Pain practice : the official journal of World Institute of PainHaneen Sabet, Ahmed Samir, Basant Lashin, Abdallah Abbas, Shrouk Ramadan, Mohamed El-Moslemani, Ahmed F Younis, Obai Yousef, Rovan Ahmed Rouby, Alaa Abd-Elsayed
OBJECTIVE: To evaluate the effectiveness and safety of proximal and distal ultrasound-guided greater occipital nerve block (US-GONB) in patients with migraine. METHODS: PubMed, Scopus, Web of Science, and the Cochrane Library were searched up to July 2025. Studies assessing US-GONB in migraine were included. Data were pooled using a random-effects model and expressed as mean difference (MD) with 95% confidence intervals (CI). Subgroup analyses were conducted based on the injection site. RESULTS: Twelve studies (658 patients) were included. US-GONB significantly reduced pain intensity (MD = -3.48 points, 95% CI [-3.84, -3.11]), monthly headache frequency (MD = -9.12 days, 95% CI [-11.65, -6.58]), headache duration (MD = -18.98 h, 95% CI [-26.86, -11.11]), and monthly analgesic use (MD = -10.01, 95% CI [-12.91, -7.11]). No significant subgroup difference was observed in pain intensity between injection sites. For monthly headache frequency, a significant subgroup difference was observed, with the proximal subgroup demonstrating numerically larger reductions than the distal subgroup (-10.83 vs. -6.36 days; p = 0.006). Adverse events were generally mild and transient: loss of pinprick sensation occurred in 80% of proximal vs. 100% of distal injections, dizziness in 22.7% vs. 3.9%, moderate-to-severe migraine attacks in 20.1% vs. 12.9%, and cerebellar-like symptoms in 12.5% vs. 0%, respectively. Vasovagal syncope (9.1%) and local pain (8.1%) were reported only in proximal injections. CONCLUSIONS: US-GONB appears to be a safe and effective intervention for migraine, significantly improving pain and headache burden. Proximal injections may be associated with greater reductions in headache frequency; however, these findings were based on indirect comparisons. Further comparative trials are warranted to optimize anatomical targeting.
Neurosurgical reviewDong Hoon Kim, Jin-Young Kim, Jung-Woo Hur, Jae Taek Hong
Acellular dermal matrix (ADM) is a tissue-engineered biological scaffold widely adopted in plastic reconstructive surgery, yet its application in spine surgery remains largely underexplored. No prior systematic review has synthesized the available evidence. A systematic search of PubMed, Embase, Cochrane CENTRAL, Web of Science, and Scopus was performed from inception through 31 July 2026, following PRISMA 2020 guidelines (PROSPERO: CRD420261326660). Studies were stratified a priori into three evidence tiers: direct spine surgery evidence, craniovertebral/neuraxis evidence, and indirect cranial evidence. Risk of bias was assessed with ROBINS-I and JBI checklists; certainty was rated using GRADE. Ten studies comprising 385 enrolled patients met inclusion criteria: 172 patients in seven studies providing direct spine surgery evidence, 13 patients in two craniovertebral/neuraxis studies, and 200 patients in one predominantly cranial duraplasty series. Five application categories were identified. The single comparative study-a propensity score-matched cohort of 108 patients undergoing ACDF-reported lower Swallowing Impairment Scores at the pre-specified three-month endpoint (0.26 ± 0.16 vs. 0.68 ± 0.27, p = 0.01, significant after Bonferroni correction), although the observed difference (Δ = 0.42) fell below the suggested minimal clinically important difference, and adhesion scores did not differ between groups. All remaining studies were uncontrolled. GRADE certainty was very low across all outcomes. Efficacy of ADM in spine surgery cannot be determined from the current evidence base. Reported adverse events were infrequent, but ascertainment was neither standardized nor prospective, and these data are insufficient to establish safety. Findings are product- and indication-specific and should not be generalized across ADM formulations or clinical applications.
