Journal of neurosurgery最新文献

{"title":"Let the light in: influence of fluorescence-guided resection with 5-aminolevulinic acid on surgical outcomes, extent of resection, and survival in subventricular zone glioblastoma.","authors":"Yosef Laviv, Paz Lev, Sapir Lev, Andrew A Kanner, Suzana Fichman, Alexandra Benouaich-Amiel, Dror Limon, Tali Siegal, Shlomit Yust Katz","doi":"10.3171/2025.3.JNS242570","DOIUrl":"https://doi.org/10.3171/2025.3.JNS242570","url":null,"abstract":"<p><strong>Objective: </strong>Near-infrared fluorescence with 5-aminoleulinic acid (5-ALA) is an important tool to guide resection of glioblastoma (GBM). However, in the ventricular wall and ependyma, there may be visible fluorescence in response to 5-ALA even in the absence of tumor cells. This may impact the surgical decision to continue resection into the ventricles when the GBM is located in close proximity to the subventricular zone (SVZ). The aim of this study was to determine the surgical, radiological, and oncological implications of fluorescence-guided resection (FGR) of SVZ GBM.</p><p><strong>Methods: </strong>The electronic medical records of adult patients with newly diagnosed SVZ GBM under treatment at a tertiary medical center between January 2011 and December 2021 were retrospectively reviewed. Clinical, surgical, radiological, and outcome parameters were compared between patients resected under fluorescence guidance (FGR group) and the white light (WL)-only group, with overall and within subgroups defined by the following known prognostic factors: age (≥ 55 vs < 55 years), use of chemoradiation (yes vs no), O6-methylguanine-DNA-methyltransferase (MGMT) methylation status (methylated vs unmethylated), and performance status score (≥ 80 vs ≤ 70).</p><p><strong>Results: </strong>The cohort included 94 patients. Compared to the WL group (n = 46), the FGR group (n = 48) was characterized by lower postoperative tumor volume (3.97 ± 6.92 cm3 vs 7.21 ± 6.81cm3, p = 0.038), greater extent of resection (90.91% ± 12.9% vs 81.19% ± 17.69%, p = 0.005), and higher rates of gross-total resection (28.6% vs 11.6%, OR 0.296, 95% CI 0.0968-0.9057, p = 0.0329). This group also had higher rates of intraoperative ventricular entry (72.9% vs 42.2%, p = 0.003) and shunt placement (by > 2.5-fold, p = 0.199). There were no significant between-group differences in distant recurrences or leptomeningeal dissemination. Gross-total resection showed a trend-level association with increased 1-year overall survival (HR 0.308, 95%CI 0.073-1.3, p = 0.089). When compared to the entire cohort, FGR was significantly associated with increased overall survival for the subgroups of patients that were < 55 years of age (HR 0.489, p = 0.026), treated with the Stupp protocol (HR 0.562, p = 0.0086), and had a Karnofsky Performance Scale score > 70 (HR 0.428, p = 0.00049), and this association reached near significance for patients with MGMT-methylated status (HR 0.512, p = 0.074). Such significant differences were not demonstrated for any of the WL subgroups.</p><p><strong>Conclusions: </strong>FGR using 5-ALA had a significant favorable impact on extent of resection and residual tumor in patients with SVZ GBM. These positive effects associated with FGR appeared to outweigh its negative effects of increased rates of ventricular entry and shunt surgery, which had no meaningful impact on most surgical, radiological, and oncological outcomes, including survival. In patients wit","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-12"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564877","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Petechial hemorrhage in mechanical thrombectomy for distal and medium-vessel occlusions: technical considerations and outcomes.","authors":"Muhammed Amir Essibayi, Hamza Adel Salim, Melissa J Fazzari, Deepak Khatri, Amanda Baker, Basel Musmar, Nimer Adeeb, Nils Henninger, Sri Hari Sundararajan, Anna Luisa Kühn, Jane Khalife, Sherief Ghozy, Luca Scarcia, Leonard L L Yeo, Benjamin Y Q Tan, Robert W Regenhardt, Jeremy J Heit, Nicole M Cancelliere, Aymeric Rouchaud, Jens Fiehler, Sunil A Sheth, Ajit S Puri, Christian Dyzmann, Marco Colasurdo, Leonardo Renieri, João Pedro Filipe, Pablo Harker, Yasmin Aziz, Răzvan Alexandru Radu, Mohamad Abdalkader, Piers