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OBJECTIVE The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs. METHODS In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors. RESULTS Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1–180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05–0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11–0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97–0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes. CONCLUSIONS The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients’ risk of hearing loss.

Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports.To report a multicenter experience assessing microsurgery safety/efficacy.Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021).Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%.Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Unlike the autosomal dominant inheritance of neurofibromatosis 2, there are no known inherited risk factors for sporadic, unilateral vestibular schwannoma (VS), which comprise most VS cases. The authors tested a hypothesis positing a genetic contribution to predisposition to these lesions by analyzing familial clustering of cases.Familial clustering of individuals with unilateral VS was analyzed in two independent genealogical resources with linked diagnosis data: the Veterans Health Administration Genealogy Resource and the Utah Population Database. Tests for excess relatedness, estimation of relative risks (RRs) in close and distant relatives, and identification of pedigrees with a significant excess of unilateral VS among descendants were performed.The average pairwise relatedness of the Veterans Health Administration Genealogy Resource VS cases significantly exceeded the expected relatedness ( p = 0.016), even when close relationships were ignored ( p = 0.002). RR for third- and fifth-degree relatives developing VS were significantly elevated (RR, 60.83; p = 0.0005; 95% confidence interval [CI], 7.37-219.73) and (RR, 11.88; p = 0.013; 95% CI, 1.44-42.90), respectively. No VS-affected first-, second-, or fourth-degree relatives were observed. In the Utah Population Database population, no first- or second-degree relatives with VS were observed. RR for fifth-degree relatives developing VS was significantly elevated (RR, 2.23; p = 0.009; 95% CI, 1.15-3.90).These results provide strong evidence for an inherited predisposition to sporadic, unilateral VS. This study exhibits the value of genealogical resources with linked medical data for examining hypotheses regarding inherited predisposition. The high-risk unilateral VS pedigrees identified in two independent resources provide a powerful means of pursuing predisposition gene identification.

Calcifying pseudoneoplasms of the neuraxis (CAPNONs) are uncommon benign lesions that are rarely diagnosed radiographically. We report an unusual case of a left middle cerebellar peduncle CAPNON with vasogenic edema and a perilesional cyst. The patient was a 36-year-old woman with a 20-year history of left-sided hearing loss that had recently progressed. Computed tomography and magnetic resonance imaging showed a heterogenous calcified lesion with vasogenic edema and a perilesional cyst in the left middle cerebellar peduncle. Although it is a rare radiographic feature of CAPNON, vasogenic edema should be included as a possible feature of this uncommon tumefactive lesion.

OBJECTIVE Giant (maximum diameter ≥ 4 cm) pituitary macroadenomas are complex tumors that require resection for decompression of optic nerves, relief of mass effect, and symptom improvement. Given the lack of surgical accessibility, the lateral extent of the lesions, and the invasion of the cavernous sinus, management presents a significant challenge. Transsphenoidal, transcranial, and combined approaches have been viable options for resection. The authors present their findings from a large series of patients to characterize giant pituitary adenomas, document outcomes, and outline surgical nuances in resection of these tumors. METHODS The authors reviewed 887 consecutive patients who underwent resection of pituitary adenomas at a single institution. From this group, 108 patients with giant pituitary adenomas who underwent resection between January 1, 2002, and December 31, 2020, were identified for inclusion in the study. The patient demographics, clinical presentation, tumor imaging characteristics, surgical approaches, and postoperative outcomes were analyzed using descriptive statistics. RESULTS The mean preoperative tumor diameter in this cohort was 4.6 ± 0.8 cm, with a mean volume of 25.9 ± 19.2 cm3. Ninety-seven patients underwent transsphenoidal approaches only, 3 underwent transcranial resection, and 8 patients underwent a combined approach. Gross-total resection was achieved in 42 patients. Tumor stability without a need for additional therapy was achieved in 77 patients, with 26 patients undergoing subsequent adjuvant radiotherapy. Among 100 patients with sufficient follow-up, 14 underwent adjuvant therapy—repeat operation and/or adjuvant radiation therapy—because of recurrence or tumor progression. Six patients with recurrence were observed without additional treatment. Overall, the morbidity associated with removal of these lesions was 11.1%; the most common morbidities were cerebrospinal fluid leak (5 patients, 4.6%) and hydrocephalus (4 patients, 3.7%). One death due to postoperative pituitary apoplexy of the residual tumor and malignant cerebral edema occurred in this cohort. CONCLUSIONS Giant pituitary tumors still represent a surgical challenge, with significant morbidity. Gross-total resection occurs in a minority of patients. Surgical goals for removal of giant pituitary tumors should include attempts at removal of most tumor tissue to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor. Experience with both transsphenoidal and multiple transcranial techniques is necessary for minimizing complications and improving outcomes.