Neurosurgical reviewAnish Kalyana, Daniel Coles, Sameer Khalil, Mohammad Mahmud, Roshni Beeharry, Sanjay Cheema, Anouk Borg, Tim M Young
Trigeminal neuralgia affects approximately 3% of patients with multiple sclerosis - a far higher prevalence than in the general population. The associated pain often proves refractory to medication, prompting consideration of neurosurgical intervention. The variable efficacy, tolerability, and durability of available procedures, compounded by factors such as multiple sclerosis subtype and neuroimaging findings, require evidence to guide personalised surgical decision-making. This systematic review evaluates surgical interventions for trigeminal neuralgia in multiple sclerosis, analysing how patient and disease-specific variables influence outcomes. A systematic review with narrative synthesis was performed. Following PRISMA guidelines, Embase, PubMed, and Scopus were searched (January 2000 - April 2026). Studies assessing pain relief from surgical procedures for trigeminal neuralgia in multiple sclerosis using the Barrow Neurological Institute Pain Scale were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Thirty-two studies, encompassing 1617 patients, met the inclusion criteria. Microvascular decompression in cases with demonstrable neurovascular conflict provided durable outcomes offset by higher risks of serious complications (including one fatality), despite inherent diagnostic uncertainty regarding whether pain was specifically driven by multiple sclerosis. Partial sensory rhizotomy displayed favourable pain relief (initial success range: 95.3-100%) and durability (recurrence ranging from 20.1 to 79 months). Whilst some studies noted a lack of major complications, some cases of severe trigeminal dysfunction including anaesthesia dolorosa were reported (n = 3; 7.5%). Percutaneous ablative procedures (initial success ranging from 58 to 100%) and gamma knife radiosurgery (initial success ranging from 52.7 to 97.3%) achieved comparable pain control rates to classical trigeminal neuralgia cohorts. They also featured a mild complication profile, though durability was suboptimal (recurrence ranging from 7.4 to 74.5 months for gamma knife radiosurgery and 8-60 months for percutaneous procedures) and repeat procedures were typically tolerable. Differing gamma knife radiosurgery dosages (</>80 Gy) were not associated with significant differences in pain control. Preliminary outcomes of arachnoid-trigeminal nerve release from a 2025 study highlighted promising results with 75% of patients achieving Barrow Neurological Institute Pain Scale I at final follow-up. Gamma knife radiosurgery and percutaneous ablative procedures represent well-tolerated surgical options with comparable outcomes to primary trigeminal neuralgia cohorts regardless of plaque burden. Partial sensory rhizotomy demonstrated notable efficacy and durability in refractory multiple sclerosis-associated trigeminal neuralgia, particularly in the absence of neurovascular conflict, and warrants earlier consideration in the surgical pathway. Microvascular decompression may offer long-term durability where neurovascular conflict is demonstrated. However, its higher procedural risk and the diagnostic uncertainty inherent in multiple sclerosis-associated trigeminal neuralgia cases with concurrent neurovascular conflict necessitate cautious patient selection. High-resolution preoperative imaging is therefore recommended to guide personalised modality selection. Prospective studies are needed to further validate surgical decision-making and establish standardised outcome reporting in this population.
Journal of neuro-oncologyShashank Rajkumar, Harrison Moy, XueMei Ji, Mariam Aboian, Veronica Chiang
PURPOSE: Stereotactic radiosurgery (SRS) effectively treats brain metastases, yet some lesions ultimately require post-SRS surgery due to local failure. We examined whether the use of volumetric changes in FLAIR hyperintensity and/or necrosis in conjunction with enhancing volumetric changes after Gamma Knife SRS correlate with pathological outcome at subsequent surgery. METHODS: We queried our institutional database for patients who received first-time SRS for a single brain metastasis and later underwent surgical resection of the same lesion. Tumor volumes were measured manually before SRS and at 6 weeks, 3 months, and 6 months post-treatment. FLAIR:enhancing (FER) and enhancing:necrotic ratios were analyzed. Linear mixed-effects models assessed variables influencing volume trajectories; Pearson correlation examined associations with pathological outcome. RESULTS: Thirty-six patients met inclusion criteria. Mean enhancing volume changed - 28.5%, - 25.8%, and - 18.9% from baseline at 6 weeks, 3 months, and 6 months, respectively. Mean FLAIR volume changed - 16.9%, - 22.2%, and - 2.4% at the same intervals. Percent changes in FLAIR and enhancing volume correlated significantly at 6 weeks (p = 0.004) and 3 months (p < 0.001). FER trended differently between RN and recurrent tumor with patients who developed radiation necrosis (RN) having significantly lower FLAIR volumes at 6 weeks compared to those with recurrent tumor. Baseline lesion size, FLAIR volume, FER (all p < 0.001), primary cancer type, and sex (both p = 0.02) influenced FLAIR trajectories. CONCLUSIONS: Perilesional edema and enhancement trajectories after SRS are variable but may help distinguish RN from recurrent tumor, particularly at early follow-up. Incorporation of automated edema volumetry should be considered in routine post-SRS surveillance.
