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.

OBJECTIVE Endoscopic endonasal transsphenoidal pituitary surgery is a diffuse and well-established surgical technique: over the years, the transseptal approach via a nasal mucosal incision has also gained popularity. Here we describe our preliminary experience with an entirely endoscopic one-nostril transseptal transsphenoidal approach (EONOTTA) for pituitary sellar tumor resection; the surgical corridor runs through the entire length of the nasal septum via an incision in the nasal mucosa. METHODS A total of 40 patients with a midline prevalent pituitary tumor who underwent EONOTTA from January 2022 to June 2023 were retrospectively reviewed for the evaluation of the safety and efficacy of this technique. RESULTS At 1 year follow-up, all patients had no recurrence, and the degree of tumor resection was comparable to that of the control group undergoing the traditional endoscopic endonasal approach. A low rate of nasal and post-surgical complications occurred; globally, EONOTTA was not time-consuming, and a better functional result was noticed, with a better quality of life for patients. CONCLUSIONS This study confirms, in our preliminary experience, the EONOTTA's excellent risk-benefit ratio in selected cases; for an experienced multidisciplinary team, it provides a good maneuverability and a functional outcome while preserving the integrity of the nasal mucosa.

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.