Unplanned readmission after transsphenoidal resection of pituitary adenoma can occur in up to 10% of patients but is unpredictable.To develop a reliable system for predicting unplanned readmission and create a validated method for stratifying patients by risk.Data sets were retrospectively collected from the National Surgical Quality Improvement Program and 2 tertiary academic medical centers. Eight machine learning classifiers were fit to the National Surgical Quality Improvement Program data, optimized using Bayesian parameter optimization and evaluated on the external data. Permutation analysis identified the relative importance of predictive variables, and a risk stratification system was built using the trained machine learning models.Readmissions were accurately predicted by several classification models with an area under the receiving operator characteristic curve of 0.76 (95% CI 0.68-0.83) on the external data set. Permutation analysis identified the most important variables for predicting readmission as preoperative sodium level, returning to the operating room, and total operation time. High-risk and medium-risk patients, as identified by the proposed risk stratification system, were more likely to be readmitted than low-risk patients, with relative risks of 12.2 (95% CI 5.9-26.5) and 4.2 (95% CI 2.3-8.7), respectively. Overall risk stratification showed high discriminative capability with a C-statistic of 0.73.In this multi-institutional study with outside validation, unplanned readmissions after pituitary adenoma resection were accurately predicted using machine learning techniques. The features identified in this study and the risk stratification system developed could guide clinical and surgical decision making, reduce healthcare costs, and improve the quality of patient care by better identifying high-risk patients for closer perioperative management.

Objective: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry.Methods: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients’ data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5.Results: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. ‘Severely frail’ patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21–35.44) for 30-day mortality, 3.02 (95% CI, 1.97–4.56) for major complications, and 2.94 (95% CI, 2.32–4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality.Conclusion: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

BACKGROUND Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment. OBSERVATIONS The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion. LESSONS This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Although numerous studies have established advanced patient age as a risk factor for poor outcomes following intracranial meningioma resection, large-scale evaluation of frailty for preoperative risk assessment has yet to be examined. Weighted discharge data from the National Inpatient Sample were queried for adult patients undergoing benign intracranial meningioma resection from 2015 to 2018. Complex samples multivariable logistic regression models and receiver operating characteristic curve analysis were performed to evaluate adjusted associations and discrimination of frailty, quantified using the 11-factor modified frailty index (mFI), for clinical endpoints. Among 20,250 patients identified (mean age 60.6 years), 35.4% (n = 7170) were robust (mFI = 0), 34.5% (n = 6985) pre-frail (mFI = 1), 20.1% (n = 4075) frail (mFI = 2), and 10.0% (n = 2020) severely frail (mFI ≥ 3). On univariable analysis, these sub-cohorts stratified by increasing frailty were significantly associated with the development of Clavien–Dindo grade IV (life-threatening) complications (inclusive of those resulting in mortality) (1.3% vs. 3.1% vs. 6.5% vs. 9.4%, p

Craniocervical junction (CCJ) vascular abnormalities can be challenging to treat because of the surrounding density of critical neurovascular anatomy. Although most dural arteriovenous fistulas (dAVFs) are now treated with endovascular surgery, dAVFs near the CCJ are often better suited for microsurgical obliteration with precise vascular control.We describe our microsurgical approach to treating dAVFs at the CCJ. This includes a far-lateral approach with a small incision centered over the transverse process of the atlas and circumferential skeletonization of the vertebral artery in addition to clipping the fistula to limit lesion recurrence.Definitive microsurgical treatment of CCJ dAVFs can be accomplished using a minimally invasive approach.