Child's nervous system : ChNS : official journal of the International Society for Pediatric NeurosurgeryRebecca White, April Gormon, Duc T Nguyen, Travis Herzog, Daniel Curry
PURPOSE: This study's objective was to investigate barometric pressure changes that are most strongly associated with symptom exacerbations in shunted hydrocephalus patients. To achieve this, we conducted in-depth analysis of hospital encounter data and examined their correlation with variations in sea level pressure (SLP). Ultimately, our findings may inform hydrocephalus management strategies by identifying potential environmental triggers, reducing unnecessary hospital visits, and guiding the future design of CSF diversion technologies that are more responsive to external conditions. METHODS: We conducted a retrospective analysis of the daily hydrocephalus encounters census of a tertiary children's hospital and compared it with weather parameters, including fluctuations in SLP as measured in 8-h intervals, maximum daily rate of change, daily minimum SLP, and daily mean SLP. Data was analyzed in a univariate and multivariable Poisson generalized linear models, and census was compared to weather fluctuations on the day of encounter, the following day, and 2 days afterward. RESULTS: In univariable analysis, hydrocephalus encounters were associated with the daily maximum rate of change, daily maximum SLP, daily minimum SLP, and daily mean SLP. These associations maintained 1 day and 2 days after the hospital encounters. In multivariate analysis, the daily maximum SLP and daily minimum SLP were associated with patient encounters both 1 and 2 days after the analyzed census date. Associations were also observed between daily minimal SLP, daily maximum SLP, and maximum daily 8-h SLP. CONCLUSION: This study documents an association between fluctuations in atmospheric pressure and daily hydrocephalus census at a single tertiary medical center. Weather-related influences should be considered when evaluating shunt malfunction in patients with chronic shunted hydrocephalus.
BMJ openSruthi Pandipati Thomas, Sharon Ramey, Mark Conaway, Stephen Kralik, Rachel Arp, Jeffrey S Raskin, Nisha Gadgil, Neena Marupudi, Darcy Fehlings
INTRODUCTION: Dystonia, a form of elevated muscle tone in CP, significantly impairs function and quality of life. Multiple neurosurgical interventions are used to reduce dystonia, including intrathecal baclofen (ITB) and ventral dorsal rhizotomy (VDR). ITB is used most often for moderate to severe generalised dystonia in CP; however, the evidence supporting its effectiveness is weak due to patient variability and study limitations. Further, VDR is becoming more prevalent but there is minimal data available on its outcomes. This proposal aims to evaluate ITB and VDR's ability to reduce quantitative and functionally impactful dystonia as well as reduce spasticity, improve motor function, improve mood and improve quality of life. Secondary analysis will focus on identifying child characteristics of a positive response to ITB and VDR to allow for better patient selection. METHODS AND ANALYSIS: We will conduct a prospective observational study of 52 children with CP and moderate-severe dystonia (Barry Albright Dystonia Scale (BADS) greater than 14) who receive ITB (n=35) and VDR (n=17). Children will be enrolled at three sites in the USA: Texas Children's Hospital (Houston), Lurie Children's Hospital (Chicago) and C.S. Mott Children's Hospital (Ann Arbor). Changes will be measured in dystonia, spasticity, gross and fine motor function and multiple patient-reported outcomes related to quality of life, participation, depression, anxiety and pain. Children enrolled in the study will undergo detailed characterisation of brain malformation and injury patterns. The primary analysis will use repeated measures models to estimate changes from baseline in BADS scores at 3, 6 and 12 months. Secondary analyses will apply the same strategies to the other outcome measures. Subgroup analyses will investigate unique characteristics of children with a positive response to either intervention. A multidimensional or composite measure will also be created. ETHICS AND DISSEMINATION: Primary ethics approval was provided by the Baylor College of Medicine Institutional Review Board (H-54449). Primary caregivers of all participants were consented for the study. Participants with capacity were asked to assent. Results of the study will be disseminated via peer-reviewed presentations at scientific conferences and open access publication. TRIAL REGISTRATION NUMBER: NCT06606574.
