Purely cystic meningiomas are extremely rare extra-axial neoplasms that can mimic aggressive malignancies, like glioblastoma multiforme (GBM), because radiologically and intraoperatively they lack a visible solid component and demonstrate postcontrast enhancement and significant vasogenic edema. The authors present a case of a purely cystic intra-axial meningioma mimicking GBM with an accompanying systematic review of the literature. An 84-year-old female presented with expressive dysphasia. MRI revealed a 3-cm inhomogeneously enhancing intra-axial left temporal lobe mass with apparent MRI presentation of central necrosis, suggesting a high-grade glioma. Intraoperatively, the lesion appeared vascular and infiltrative like a GBM; however, histopathological and immunohistochemical analyses (somatostatin receptor 2 antigen positive, progesterone receptor positive, glial fibrillary acidic protein negative) confirmed an angiomatous meningioma (WHO grade 1). Postoperatively, the patient’s symptoms resolved, and 10 years of annual follow-up MRI studies confirmed no recurrence. Only 3 other purely cystic meningioma cases (extra-axial) were identified in the literature. Cystic meningiomas are rarely GBM “imitators.” Surgeons should consider cystic meningioma when classic radiological hallmarks are absent. Despite an aggressive imaging profile, these tumors are biologically and clinically benign. Gross-total resection remains the gold-standard treatment, offering excellent long-term prognosis and the potential for a permanent cure. This case highlights the need for histological tissue diagnosis before final treatment plans are considered. https://thejns.org/doi/10.3171/CASE26438

OBJECTIVES Transsphenoidal surgery for the resection of pituitary neoplasms has evolved over the years. The current study sought to summarize visual outcomes following transsphenoidal surgery for sellar and parasellar lesions and evaluate how these outcomes are reported across the literature. METHODS A systematic review was conducted in accordance with PRISMA guidelines. PubMed, EMBASE, Scopus and Cochrane Library database were searched from inception through October 2023. Studies were included if they reported pre- and post-operative visual outcomes for patients undergoing transsphenoidal resection of sellar or parasellar lesions. Reviews, abstracts, and non-English studies were excluded. Rates of pre- and postoperative visual loss, visual field defects, and visual acuity impairment were collected. Postoperative outcomes were categorized as improved, normalized, unchanged, or worsened. RESULTS Of 3828 studies identified, 236 met inclusion criteria and were included in the analysis. Pituitary adenomas accounted for 80% of cases, followed by craniopharyngiomas (14%) and meningiomas (4%). Preoperative visual loss, visual field defects, and visual acuity impairment were present in 55%, 51%, and 37% of patients, respectively. Postoperative improvement occurred in 76% of patients with visual loss, 73% with visual field defects, and 64% with visual acuity impairment, while 2%-11% experienced worsening of symptoms. Reporting completeness varied across studies, with fewer than half of studies reporting both pre- and post-operative outcomes. CONCLUSIONS Across all studies, approximately 76% of patients with preoperative visual impairment experienced postoperative improvement following transsphenoidal surgery. Reporting of visual outcomes remains highly variable, underscoring the need or standardized definitions and outcome measures in future research.

This systematic review analyzed treatment strategies and outcomes for spinal low-grade gliomas, based on data from 63 studies encompassing 954 patients. Surgery was the primary treatment, with gross total or subtotal resection associated with improved survival. Subtotal resection followed by radiotherapy prolonged progression-free survival. Fractionated radiotherapy (45-50 Gy) showed disease stabilization and neurologic improvement, with some studies reporting a 5 year progression-free survival of 93% and an overall survival of 100%. Chemotherapy was mainly used in recurrent cases. Prognosis varied by histology; pilocytic astrocytomas showed excellent survival, while infiltrative gliomas were linked to poorer long-term outcomes.

Simple Summary This study presents the Endoscopic One-Nostril Transseptal Transsphenoidal Approach (EONOTTA) as a minimally invasive surgical technique for selected cases of pituitary macroadenomas. Derived from the classic endoscopic endonasal approach, EONOTTA allows excellent exposure of the sellar region while preserving nasal mucosa and olfactory function. The technique offers comparable disease control to standard endoscopic endonasal approaches, with reduced sinonasal morbidity and postoperative discomfort. Despite limitations such as retrospective design and small sample size, findings support EONOTTA as a safe, efficient alternative for non-extended pituitary tumors requiring limited surgical exposure.