Klein, Thomas R Marotta, Julian Spears, Takahiro Ota, Ashkan Mowla, Kareem El Naamani, Pascal Jabbour, Arundhati Biswas, Frédéric Clarençon, James E Siegler, Thanh N Nguyen, Ricardo Varela, Nestor R Gonzalez, Markus A Möhlenbruch, Vincent Costalat, Benjamin Gory, Vivek Yedavalli, Christian Paul Stracke, Constantin Hecker, Gaultier Marnat, Hamza Shaikh, Christoph J Griessenauer, David S Liebeskind, Alessandro Pedicelli, Andrea M Alexandre, Tobias D Faizy, Illario Tancredi, Erwah Kalsoum, Boris Lubicz, Aman B Patel, Vitor Mendes Pereira, Adrien Guenego, Adam A Dmytriw, David J Altschul","doi":"10.3171/2025.3.JNS243030","DOIUrl":"https://doi.org/10.3171/2025.3.JNS243030","url":null,"abstract":"<p><strong>Objective: </strong>Mechanical thrombectomy (MT) is well established for large-vessel occlusion (LVO) strokes, but its safety in distal and medium-vessel occlusions (DMVOs) requires further investigation. This study analyzed the relationship between procedural approaches, petechial hemorrhage (PetH), and clinical outcomes in DMVO thrombectomy, with particular attention to technical considerations and the complex interplay between tissue injury and hemorrhagic complications.</p><p><strong>Methods: </strong>A retrospective cohort study was conducted on DMVO stroke patients treated with MT at 37 stroke centers worldwide from 2016 to 2024. Patients were categorized based on follow-up imaging into those with or without PetH. Four logistic regression models analyzed the association of PetH with favorable functional outcomes (modified Rankin Scale score ≤ 2) at 90 days, early neurological improvement (≥ 4-point National Institutes of Health Stroke Scale score decrease at 24 hours), all-cause mortality, and independent determinants of PetH. Adjusted odds ratios (aORs), 95% confidence intervals, and p values were reported.</p><p><strong>Results: </strong>Of 1428 patients, 439 (30.7%) developed PetH. Factors independently associated with PetH were multiple thrombectomy passes (aOR 1.58, 95% CI 1.21-2.06; p = 0.001), IV thrombolysis (aOR 1.31, 95% CI 1.01-1.69; p = 0.04), and the combined use of a stent retriever with aspiration as the first-line method compared with aspiration alone (aOR 1.66, 95% CI 1.15-2.38; p = 0.007). Conversely, general anesthesia (aOR 0.55, 95% CI 0.40-0.77; p < 0.001), higher Alberta Stroke Program Early CT Scores (aOR 0.76, 95% CI 0.69-0.83; p < 0.001), and successful recanalization (aOR 0.56, 95% CI 0.39-0.80; p = 0.002) were significantly associated with a lower odds of PetH. PetH was associated with a decreased odds of favorable functional outcomes (aOR 0.51, 95% CI 0.36-0.73; p < 0.001), reduced early neurological improvement (aOR 0.59, 95% CI 0.44-0.79; p < 0.001), and increased all-cause mortality (aOR 1.84, 95% CI 1.23-2.76; p < 0.001).</p><p><strong>Conclusions: </strong>PetH is a frequent sequela following MT in DMVO strokes and is associated with poorer outcomes, likely reflecting underlying ischemic injury rather than direct causation. Procedural factors influence PetH risk, suggesting medical treatment as first-line therapy for DMVOs, with MT reserved for refractory cases using less aggressive approaches.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-13"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564881","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multi-institutional recommendations on the use of 7T MRI in deep brain stimulation.","authors":"Erik H Middlebrooks, Maarten Bot, Rémi Patriat, Jonathan C Lau, Sanjeet S Grewal, Xiangzhi Zhou, Shengzhen Tao, Sina Straub, Essa Yacoub, Robert McGovern, Noam Harel","doi":"10.3171/2025.3.JNS243024","DOIUrl":"https://doi.org/10.3171/2025.3.JNS243024","url":null,"abstract":"<p><p>Deep brain stimulation (DBS) is an established therapeutic intervention for a range of neurological disorders, including Parkinson's disease, essential tremor, and epilepsy. The efficacy of DBS is predicated on the modulation of dysfunctional neural circuits through the application of electrical pulses. Recent advancements in MRI technology have facilitated the visualization of brain nuclei and their associated networks, which is critical for proper patient-specific targeting of electrodes in surgical procedures. This advancement aims to personalize surgical planning and