BMJ openSamuel Lichtman-Mikol, Joshua M Lang, Himanshu Nagar, Raed Zuhour, Kevin V Chaung, Nicholas G Zaorsky, Soumyajit Roy, Prateek M Mendiratta, Jonathan E Shoag, J…
INTRODUCTION: Prostate cancer (PCa) is the most commonly diagnosed cancer in men worldwide. A rising proportion of men present with de novo metastatic disease, a state associated with poor survival outcomes and limited curative treatment options. Within this group, a subset of patients exhibit oligometastatic disease, defined by a limited number of metastases, which may represent a distinct clinical entity with potential for long-term disease control. Emerging evidence suggests that metastasis-directed radiotherapy (MDRT), including stereotactic body radiation therapy (SBRT), may improve progression-free survival in this population. However, current evidence is largely limited to phase II trials in the metachronous setting and retrospective studies in the synchronous setting. Furthermore, predictive biomarkers of treatment response in these patients remain undefined. We aim to evaluate, within a large randomised multicentre phase II trial, the efficacy and biological impact of MDRT in men with de novo oligometastatic PCa. METHODS AND ANALYSIS: Patients with de novo oligometastatic hormone-sensitive prostate cancer (omHSPC), defined as up to 10 sites of metastatic disease by prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/CT or up to five sites of metastatic disease by conventional imaging, are randomised (1:1) to standard of care (SOC) or SOC plus MDRT. SOC includes 12 months of androgen deprivation therapy plus an androgen receptor pathway inhibitor, with definitive treatment to the prostate by radiotherapy (RT). A predefined subset is allowed to undergo radical prostatectomy if clinically appropriate. MDRT involves SBRT to all metastatic sites identified on conventional imaging or PSMA PET/CT. Target enrolment is 200 patients, stratified by diagnostic imaging modality, number of bone metastases, plan to MDRT all sites of metastases and local therapy approach.Prostate RT may be delivered using moderate (20 fractions) or ultra-hypofractionation (five fractions), with optional simultaneous-integrated-boost to dominant intraprostatic lesions. MDRT regimens aim for a biologically effective dose ≥100 Gy (α/β=1.5) using 1-5 fractions. Gross tumour volumes are delineated based on MRI, CT and PSMA PET/CT.The primary endpoint is failure-free survival, defined using cause-specific PCa death. The study is powered at 80% to detect a HR of 0.58 using a one-sided alpha of 0.05. Secondary endpoints include radiographic progression-free survival, overall survival (OS), time to next intervention, time to castration-resistant PCa, PCa-specific mortality and patient-reported outcomes. Biospecimen collection and imaging data will support future translational analyses. Data from this trial is preplanned to be pooled with the STAMPEDE 2 (NCT06320067) trial, a phase III randomised trial to assess OS benefit of MDRT in men with de novo omHSPC. ETHICS AND DISSEMINATION: This clinical trial is approved by the Case Comprehensive Cancer Center Institutional Review Board (STUDY20231440). The results will be disseminated via peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT06150417 (https://clinicaltrials.gov/study/NCT06150417).
Child's nervous system : ChNS : official journal of the International Society for Pediatric NeurosurgeryAnaïs Chivet, Julie Bonheur, Diane Doummar, Sarah Ferrand-Sorbets, Laurent Goetz, Georg Dorfmuller
Hamartoma of the floor of fourth ventricle (HFFV) is an extremely rare entity known to be causing focal movement disorders in children. According to the few reported cases in literature, the only effective treatment is disconnection or resection of the lesion which can be very challenging in this anatomic area. We report a 15-year-old child with a fourth ventricle floor's limited nonexophytic hamartoma revealed by brief paroxysmal movement disorder episodes since the age of 5 months, without EEG correlate. He was treated for the first time by safe surgical electrophysiology-guided resection, with promising results on epileptic disease. This positive result opens interesting prospects for improving the surgical management of other lesions affecting this anatomical region, while limiting postoperative neurological deficits.
