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 [...].