postoperative programming by integrating patient-specific anatomical and connectivity models. The advent of clinical ultrahigh-field MRI, particularly 7T MRI, significantly enhances the targeting of DBS by improving spatial resolution, signal-to-noise ratio, and tissue contrast. Compared with lower field strengths, 7T MRI provides superior visualization of deeply situated brain nuclei and their extensive cortical projections, including the subthalamic nucleus, globus pallidus internus, and thalamus. This review synthesizes a multi-institutional consensus regarding the technical and clinical applications of 7T MRI, drawing on experience from more than 1000 procedures using 7T DBS. It encompasses both imaging acquisition and postprocessing techniques aimed at optimizing image quality. Our extensive clinical experience informs best practices for correcting distortions, mitigating image artifacts, and employing specific imaging sequences that enhance the visualization of common DBS targets. The insights and recommendations presented are intended to promote the safe and effective utilization of 7T MRI in DBS.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-11"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The modified Brain Injury Guidelines: safe, sensitive, but not yet specific.","authors":"Lindsey M Freeman, Andrew Mecum, Michael W Cripps, Peter J Lennarson","doi":"10.3171/2025.3.JNS242874","DOIUrl":"10.3171/2025.3.JNS242874","url":null,"abstract":"<p><strong>Objective: </strong>The modified Brain Injury Guidelines (mBIG) have been determined safe, but statistical analyses are limited to lower-severity mBIG 1 and mBIG 2 populations. The aim of this study was to determine the sensitivity of mBIG criteria for the need for neurosurgical intervention and to evaluate associations between individual mBIG 3 radiographic criteria and need for intervention.</p><p><strong>Methods: </strong>The records of all head trauma patients presenting to a level I trauma center from May 2020 to December 2023 were retrospectively reviewed. Patients without intracranial hemorrhage (ICH) on first CT imaging of the head and those who underwent intervention at an outside hospital were excluded. Radiographic stability versus progression on repeat CT imaging was collected. Clinical outcome measures were neurosurgical intervention, length of stay, and mortality. Patients were sorted based on published mBIG criteria and compared with prior studies reporting on intervention by the Brain Injury Guidelines (BIG) group.</p><p><strong>Results: </strong>A total of 1128 patients with a mean age of 54.9 (SD 21.2) years, 67.7% male, were included. Most patients (69.7%) were in the mBIG 3 group. Ninety-seven patients (8.6%), all in the mBIG 3 cohort, received intervention after initial CT imaging. An additional 113 patients (10.0%) underwent intervention after some period of observation and at least one repeat CT study, of whom 112 were in the mBIG 3 group and 1 was in the mBIG 2 group (0.6% of mBIG 2 patients, 0.5% of those requiring intervention, and 0.09% of the entire study population). mBIG 3 criteria were 99.5% sensitive for the need for neurosurgical intervention. mBIG 2+3 criteria were 100.0% sensitive, consistent with the cumulative literature of all iterations of BIG. Their specificities were 37.2% and 18.1%, respectively. There was no correlation between intervention and anticoagulant/antiplatelet use (p = 0.069). Progression of ICH was associated with intervention within the mBIG 3 cohort (p < 0.001). In post hoc multivariate analysis of mBIG 3 patients with Glasgow Coma Scale scores of 13-15, significant associations were found between each specific mBIG 3 radiographic criterion and intervention, except intraparenchymal hemorrhage (IPH) (p = 0.205) and subarachnoid hemorrhage (SAH) (p = 0.274).</p><p><strong>Conclusions: </strong>The mBIG 3 criteria are 99.5% sensitive for the need for neurosurgical intervention. Criteria requiring hospital admission (mBIG 2+3) are 100.0% sensitive. Radiographic mBIG 3 criteria for IPH and SAH alone are poor predictors for the need for neurosurgical intervention in patients with favorable neurological status. The recommendation against routine repeat CT head imaging in mBIG 1 and 2 patients is supported by the findings of this study.