Herniation of parahippocampal gyrus is usually caused by pressure differentials intracranially, and herniation without known risk factors is extremely rare. We describe a patient with a long history of seizures and a remote status epilepticus event. On magnetic resonance imaging, a presumed left temporal lobe tumor was observed. On neurosurgical consultation, the lesion was identified as a chronic mesial temporal lobe herniation. The patient lacked history that would suggest risk of cerebral herniation. Accurately identifying the patient’s chronic temporal lobe herniation radiographically likely saved this patient from unnecessary surgery or biopsy and allowed the patient to receive appropriate conservative care.

Introduction The modified early warning score (mEWS) has been used to identify decompensating patients in critical care settings, potentially leading to better outcomes and safer, more cost-effective patient care. We examined whether the admission or maximum mEWS of neurosurgical patients was associated with outcomes and total patient costs across neurosurgical procedures. Methods This retrospective cohort study included all patients hospitalized at a quaternary care hospital for neurosurgery procedures during 2019. mEWS were automatically generated during a patient's hospitalization from data available in the electronic medical record. Primary and secondary outcome measures were the first mEWS at admission, maximum mEWS during hospitalization, length of stay (LOS), discharge disposition, mortality, cost of hospitalization, and patient biomarkers (i.e., white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin). Results In 1,408 patients evaluated, a mean first mEWS of 0.5 ± 0.9 (median: 0) and maximum mEWS of 2.6 ± 1.4 (median: 2) were observed. The maximum mEWS was achieved on average one day (median = 0 days) after admission and correlated with other biomarkers (p0.0001). Scores correlated with continuous outcomes (i.e., LOS and cost) distinctly based on disease types. Multivariate analysis showed that the maximum mEWS was associated with longer stay (OR = 1.8; 95% CI = 1.6-1.96, p = 0.0001), worse disposition (OR = 0.82, 95% CI = 0.71-0.95, p = 0.0001), higher mortality (OR = 1.7; 95% CI = 1.3-2.1, p = 0.0001), and greater cost (OR = 1.2, 95% CI = 1.1-1.3, p = 0.001). Machine learning algorithms suggested that logistic regression, naïve Bayes, and neural networks were most predictive of outcomes. Conclusion mEWS was associated with outcomes in neurosurgical patients and may be clinically useful. The composite score could be integrated with other clinical factors and was associated with LOS, discharge disposition, mortality, and patient cost. mEWS also could be used early during a patient's admission to stratify risk. Increase in mEWS scores correlated with the outcome to a different degree in distinct patient/disease types. These results show the potential of the mEWS to predict outcomes in neurosurgical patients and suggest that it could be incorporated into clinical decision-making and/or monitoring of neurosurgical patients during admission. However, further studies and refinement of mEWS are needed to better integrate it into patient care.

Superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass is a critical treatment for moyamoya disease and steno-occlusive cerebrovascular disease. Combined bypass (direct + indirect) optimizes the chance of durable flow augmentation but can complicate wound closure from tissue disruption.We describe our technique for combined direct and indirect (encephaloduromyosynangiosis; EDAMS) STA-MCA bypass using a hinged bone flap. In addition to a direct bypass, EDAMS provides multiple sources for indirect revascularization. The hinged bone flap gently approximates the muscle and pia for secondary vascular ingrowth.Combined STA-MCA bypass with a hinged bone flap safely maximizes revascularization potential.

