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

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.

BACKGROUND AND OBJECTIVES: Despite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a “four-by-four” technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions. METHODS: We describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes. RESULTS: The described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing. DISCUSSION: The transcranial approach (“from above”) remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision. CONCLUSION: The authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.

The modern period of neurosurgery in Bosnia and Herzegovina began with the first neurosurgical procedure performed by Dr. Karl Bayer in 1891 on 3 patients with depressed skull fractures and epilepsy. In 1956 the Department of Surgery in Sarajevo designated several beds specifically for a neurosurgical unit. A significant milestone in the history of neurosurgery in Bosnia and Herzegovina was the establishment of the Division of Neurosurgery at the Clinical Center University of Sarajevo in 1970. The first neurosurgeon to complete his training in Bosnia and Herzegovina was Dr. Faruk Konjhodžić. The first female neurosurgeon was Dr. Nermina Iblizović. Presently, there are 7 neurosurgical departments in the country, located in Sarajevo, Tuzla, Zenica, Mostar, Banja Luka, Bihać, and Foča. The Association of Neurosurgeons in Bosnia and Herzegovina, founded in 2003, is a member of the European Association of Neurosurgical Societies and the World Federation of Neurosurgical Societies. The aim of this historical paper is to provide a concise chronology of important events and mention key individuals who have contributed to the development of modern neurosurgery in Bosnia and Herzegovina.

Objective. Anticoagulant therapy is a risk factor for repeated intratumoral hemorrhage and acute enlargement of a vestibular schwannoma (VS) with neurological deficits. Therefore, we describe two cases of patients on oral anticoagulant therapy with intratumoral hemorrhage in which anticoagulant therapy prior to surgical resection was discontinued. We also discuss other similar cases from the literature since this is a rare event. Case Reports. We described the two cases of intratumoral hemorrhage in acoustic neurinoma and conducted a literature review of similar cases of patients with intratumoral hemorrhage in acoustic neurinoma who were also on oral anticoagulants. Both patients presented with CN-VII palsy prior to surgery; both also fully recovered after surgery except for hearing loss on the tumor side. Our literature review found 50 cases of VS (reported as vestibular schwannomas in the literature) with intratumoral hemorrhage. From this total, 11 patients used oral anticoagulant therapy with reported poor outcomes and high mortality; 9 of these 11 cases were reported in the past 20 years. The incidence is expected to rise due to increased use of anticoagulant therapy due to onset of atrial fibrillation, atherosclerosis, and thromboembolism from longer human lifespan. Conclusion. Anticoagulant therapy represents a risk factor for intratumoral hemorrhage and acute enlargement of VS tumor mass with neurological deficits.

The beginnings of neurosurgery in Croatia date to the end of the 19th century when Teodor Wickerhauser performed the first craniotomy in the country in 1886. Exactly 60 years later, in 1946, Danko Riessner founded a separate neurosurgical ward in Zagreb and is therefore considered the founder of Croatian neurosurgery. His main scientific contribution was a paper on the shifting of brain masses, published in 1939. The Department of Neurosurgery at the University of Zagreb was founded in 1974 as one of the first institutions of its kind in Southeast Europe. Finally, the Croatian Neurosurgical Society was founded in 1992 to promote the neurosurgical profession and science at the national level. This historical vignette aimed to provide a brief chronology of the most important events and notable people in the history of Croatian neurosurgery, as well as to commemorate its founders and highlight its development from the beginning to its current state of proficiency and expertise.