In this video, we present the surgical technique and operative nuances of the zygomatic pretemporal skull base approach for resection of a large left sphenoid wing and middle cranial fossa radiation-induced meningioma (RIM) with invasion and encasement of the middle cerebral artery (MCA). RIMs represent a distinct and surgically challenging entity due to aggressive biological behavior, altered tissue planes, and frequent vascular involvement. In the present case, prior childhood cranial irradiation resulted in dense tumor adherence to the MCA within radiation-altered tissue, necessitating meticulous microsurgical technique. The zygomatic pretemporal approach effectively converts a deep skull base lesion into a convexity-like lesion, providing a wide basal surgical corridor, reducing working distance, and minimizing frontal and temporal lobe retraction. After zygomatic osteotomy and extradural skull base drilling, early devascularization was achieved through removal of the sphenoid ridge and division of the meningo-orbital band. Intradural microsurgical dissection focused on internal tumor debulking followed by sharp arachnoid dissection to circumferentially separate the tumor from the MCA and its branches. In areas of dense adherence, vessel-preserving strategy was prioritized. A Simpson Grade I resection was achieved without vascular injury. Zygomatic reconstruction using low-profile “dog-bone” plates allowed anatomical realignment of the osteotomized segment, preservation of temporalis muscle function, and excellent cosmetic outcome. Postoperative imaging confirmed gross total resection (GTR) and stable reconstruction. The patient recovered without new neurological deficits and demonstrated complete resolution of preoperative hemiparesis at follow-up. This case highlights the value of the zygomatic pretemporal skull base approach in achieving radical resection of complex sphenoid wing RIMs while facilitating safe dissection of critical neurovascular structures.

Anterior clinoidal meningioma (ACM) remains a challenging lesion to treat surgically due to its intricate neurovascular relationships with surrounding anatomy and often presents with ipsilateral visual loss. Anterior clinoidectomy (AC) by skilled skull base surgeons enables early optic nerve (ON) decompression, tumor devascularization, and radical tumor resection. The authors provide an update on ACM surgery, current views on the role of AC and its impact on outcomes in surgical treatment, as well as a new 2 stage 4 by 4 step concept of ON decompression involving AC. A systematic review of PubMed and meta-regression of surgically treated ACMs was performed. In total, 908 patients were analyzed; 415 (45.7%) underwent routine AC (performed in all cases) and 493 (54.3%) underwent selective AC (planned preoperatively). The routine AC cohort showed higher risk for new cranial-nerve (CN) deficits (12.5% vs. 3.0%; p < 0.001), vascular complications (6.7% vs. 3.3%; p = 0.02), and new focal neurological deficits (5.5% vs. 2.3%; p = 0.04). No differences were found in visual outcomes, gross-total resection, mortality, recurrence, or other major complications. Random-effects meta-regression of routine AC showed increased odds of new CN deficit (odds ratio [OR], 3.34; 95% confidence interval [95% CI], 1.51–7.38; p = 0.005; heterogeneity [I2] = 60.5%) and vascular complication (OR, 2.59; 95% CI, 1.05–6.38; p = 0.04; I2 = 47.8%), with moderate and substantial heterogeneity among routine AC studies, respectively. In experienced hands, AC remains an invaluable tool for ACM treatment as it offers more consistent tumor devascularization, prevention of tumor recurrence, optic nerve decompression, and increased working space, which facilitates optimal tumor resection and better long‐term control and functional outcome. We propose a new didactical structured concept of routine AC via 2-stage, 4 by 4 steps to improve the utility of AC and decrease associated operative risks compared to selective AC.

BACKGROUND White cord syndrome (WCS) is a rare and extremely serious complication that can occur following spinal decompression procedures for severe mostly cervical spinal stenosis. It is often reported immediately after surgery or several hours to days postoperatively and is identified via a diagnosis of exclusion based on new-onset sudden motor weakness after a decompression procedure. OBSERVATIONS The authors report the illustrative case of a 54-year-old female patient with WCS, who was managed with surgical intervention, corticosteroid therapy, and mean arterial blood pressure support. Additionally, the authors systematically reviewed an additional 27 cases of WCS documented in the literature. LESSONS A relatively favorable clinical outcome was observed in this patient following surgical intervention combined with corticosteroid therapy and mean blood pressure support. Currently, there are no established guidelines for the treatment of WCS; however, in any patient experiencing sudden neurological deterioration after cervical spinal decompressive surgery—especially when a known cause is unidentified—WCS should be considered as a potential diagnosis, and prompt treatment should be initiated to attempt to improve outcomes. https://thejns.org/doi/10.3171/CASE25542

In recent years, neurosurgery and clinical neuroscience have undergone a profound transformation, driven by an increasingly interdisciplinary approach that integrates technological innovation, the refinement of therapeutic protocols, and novel rehabilitative paradigms [...].