PURPOSE: To evaluate dose selection and post-treatment management after Gamma Knife surgery (GKS) for large brain metastases, with a focus on early identification of true progression. METHODS: This retrospective single-institution study included 143 patients with large brain metastases (tumor volume ≥ 4 cm3) treated with primary GKS between 2016 and 2024. One dominant lesion per patient was analyzed. Treatment modality (single-session, staged, or hypofractionated) and dose selection were individualized. Radiographic progression was defined as a ≥ 20% increase in longest tumor diameter from nadir. True progression was defined as sustained enlargement or the need for salvage treatment, whereas lesions that stabilized or regressed without intervention were classified as pseudoprogression. RESULTS: Median overall survival was 15.3 months. During follow-up, 47 lesions showed radiographic progression: 42 true progression, 4 pseudoprogression, and 1 intratumoral hemorrhage. The 6-, 12-, and 24-month cumulative incidences of true progression were 17.4%, 31.5%, and 33.1%, respectively. True progression did not differ by treatment modality or tumor volume. A marginal dose ≥ 57.6 Gy biologically effective dose (BED10) was associated with a lower risk of true progression (subdistribution hazard ratio [SHR], 0.46; p = 0.02). Recurrent peritumoral edema developed earlier in true progression than pseudoprogression (median, 173.5 vs. 564 days; p = 0.001). Lower marginal dose at repeat GKS was associated with subsequent true progression (SHR, 0.82; p = 0.02). CONCLUSION: A BED10 ≥ 57.6 Gy improved local control in large brain metastases. Recurrent peritumoral edema accompanying tumor enlargement within 1 year after GKS strongly suggested true progression and should prompt consideration of early salvage intervention. CLINICAL TRIAL REGISTRATION: Clinical trial number: not applicable.
BMJ openAmara Anyanwu, Dima Suki, Annelise Huynh, Giulio Draetta, Kyle Noll, J Jack Lee, Frederick F Lang, Mei Rui
INTRODUCTION: Neurosurgical patients commonly experience significant preoperative anxiety, which can negatively impact surgical outcomes and recovery trajectories. Music, as a powerful neurophysiological modulator of the human stress response, offers a non-pharmacological, non-invasive and cost-effective approach to anxiolysis by stabilising the hypothalamic-pituitary-adrenal axis and autonomic nervous system. The goal of this study is to evaluate the effects of live and recorded music on preoperative stress, serum-level and plasma-level biomarkers, perceived pain, anxiety and mood states in neurosurgical cancer patients. METHODS AND ANALYSIS: Enrolled neurosurgical patients (n=132) will be equally randomised to one of three groups: (1) simulated live music intervention using a Steinway Spirio M recording/player piano, (2) recorded music played through ambient speakers, or (3) control (no music). The musical selections will all incorporate 16 validated Compositional Elements of Relaxation (CERs). The intervention period will last 30 min.Endpoints will be assessed using validated pre-intervention and post-intervention questionnaires, including the State-Trait Anxiety Inventory-State subscale (STAI-S), the Profile of Mood States-Short Form (POMS-SF), and the Visual Analogue Scale for Pain (VASP), as well as serum biomarkers (eg, interleukin-6, cortisol and epinephrine) analysed using broad-spectrum proteomic and metabolomic approaches.The study will be conducted from January 2025 to January 2028. ETHICS AND DISSEMINATION: This study protocol was approved by the review board at MD Anderson Cancer Center on 12 May 2025. The results of this study will be disseminated through peer-reviewed journals and presented at relevant scientific conferences. TRIAL REGISTRATION NUMBER: NCT06536504.
Journal of neuro-oncologyAnita L Kalluri, Austin Carmichael, Maureen Rakovec, Kelly Jiang, Megan Parker, Carly Weber-Levine, Divyaansh Raj, Josh Materi, Karisa C Schreck, Iban Aldecoa,…
PURPOSE: Oligodendroglioma, an adult diffuse glioma now defined by molecular criteria, is typically managed first surgically. This retrospective cohort study correlates surgical characteristics with postoperative outcomes in purely molecularly defined oligodendroglioma. METHODS: Adults with surgically managed 1p/19q co-deleted, IDH-mutated oligodendroglioma were identified. Medical records were reviewed for demographics, radiologic features, treatments, and postoperative outcomes. RESULTS: Two hundred seventy-seven patients (207 grade 2, 70 grade 3) were included; most presented with seizures (173/267, 64.8%), non-contrast enhancing lesions (128/213, 60.1%), and frontal lobe tumors (170/267, 63.7%). Subtotal resection (STR, 115/249, 46.2%) and gross total resection (GTR, 97/249, 39.0%) were more common than biopsy (37/249, 14.9%). Awake procedures were performed in 25/173 (14.5%) cases. New permanent neurological deficits occurred in 24/254 (9.4%) patients. Median (IQR) follow-up was 57 (20-107) months. Individuals undergoing GTR or STR had longer median progression-free survival (PFS) than patients who underwent biopsy (76 versus 44 months, p = 0.007). In multivariable analysis, GTR, but not STR, was an independent predictor of improved PFS compared to biopsy after adjusting for demographics, grade, and adjuvant treatment (p = 0.026). The PFS benefit of GTR over biopsy was maintained in subgroup analyses of grade 2 tumors (p = 0.032) but not grade 3 tumors (p = 0.549). CONCLUSIONS: In this retrospective cohort of individuals with molecularly defined oligodendrogliomas, GTR was associated with prolonged PFS compared to biopsy without an observed increase in postoperative neurological deficits.