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"999-1008"},"PeriodicalIF":3.6,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564882","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter to the Editor. Management of patients discharged from the hospital after VPS surgery.","authors":"Junwei Lu, Jing Zhou, Yuanyuan Li","doi":"10.3171/2025.4.JNS25484","DOIUrl":"10.3171/2025.4.JNS25484","url":null,"abstract":"","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1161-1163"},"PeriodicalIF":3.6,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564879","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extreme subparaneurial ganglion cysts. Part 1: Principles and implications.","authors":"Godard C W de Ruiter, Byung-Chul Son, Kirsten M Hayford, B Matthew Howe, Kimberly K Amrami, Miguel A Reina, Robert J Spinner","doi":"10.3171/2025.2.JNS242815","DOIUrl":"https://doi.org/10.3171/2025.2.JNS242815","url":null,"abstract":"<p><strong>Objective: </strong>The formation and propagation of intraneural ganglion cysts (INGCs) is being elucidated by the unified articular theory. Its principles include a connection for joint fluid to egress from a synovial joint via an articular branch to a parent nerve and cyst following the path of least resistance, dependent on pressures and pressure fluxes. The occurrence of so-called extreme peroneal or tibial INGCs in the popliteal fossa extending to the sciatic nerve has been reported. One rarely described variant with a circumferential cyst within the subparaneurial compartment outside the epineurium of nerve(s) has been previously illustrated, but its mechanism and morphology have not been clarified. In this study, the authors aimed to investigate this type of cyst to challenge the principles of the unified articular theory.</p><p><strong>Methods: </strong>Four novel cases of patients with peroneal INGCs and \"extreme subparaneurial cyst(s)\" of the sciatic nerve and its distal branches were investigated: 3 arose from the superior tibiofibular joint (STFJ) and 1 from the knee joint. Three other cases of recognized extreme subparaneurial cyst (2 peroneal and 1 tibial from the STFJ) and 1 case of a peroneal subparaneurial cyst in the literature were reinterpreted. Data on clinical presentation, MR images, and surgical results were analyzed.</p><p><strong>Results: </strong>In all 8 cases, subparaneurial extension was observed to different degrees along the sciatic, tibial, common peroneal, sural, and deep and superficial peroneal nerves, as was subparaneurial-to-subparaneurial communication at the sciatic nerve bifurcation (i.e., crossover). Sequential MRI performed in 7 patients showed variable dynamic changes, including extreme ascent and descent. Extraneural rupture of the subparaneurial cyst, with spread into the surrounding tissue, was present at the sciatic nerve bifurcation in 6 cases.</p><p><strong>Conclusions: </strong>The authors provide pathoanatomical and pathophysiological evidence supporting that extreme subparaneurial cysts follow the principles of the articular theory. They propose a distribution pattern that explains the occurrence and evolution of extreme subparaneurial cysts along the sciatic nerve and its distal branches in patients with peroneal or tibial INGCs and subepineurial cysts. Crossover in the subparaneurial compartment allows potentially extensive circumferential distribution within connected nerves. Also, dynamic factors can lead to dramatic changes in cyst size and appearance from reabsorption or extraneural rupture. In Part 2 of this study, the authors provide evidence showing that a fenestration in the epineurium allows cysts to pass from the subepineurial-to-subparaneurial, subparaneurial-to-subparaneurial, and subparaneurial-to-subepimyseal compartments.