Intracranial epidermoid cysts are rare, benign lesions accounting for 1% of intracranial tumors.1 They may arise from misplaced squamous epithelium during neural tube closure, and are found in the paramedian position, cerebellopontine angle, or parasellar region with other locations considered rare.2-4 The far lateral approach and its extensions enables access and visualization of ventral and ventrolateral lesions at the craniocervical junction without retraction.5-15 A 32-year-old female presented with gait instability, visual disturbances, and severe headaches. MRI demonstrated a solid, non-contrast enhancing T1 hypointense and T2 hyperintense lesion in the right cerebellomedullary cistern with mass effect on cerebellum and brainstem, consistent with radiological findings of epidermoid cysts. The patient underwent far lateral suboccipital craniotomy with partial posterior medial condylectomy and C-1 hemilaminectomy while prone, which enabled unobstructed ventral view. A 4 hand (ie, 2 surgeon) microsurgical technique in tumor resection enabled dynamic, gentle tissue retraction and safe tumor resection. Apart from transient swallowing problems that resolved 2 weeks post-operation, the patient's postoperative course was uneventful. Follow-up MRI revealed gross total removal. This video demonstrates the steps, anatomy, and technical nuances for vascular and neural preservation during removal of epidermoid cysts in the cerebellomedullary cistern. To the best of our knowledge, this is the first operative video showing the resection of a pure cerebellomedullary cistern epidermoid cyst. The utility of fat graft dural closure enhancement decreased the risk of CSF leak. The patient provided consent. Institutional review board approval was not required for individual cases and thus was not sought.

Introduction: Aneurysms of brain vessels are life-threatening conditions with various adverse outcomes, some stemming from microsurgical intervention, particularly when major vessel perforators are inadequately protected. The use of endoscopes enhances the approach to aneurysms by providing closer visualization (180–360 degrees) of the local anatomy, potentially reducing accidental damage. To improve visualization and efficiency, a microscope-integrated 45-degree angled microinspection endoscopic tool (QEVO®, Carl Zeiss, OberkochenTM) has been developed and employed in various neurosurgical procedures. Methods: Between 2021 and 2025, 27 brain aneurysms were treated with QEVO® assistance at the Department of Neurosurgery, Clinical Center of the University of Sarajevo. The choice of the videos corresponds to the best image quality in videos and on the microscopic determination of adjacent vessel perforators, which were not adequately seen purely by the surgical microscope in specific cases. Exclusion criteria included cases without a need for QEVO® assistance in perforator visualization, severe brain edema, intraoperative aneurysm rupture, posterior circulation, or low video quality. Results: Case 1 demonstrates an anterior choroidal artery (AchA) aneurysm; Case 2 presents an anterior communicating artery (AcommA) aneurysm; and Case 3 features contralateral middle cerebral artery (MCA) microsurgical clipping with QEVO® assistance. Conclusions: The QEVO® tool significantly improves the visualization of aneurysm–perforator relationships, increasing the likelihood of preserving perforators during standard microsurgical clipping. This innovative approach may reduce surgical complications and enhance patient outcomes, highlighting the tool’s potential as an adjunct in aneurysm microsurgery.

OBJECTIVE The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA. METHODS A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed. RESULTS Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage. CONCLUSIONS Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.

OBJECTIVE Brainstem cavernous malformations (BSCMs) were once considered inoperable. Microsurgical resection now represents a valuable option for treating patients with hemorrhagic or symptomatic lesions. The aim of this study was to provide a practical guide for surgical planning by analyzing postoperative neurological and functional outcomes. METHODS The early- and long-term neurological (National Institutes of Health Stroke Scale [NIHSS] score) and functional (modified Rankin Scale [mRS] and Glasgow Outcome Scale [GOS] scores) outcomes of 32 patients who underwent surgery for hemorrhagic BSCM were reviewed. The three-step surgical planning was based on an anatomosurgical algorithm. RESULTS Nine lesions (28.1%) were located in the mesencephalon, 19 (59.4%) in the pons, and 4 (12.5%) in the medulla. A fronto-temporo-orbito-zygomatic approach was selected to reach anterior mesencephalic BSCMs (2, 6.3%). A retrosigmoid approach and its extended variant were selected for lateral mesencephalic (6, 18.8%), anterior (2, 6.3%) and lateral (13, 40.6%) pontine, and anterior (1, 3.1%) and lateral (1, 3.1%) medullary BSCMs. A supracerebellar infratentorial approach was selected for posterior mesencephalic BSCMs (1, 3.1%). A telovelar approach was selected for posterior pontine (4, 12.5%) and medullary (2, 6.3%) BSCMs. Total resection was achieved in 29 cases (90.6%), with a 12.5% rate of surgical complications. The NIHSS score progressively improved at both the early (5.16 ± 3.70 vs 4.63 ± 2.78, p = 0.446) and late (4.63 ± 2.78 vs 2.41 ± 2.39, p < 0.001) postoperative evaluations. Functional outcomes showed an initial deterioration followed by a long-term improvement (mRS score: 2.66 ± 1.07 vs 3.06 ± 1.11 vs 2.13 ± 1.29, GOS score: 3.78 ± 0.61 vs 3.59 ± 0.62 vs 4.19 ± 0.78). Time to surgery significantly correlated with early- and long-term NIHSS, mRS, and GOS scores, while the number of hemorrhages before surgery correlated with early- and long-term mRS and GOS scores. CONCLUSIONS Early surgery after the first bleed following systematic surgical planning may be considered as an effective option for managing hemorrhagic BSCMs with acceptable operative morbidity and relatively favorable early- and long-term neurological and functional outcomes.