To classify the severity of bone flap resorption (BFR) following autologous cranioplasty under bone tissue bank storage conditions and to identify potential risk factors by analyzing clinical cases exhibiting postoperative bone resorption. A retrospective analysis was conducted on clinical data from 61 patients who developed bone flap resorption after autologous cranioplasty performed with bone flaps stored under bone tissue bank conditions. Based on the Oulu Resorption Scale, patients were categorized into four groups: no bone flap resorption (NBFR), mild BFR (MBFR), intermediate BFR (IBFR), and severe BFR (SBFR). Clinical characteristics were compared across these groups. Variables showing statistical significance (p < 0.05) in univariate analyses were subsequently entered into a multivariate ordinal logistic regression model to evaluate their association with the development and severity of BFR. All 61 patients completed follow-up, with a median follow-up duration of 378.0 days (interquartile range: 178.5-605.5 days). By the end of follow-up, 16 patients (26.2%) had developed BFR, including 9 cases (14.8%) of MBFR, 4 cases (6.6%) of IBFR, and 3 cases (4.9%) of SBFR. Univariate analysis revealed that smoking Pre- decompressive craniectomy (Pre-DC), traumatic brain injury (TBI), number of bone flaps ≥ 2, cranial defect area > 92.11 cm², and bone flaps located in the frontotemporoparietal region were significantly associated with an increased risk of BFR (all p < 0.05). Multivariate ordinal logistic regression analysis identified smoking Pre-DC, TBI, and cranial defect area > 92.11 cm² as independent risk factors for BFR, whereas having fewer than two bone flaps served as a protective factor against resorption (all p < 0.05). Autologous cranioplasty using bone flaps preserved under bone tissue bank conditions is associated with a low complication rate. With careful patient selection, it remains an admissible reconstructive option following decompressive craniectomy.
PituitaryDanyal Z Khan, Zhehua Mao, Anjana Wijekoon, Adrito Das, Simon C Williams, Ann Blandford, Abhiney Jain, Lauren Harris, Anouk Borg, Neil L Dorward, Matthew J Cla…
INTRODUCTION: Precise anatomical navigation is fundamental to safe endoscopic pituitary surgery, a high-stakes procedure characterised by a challenging learning curve. While traditional navigation systems often rely on workflow-disrupting probes or static preoperative imaging, advancements in computer vision AI (CVAI) now enable dynamic, real-time pixel-level anatomical segmentation directly from live surgical video. Our group has previously conducted a series of preclinical human-computer interaction studies to refine the system's design, alongside digital and high-fidelity physical simulations demonstrating the potential benefit of AI assistance in improving surgical performance, training, and safety. Building on this foundation, the current study represents a first-in-human evaluation of real-time pixel-level CVAI anatomical segmentation in the neurosurgical operating room - assessing feasibility, human factors and clinical outcomes, while iteratively improving the system. METHOD: Guided by the DECIDE-AI and IDEAL frameworks, this single-centre evaluation comprises an initial proof-of-concept of CVAI anatomical segmentation in endoscopic transsphenoidal pituitary surgery. The AI model utilised a DINOv3-derived vision transformer architecture, deployed via a high-performance edge computing unit to achieve low-latency real-time inference without reliance on cloud infrastructure. Feasibility and functionality were assessed via structured questionnaire, prospective observation, and blinded retrospective review of the recordings of the endoscopic surgical video feed and wider operating room environment. Continuous multi-stakeholder feedback through validated human factors surveys drove iterative technical refinements between cases. Routine clinical outcomes, aligning with the standard pituitary surgery core outcome set, were collected. RESULTS: Eight patients with pituitary adenomas were enrolled. The CVAI system was successfully deployed in six cases, demonstrating acceptable real-time pixel-level sella segmentation accuracy. Deployment failed pre-operatively in two cases owing to a single platform-level boot-configuration