Ruptured blister aneurysms have significant rates of morbidity and mortality, but evidence of positive results with use of flow-diverting stents such as the Pipeline embolization device (PED) is growing. The authors describe the staged endovascular treatment of a ruptured left internal carotid artery blister aneurysm in a patient with a Hunt and Hess grade IV subarachnoid hemorrhage. PED placement was done via the common femoral artery using a triaxial delivery system. The telescoping stent technique performed over 48–72 hours achieved sufficient coverage of the aneurysm neck while limiting treatment time during the acute presentation and allowing interim dual antiplatelet treatment. A staged approach allows the targeting of a second PED placement in patients whose aneurysm continues to fill on the first follow-up angiogram. The authors have not experienced increased thromboembolic complications with this approach. Complete occlusion was achieved by postbleed day 8. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2264

OBJECTIVE Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

OBJECTIVE The aim of this study was to describe the efficacy, clinical outcomes, and complications of open cerebrovascular surgery, endovascular surgery, and conservative management of dolichoectatic vertebrobasilar aneurysms (DVBAs). METHODS Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane databases according to PRISMA guidelines. A meta-analysis was conducted for clinical presentation, treatment protocols, and clinical outcomes—good (improved or stable clinical status) or poor (deteriorated clinical status or death)—and mortality rates. RESULTS The 9 identified articles described 41 cases (27.5%) of open cerebrovascular surgery, 61 endovascular procedures (40.9%), and 47 cases (31.5%) of conservative management for DVBAs. The total cohort had a good outcome rate of 51.9% (95% CI 28.3%–74.6%), a poor outcome rate of 45.5% (95% CI 23.0%–70.1%), and a mortality rate of 22.3% (95% CI 11.8%–38.0%). The treatment groups had comparable good clinical outcome rates (open cerebrovascular surgery group: 24.7% [95% CI 2.9%–78.2%]; endovascular surgery group: 69.0% [95% CI 28.7%–92.5%]; conservative management group: 57.7% [95% CI 13.0%–92.5%]; p = 0.19) and poor outcome rates (open vascular surgery group: 75.3% [95% CI 21.8%–97.1%]; endovascular surgery group: 27.2% [95% CI 5.6%–0.70.2%]; conservative management group: 39.9% [95% CI 9.1%–81.6%]; p = 0.15). The treatment groups also had comparable mortality rates (open vascular surgery group: 39.5% [95% CI 11.4%–76.8%]; endovascular surgery group: 15.8% [95% CI 4.4%–43.0%]; conservative management group: 19.2% [95% CI 6.8%–43.5%]; p = 0.23). CONCLUSIONS The current study of DVBAs illustrated poor outcomes and high mortality rates regardless of the treatment modality. The subgroup analysis showed heterogeneity among the subgroups and advice for personalized management.

Inflammatory disease of the pituitary gland is known as hypophysitis. There are multiple histological subtypes, the most common being lymphocytic, and the pathogenesis is variable and diverse. Hypophysitis can be primary and idiopathic or autoimmune related, or secondary to local lesions, systemic disease, medications, and more. Although hypophysitis was previously accepted as an exceedingly rare diagnosis, a greater understanding of the disease process and new insights into possible etiologic sources have contributed to an increased frequency of recognition. This review provides an overview of hypophysitis, its causes, and detection strategies and management.

Background When resident physicians fail to demonstrate appropriate milestone competencies early in their neurologic surgery residency, a plan of remediation is necessary. Methods Once any psychologic, physical, or behavioral causes of identified knowledge or psychomotor deficiencies have been identified and addressed, the next step is to develop a plan to close these gaps. Specific areas that are assessed for deficits include medical knowledge, clinical reasoning and judgment, clinical skills, time management and organization, interpersonal skills, communication, and professionalism. Specific learning goals and objectives, as well as teaching and learning methods, pertain to the unique areas of deficit, and all of these must be considered with the goal of developing a resident-specific remediation plan. Results A plan for assessment of the remediation process is described, including an evaluation of what constitutes individual resident remediation success. Conclusions Finally, a discussion of the prior resident remediation studies across many disciplines is made.

Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation. After emergency surgery, an angiogram was performed, and the patient was diagnosed with moyamoya disease. Six months later, the patient was treated for moyamoya using direct and indirect revascularization; after surgery there was excellent vascularization in both regions of the bypass and no further progression of moyamoya changes. This case illustrates a rare example of intracerebral hemorrhage associated with moyamoya changes in the posterior vascularization in a pediatric patient and subsequent use of direct and indirect revascularization to reduce the risk of future hemorrhage and moyamoya progression.

Primary pituitary abscesses are extraordinarily rare lesions, especially in pediatric populations, with very few cases described in the literature. Here we review this rare condition and discuss its management. We report a case of a previously healthy 12-year-old female patient who presented with vomiting and meningismus. We review the literature on pediatric patients presenting with pituitary abscesses and the described treatments. An operative video demonstrating our surgical technique is provided. Magnetic resonance imaging of the brain revealed a rim-enhancing, diffusion-restricting sellar lesion concerning for abscess. No sinus disease or other structural cause of intracranial infection was identified. An endoscopic transsphenoidal approach was used to visualize the endonasal structures, and microscopic guidance was used for evacuation of the abscess. Purulent material was drained immediately upon entry into the lesion. Tissue cultures grew Cutibacterium acnes. Postoperatively, the patient was hypocortisolemic but otherwise endocrinologically normal. She was discharged four days later on oral hydrocortisone and intravenous ceftriaxone without any neurologic deficit. To the best of our knowledge, this is the second report in the literature of a primary pituitary abscess due to C. acnes infection.

To compare the efficacy, outcomes, and complications of single session (SS-SRS) and multisession (MS-SRS) stereotactic radiosurgery in the treatment of intracranial meningiomas.Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment protocols and outcomes were conducted. After the selection process, 20 articles describing 1483 cases were included.A total of 1303 patients who underwent SS-SRS and 180 patients who underwent MS-SRS for the management of their intracranial meningioma were reported in the included studies. SS-SRS and MS-SRS had comparable one-year (SS-SRS: 98% vs. MS-SRS: 100%, p 0.99) and five-year (SS-SRS: 94% vs. MS-SRS: 93%, p = 0.71) tumor control rates. The groups also had comparable tumor volume reduction/tumor regression rates (SS-SRS: 44% vs. MS-SRS: 25%, p = 0.25), tumor volume stability rates (SS-SRS: 51% vs. MS-SRS: 75%, p = 0.12), and tumor progression rates (SS-SRS: 4% vs. MS-SRS: 4%, p = 0.89). SS-SRS and MS-SRS yielded similar complication rates (10.4% vs. 11.4%, p = 0.68) and comparable functional improvement rates (MS-SRS: 44% vs. SS-SRS: 36%, p = 0.57). However, MS-SRS was used for significantly larger tumor volumes (MS-SRS: 23.8 cmSS-SRS and MS-SRS resulted in comparable tumor control, tumor volumetric change, and functional outcomes despite significant biases in selecting patients for SS- or MS-SRS.

OBJECTIVE Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS Six patients with a median age of 12 years (range 7–16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Developed over 50 years ago, the microscopic transsphenoidal approach is a simple, efficient technique with proven efficacy for the surgical treatment of an array of sellar and parasellar diseases. Although utilization of fully endoscopic transsphenoidal approaches has dramatically increased recently because it offers enhanced visualization, current outcomes data do not clearly favor either approach. Potential advantages of the microscope that persist in the endoscopic era include decreased operative time; preservation of a single-surgeon, unobstructed, twohanded microsurgical technique; and limited disruption of the nasal mucosa. Endoscope-assisted microsurgical approaches can also be used to overcome limitations in visualization while preserving the aforementioned advantages.