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-11"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564843","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying features of prior hemorrhage in cerebral cavernous malformations on quantitative susceptibility maps: a machine learning pilot study.","authors":"Serena Kinkade, Hui Li, Stephanie Hage, Janne Koskimäki, Agnieszka Stadnik, Justine Lee, Robert Shenkar, John Papaioannou, Kelly D Flemming, Helen Kim, Michel Torbey, Judy Huang, Timothy J Carroll, Romuald Girard, Maryellen L Giger, Issam A Awad","doi":"10.3171/2025.3.JNS243051","DOIUrl":"10.3171/2025.3.JNS243051","url":null,"abstract":"<p><p>Features of new bleeding on conventional imaging in cerebral cavernous malformations (CCMs) often disappear after several weeks, yet the risk of rebleeding persists long thereafter. Increases in mean lesional quantitative susceptibility mapping (QSM) ≥ 6% on MRI during 1 year of prospective surveillance have been associated with new symptomatic hemorrhage (SH) during that period. The authors hypothesized that QSM at a single time point reflects features of hemorrhage in the prior year or potential bleeding in the subsequent year. Twenty-eight features were extracted from 265 QSM acquisitions in 120 patients enrolled in a prospective trial readiness project, and machine learning methods examined associations with SH and biomarker bleed (QSM increase ≥ 6%) in prior and subsequent years. QSM features including sum variance, variance, and correlation had lower average values in lesions with SH in the prior year (p < 0.05, false discovery rate corrected). A support-vector machine classifier recurrently selected sum average, mean lesional QSM, sphericity, and margin sharpness features to distinguish biomarker bleeds in the prior year (area under the curve = 0.61, 95% CI 0.52-0.70; p = 0.02). No QSM features were associated with a subsequent bleed. These results provide proof of concept that machine learning may derive features of QSM reflecting prior hemorrhagic activity, meriting further investigation. Clinical trial registration no.: NCT03652181 (ClinicalTrials.gov).</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-8"},"PeriodicalIF":3.6,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12291556/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extreme subparaneurial ganglion cysts. Part 2: The geyser theory as a mechanistic explanation for crossover.","authors":"Godard C W de Ruiter, Miguel A Reina, B Matthew Howe, Xavier Sala-Blanch, Byung-Chul Son, Kimberly K Amrami, Robert J Spinner","doi":"10.3171/2025.2.JNS242816","DOIUrl":"https://doi.org/10.3171/2025.2.JNS242816","url":null,"abstract":"<p><strong>Objective: </strong>Extreme subparaneurial ganglion cysts are poorly understood. In Part 1, the authors demonstrated that patterns of distribution in the subparaneurial space are consistent with the principles of the articular theory for intraneural ganglion cysts (INGCs). How a cyst transfers from the subepineurial to the subparaneurial compartment remains to be determined. In this part, the authors provide evidence supporting that cyst transfer occurs at the sciatic nerve bifurcation based on MRI and histological analysis, and introduce the geyser theory as an explanation for the redistribution of cysts.</p><p><strong>Methods: </strong>The authors analyze MR images obtained in patients with extreme subparaneurial cysts as well as newly identified cases of nearly extreme subparaneurial cysts (i.e., cysts visible in the subparaneurial compartment but not to the extreme degree as defined in Part 1) for potential crossover sites. They also analyze histological sections from 10 cadavers around the sciatic nerve bifurcation for the presence of openings in the epineurium and paraneurium.</p><p><strong>Results: </strong>MRI studies performed in 8 patients in Part 1 and 8 newly identified examples with nearly extreme subparaneurial INGCs showed evidence to support communication between different compartments at the sciatic nerve bifurcation (subepineurial-to-subparaneurial and subparaneurial-to-neighboring soft tissues). Openings in the epineurium of the common peroneal and tibial nerves at the sciatic nerve bifurcation were consistently found in all 10 cadaver specimens, as were openings in the paraneurium.