5%) exhibited epithelial SM. No nuclear &#x3b2;-catenin accumulation localization was detected. BRAF V600E expression was observed in 7 cases (10.1%), all within areas of SM, and confirmed with Sanger sequencing. These positive cases also showed elevated Ki-67 indices, with proliferative activity concentrated at the basal layer of the epithelium with SM. Based on these molecular and histological findings, the 7 BRAF V600E-positive cases were reclassified as PCPs. Notably, Kaplan-Meier analysis demonstrated significantly worse progression-free survival in BRAF V600E-positive cases compared to wild-type cases (p = 0.023). BRAF V600E and CTNNB1 mutation analysis is a valuable diagnostic tool for distinguishing RCC from CP. Given the potential for RCC to transform into PCP, the authors recommend BRAF V600E testing for all RCC cases. For BRAF V600E-positive cases, close monitoring of tumor progression or adjuvant therapies is advised.

Postinfectious hydrocephalus (PIH) is a severe complication following CNS infections and often requires urgent CSF diversion. However, definitive shunt placement procedures are often unfeasible in this setting due to active infection or residual inflammatory debris. In such scenarios, ventriculosubgaleal shunt (VSGS) insertion has emerged as a widely used temporary strategy. The authors conducted a systematic search of publications in the PubMed, Embase, and Cochrane Library databases, covering studies published up to June 2025. Risk of bias was assessed using Cochrane's Risk of Bias in Non-randomized Studies of Interventions tool. Data analysis was performed using RStudio (version 2025.05.0). Seven studies involving 225 patients were included in the analysis. Meta-analysis of the reviewed studies revealed that the conversion rate to ventriculoperitoneal shunt placement was 88.6% (95% CI 68.78%-96.48%, I2 = 76.1%). Among the studies, 3 reported the time to conversion, with a 95% CI of 30.13-56.58 days (I2 = 89.4%). Regarding complications, the revision rate was 25.66% (95% CI 19.37%-33.15%, I2 = 0%), the obstruction rate was 13.7% (95% CI 6.34%-27.12%, I2 = 48.5%), the infection rate was 5% (95% CI 1.03%-21.09%, I2 = 68.7%), and the migration rate was 3.87% (95% CI 1.46%-9.87%, I2 = 0%). The overall mortality rate was 13.9% (95% CI 5.21%-32.16%, I2 = 68.2%). VSGS placement represents an acceptable temporary therapy for PIH. However, more studies with larger cohorts and direct comparisons with other therapeutic strategies are necessary to establish the efficacy and long-term outcomes of VSGS use.

Insular gliomas present a unique surgical challenge due to their location near critical vascular structures and proximity to functional brain regions. While different surgical approaches to insular tumors exist, language and motor stimulation mapping are critical for a transcortical approach. The aim of this study was to determine if the transcortical approach to resection of insular gliomas remains a safe and effective strategy by assessing tumor characteristics, surgical outcomes, and postoperative functional outcomes in patients with newly diagnosed or recurrent tumors. This retrospective analysis included 502 newly diagnosed and recurrent low-grade gliomas (LGGs) and high-grade gliomas (HGGs) of the insula (in 394 unique patients) resected between September 1997 and December 2022 at a single center. Tumors were classified based on the Berger-Sanai zone schema, and contrast-enhancing and non-contrast-enhancing tumor volumes were manually segmented on MRI and used to calculate the extent of resection (EOR). Patient morbidity was assessed at multiple time points from the initial presentation to at least 6 months of follow-up. Progression-free survival (PFS) and overall survival (OS) were compared between subgroups using unadjusted and propensity score-adjusted Kaplan-Meir and Cox regression analyses. Overall, 316 (165 LGG, 151 HGG) newly diagnosed and 186 (69 LGG, 117 HGG) recurrent cases were included. Grade 2 gliomas were typically larger than grade 4 IDH-wildtype gliomas (43 cm3 vs 17.5 cm3, p < 0.001). Persistent postoperative motor and language deficits occurred in < 4% of cases with newly diagnosed grade 2 tumors, although transient deficits occurred more frequently (9.5% of cases with transient motor deficit and 20% of cases with transient language deficit). For patients with newly diagnosed grade 2 insular gliomas, OS was improved when the residual tumor volume was < 2.7 cm3. Minimizing residual tumor volume was also associated with prolonged PFS and OS for recurrent grade 2 insular gliomas. Similarly, contrast-enhancing tumor EOR > 88.6% was associated with improved PFS and OS for patients with newly diagnosed IDH-wildtype glioblastoma. Overall, surgical and medical complications occurred in < 3% of cases. Finally, new permanent arm or leg weakness was significantly associated with worse OS in multivariable analyses (HR 2.06, 95% CI 1.14-3.74; p = 0.017). Maximum safe resection using a transcortical approach and cortical and subcortical mapping continues to be a robust surgical strategy with low surgical morbidity for patients with newly diagnosed and recurrent insular gliomas.