</p><p><strong>Conclusions: </strong>The authors expand on the evidence to support cyst redistribution at the sciatic nerve bifurcation for INGCs in the knee region. They put forth a logical explanation for the development of a spectrum of extreme INGCs (ranging from a faint amount of cyst around the epineurium [wedding ring sign] to extreme subparaneurial INGCs [owl eyes]) based on principles seen in a geyser. The authors believe that radiological occurrence of crossover can be explained by the presence of fenestrations in both the epineurium and paraneurium at the sciatic nerve bifurcation, allowing cyst crossover in two steps: from the subepineurial to the subparaneurial space (\"cross\") and between a shared subparaneurial space of different nerves (\"over\"). Finally, the frequent occurrence of extraneural rupture (\"cross-out\") is due to cyst transfer into the soft tissue compartment via an opening in the outermost circumneurial layer.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-14"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564844","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter to the Editor. A viewpoint on external ventricular drainage in intraventricular hemorrhage.","authors":"Pedro Ithallo Ferreira Leite, Pedro Henrique Mouty Rabello, Eberval Gadelha Figueiredo","doi":"10.3171/2025.3.JNS25426","DOIUrl":"https://doi.org/10.3171/2025.3.JNS25426","url":null,"abstract":"","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"1-2"},"PeriodicalIF":3.5,"publicationDate":"2025-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144564878","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The carotidoclinoidal ligament in endoscopic endonasal transcavernous surgery: anatomical variations, operative techniques, and case series.","authors":"Jonathan Rychen, Yuanzhi Xu, Ludovico Agostini, Felipe Constanzo, Muhammad Reza Arifianto, Alix Bex, Limin Xiao, Vera Vigo, Aaron A Cohen-Gadol, Juan C Fernandez-Miranda","doi":"10.3171/2025.3.JNS242768","DOIUrl":"10.3171/2025.3.JNS242768","url":null,"abstract":"<p><strong>Objective: </strong>The carotidoclinoidal ligament (CCL) spans from the medial wall of the cavernous sinus (MWCS) to the internal carotid artery (ICA) and anterior clinoid process. In endoscopic endonasal transcavernous surgery, safe transection of the CCL requires not only knowledge of its typical anatomy, but also an understanding of its possible variations. The aim of this study was to analyze the anatomical variations of the CCL and the patterns of CCL invasion by pituitary adenomas (PAs).</p><p><strong>Methods: </strong>This investigation comprised an anatomical and a clinical study. Endonasal dissections of 20 specimens (40 sides) were performed to investigate CCL variations. A retrospective analysis of 145 patients with PA invading the CS (160 CS sides) was conducted to report the incidence and patterns of CCL invasion.</p><p><strong>Results: </strong>The CCL was present in all investigated sides (n = 40). In the coronal plane, 1 CCL branch was found in 20 sides (50.0%) and ≥ 2 CCL branches were found in 20 sides (50.0%). The main CCL branch was defined as the medial continuation of the proximal dural ring, marking the transition from the cavernous to the paraclinoidal ICA segment. When additional accessory CCL branches were present, they attached to the paraclinoidal ICA (n = 17, 53.1%), the horizontal cavernous ICA segment (n = 10, 31.3%), and/or the anterior genu of the cavernous ICA (n = 5, 15.6%). The CCL most commonly attached to the upper (n = 29, 72.5%) and middle third (n = 26, 65.0%) of the MWCS. In the axial plane, the CCL was found to be a fenestrated membrane in 29 sides (72.5%) and an intact membrane in 11 sides (27.5%). All CCLs attached to at least the anterior third of the MWCS. Additionally, some CCLs attached to the middle third (n = 23, 57.5%) and/or the posterior third (n = 17, 42.5%). The CCL was connected to the inferior parasellar ligament in 14 sides (35.0%). Among all PAs invading the CS, the CCL was invaded in 36 cases (22.5%). Two patterns of CCL invasion were identified: 1) tumor adherent to and infiltrating the CCL fibers (n = 30, 83.3%), and 2) CCL thickened due to tumor growth within and along the fibers (n = 6, 16.7%).</p><p><strong>Conclusions: </strong>This study represents a comprehensive analysis of the anatomical variations and patterns of invasion of the CCL, which is particularly relevant for the safe and effective resection of PA invading the CS.</p>","PeriodicalId":16505,"journal":{"name":"Journal of neurosurgery","volume":" ","pages":"916-927"},"PeriodicalIF":3.6,"publicationDate":"2025-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144512053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}