The field of neuromodulation for idiopathic generalized epilepsy is rapidly evolving. The recently completed NAUTILUS trial, an industry-sponsored multicenter, randomized, sham-controlled study evaluating centromedian nucleus (CM) stimulation, represents a landmark effort to rigorously assess this approach. Although trial results are not yet available, the need to understand and standardize the anatomical targeting of the CM remains critical. The precision of electrode placement fundamentally determines whether stimulation engages the intended thalamocortical circuits, shaping both efficacy and reproducibility across centers. The authors present a comprehensive review of the evolution of CM targeting in epilepsy, tracing its development from early stereotactic approaches to current imaging-based strategies. The authors detail the surgical targeting workflow used across NAUTILUS trial sites, which incorporates advanced MRI sequences and atlas-informed refinements. This review also offers practical resources and tools enabling clinicians to implement the described methodology in clinical and research settings. Modern CM targeting strategies reflect a transition from indirect, coordinate-based techniques to individualized, image-guided planning. These methods have been successfully implemented across centers participating in the NAUTILUS trial, enabling accurate electrode placement even in patients with complex anatomy. The workflow accommodates both direct visualization and atlas-based alternatives when imaging quality is suboptimal. This review outlines the evolution of CM neuromodulation-from Velasco's early targeting approaches to modern image-guided surgery-and provides a reproducible framework for clinicians. As neuromodulation moves toward broader clinical adoption, anatomically precise targeting will be key to optimizing outcomes. The surgical approach recommended in the NAUTILUS trial offers an implantation framework intended to support future location-based outcome analysis.

Infantile hydrocephalus is a common condition that requires surgery. However, cognitive outcomes following treatment are poorly understood, limiting the ability to prognosticate cognitive functioning or target cognitive therapies. Some studies have shown that children with infantile hydrocephalus often experience memory difficulties. Given the role of the hippocampus in memory, the aim of this study was to assess hippocampal volume in children with infantile hydrocephalus compared with controls and to further evaluate the relationship between hippocampal volume and working memory. Children with infantile hydrocephalus and healthy control children were recruited between 2015 and 2024 for comparison. All participants underwent a neuroimaging protocol that included T1-weighted structural MRI. Hippocampal volumes were extracted, verified, and corrected for total intracranial volume. Participants also completed a neurocognitive battery using a digital version of the multicolored Mr. Peanut task for assessing working memory. A multiple regression model was used to examine the impact of hippocampal volume on working memory performance. Overall, 54 participants were included in the study; 37 healthy controls (19 male, mean age 9.15 &#xb1; 2.16 years) and 17 children with infantile hydrocephalus (9 male, mean age 9.49 &#xb1; 1.55 years). There was no significant difference in age or sex between groups. Total hippocampal volume and working memory performance were significantly decreased for patients with infantile hydrocephalus compared with healthy controls (both p < 0.005). Furthermore, the multiple regression model showed that total hippocampal volume was a positive predictor of working memory performance (p < 0.01). Sex and lateral ventricle volume were not significant predictors. Children with infantile hydrocephalus had worse working memory performance and a smaller mean hippocampal volume compared with healthy controls. Similar to studies in healthy control children, hippocampal volume was a positive predictor of memory performance in the current study. These findings add to the scant existing literature characterizing cognitive deficits in infantile hydrocephalus. Additional studies with larger sample sizes and further consideration of factors that can impact working memory are needed.