issue. Iterative refinement between cases was driven by our experience and surgical team feedback. This resulted in the integration of additional anatomical structure segmentations (e.g., carotid arteries), enhanced model accuracy via training dataset expansion, and hardware firmware upgrades. Multi-stakeholder surveys demonstrated satisfactory system feasibility, usability, and acceptability among the surgical team. Both prospective observation and retrospective video review confirmed the absence of adverse events, including no significant distraction to the primary surgeon, and there were no AI-related clinical complications. CONCLUSION: This first-in-human early clinical evaluation (IDEAL Stage 1) of real-time pixel-level AI anatomical segmentation in live neurosurgery demonstrates feasibility, showcases iterative system evolution, and reports clinical and human factors outcomes. Future work will include a larger single-centre case series (IDEAL Stage 2a) with more surgical teams to further iterate the system and explore its impact on safety, training and workflow. As the underpinning AI models improve and integrate with other intra-operative navigational technologies, such tools will likely be the cornerstone of intra-operative surgical decision support systems.
Child's nervous system : ChNS : official journal of the International Society for Pediatric NeurosurgeryLeonardo Di Cosmo, Christopher Peter Imbrogno, Jad El Choueiri, Arthur Nantes, Joshua Vishal Sahgal, Francesca Totis, Ismail Zaed, Noor Ul Owase Jeelani
BACKGROUND: Ventriculoperitoneal (VP) shunting is the most common long-term treatment for pediatric hydrocephalus; however, early shunt failure remains a significant cause of morbidity and economic burden. Although individual studies have investigated risk factors for early failure, findings are fragmented and inconsistent. This meta-analysis evaluates the prevalence, predictors, and causes of 30-day VP shunt failure in pediatric patients. METHODS: Following PRISMA guidelines, databases were searched through November 2025 for studies reporting 30-day VP shunt failure in pediatric cohorts. Randomized controlled trials, prospective, and retrospective studies were included. Random-effects models were used, with risk ratios (RR) calculated for dichotomous outcomes and pooled prevalence estimated using generalized linear mixed models. RESULTS: Our analysis included 11,596 pediatric patients, with one randomized trial and 8 observational studies. The pooled prevalence of 30-day shunt failure was 13.8% (95% CI 11.2-16.8), with significantly lower rates following primary compared with secondary shunt insertion (12.6% vs 18.0%). A separate comparative analysis confirmed this reduced risk of early failure after primary insertion (RR 0.58, 95% CI 0.49-0.69; p < 0.001). When pooled female sex was associated with decreased risk of early failure, while no hydrocephalus etiology demonstrated a significant effect. Poor ventricular catheter placement was the only modifiable predictor associated with increased risk of early failure from the pooled analyses (RR 1.64, 95% CI 1.08-2.50; p = 0.02); however, this association was based on only two studies and lost significance in leave-one-out analyses. Cause-specific failure mechanisms were poorly reported across studies. Among studies reporting these outcomes, proximal catheter obstruction and malposition were the most frequently reported mechanisms of early shunt failure, followed by shunt infection. Several additional predictors were significant in individual studies and were qualitatively reported, but could not be pooled due to heterogeneous reporting. CONCLUSION: VP shunt failure affects approximately one in eight pediatric patients in the first 30 days following placement, and occurs significantly more frequently following secondary shunt insertion. Among the pooled predictors, ventricular catheter placement quality represents the most significant modifiable factor associated with early shunt survival, although this finding was based on limited data. Several predictors showed estimates suggestive of increased risk; however, prospective studies with standardized reporting are necessary to define the size of these associations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420261305777.
Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical NeurophysiologyMohammed Altaha, Ayat Jassim Al Eid, Hoor Hussain Aloraidh, Zahraa Aqeel Alshakhs, Alanoud Salah Almukhaylid, Fatimah Sami Albatih, Joud Abdulaziz Abusharifah,…
BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible neurocognitive disorder causing severe functional decline in the elderly. Cerebrospinal fluid (CSF) shunting aims to relieve ventricular stress and restore perfusion; however, high-quality placebo-controlled evidence has historically been limited. METHODS: This PRISMA-compliant systematic review and meta-analysis (PROSPERO: CRD420261372290) evaluated adults aged 60 years or older with iNPH. We included randomized controlled trials (RCTs) comparing immediate active CSF shunting against placebo or no shunting. The primary outcome was the change in gait speed using standardized timed assessments. Data were pooled using a restricted maximum-likelihood random-effects model, supplemented by Trial Sequential Analysis (TSA) and GRADE assessment to control for random error. RESULTS: Four RCTs comprising 224 patients were included. Shunting significantly improved the primary outcome of gait velocity (SMD 0.73, 95% CI 0.45 to 1.01; P < 0.0001). Significant secondary improvements were observed in qualitative gait function (SMD 0.81, P = 0.007), functional independence (OR 3.92, P < 0.0001), continuous modified Rankin Scale reduction (MD - 0.73, P < 0.0001), Mini-Mental State Examination or Montreal Cognitive Assessment scores (SMD 0.37, P = 0.009), and Symbol Digit Test performance (SMD 0.47, P = 0.002). TSA confirmed conclusive evidence for functional disability reduction before reaching the required information size. Shunting increased the incidence of positional headaches (OR 5.62, 95% CI 1.16 to 27.18). The pooled estimate for subdural hematoma was imprecise and did not reach statistical significance (OR 4.07, 95% CI 0.62 to 26.94) and should not be interpreted as evidence of an absence of risk given the small number of events. No significant difference was observed for ischemic stroke (OR 0.64, 95% CI 0.18 to 2.33), also based on few events. CONCLUSION: Cerebrospinal fluid shunting appears to provide meaningful clinical benefit in patients with idiopathic normal pressure hydrocephalus, particularly through improvement in gait velocity and functional independence. However, the evidence suggests a more limited or uncertain effect on cognitive and urinary symptoms. Importantly, the available randomized evidence is too imprecise to rule out an increase in major complications such as surgically treated subdural hematoma; positional headaches were significantly more frequent with shunting, and the largest included trial independently reported a significant excess of subdural bleeding. These safety signals warrant careful discussion with patients considering shunt surgery. These findings support shunting as an effective therapeutic option for appropriately selected patients with iNPH, while emphasizing the need for careful patient selection, standardized outcome assessment, and further high-quality, large-scale trials with longer follow-up.
Drug design, development and therapyXin Da, Zimeng Jin, Ziyi Zou, Wei Zhou, Sihui Zhu, Yulu Hu, Xinyue Wang, Qingmei Zhang, Guanghong Xu
INTRODUCTION: Postoperative acute pain is a common challenge after breast cancer surgery. This randomized controlled trial compared the analgesic effects of ultrasound-guided erector spinae plane block (ESPB) and modified intercostal nerve block (MINB) in patients undergoing unilateral modified radical mastectomy. METHODS: Seventy patients were randomly allocated to ESPB or MINB group. The primary outcomes were the 6-hour postoperative resting and movement-evoked Visual Analogue Scale (VAS) scores. Secondary outcomes included resting and movement-evoked VAS scores at 0, 3, 12, and 24 hours, intraoperative opioid consumption, rescue analgesic use within 72 hours, Quality of Recovery-15 (QoR-15) score at 24 hours, and hospital stay. RESULTS: At 6 hours postoperatively, both resting VAS (median 2 [0-2] vs 2 [2-3], P=0.005) and movement-evoked VAS (median 3 [2-4] vs 4 [3-4], P=0.015) were lower in the MINB group. Resting VAS scores at 0 and 3 hours were comparable between groups. Movement-evoked VAS scores were lower in the MINB group at all post-surgery time points (P<0.05 for all). Intraoperative remifentanil consumption was lower in the MINB group (P<0.001). Fewer patients required rescue analgesics in the MINB group (P=0.038). No significant difference was observed in QoR-15 scores between groups (P=0.055). CONCLUSION: Ultrasound-guided MINB was associated with lower 6-hour resting and movement-evoked pain scores and reduced intraoperative opioid consumption compared with ESPB, without compromising recovery quality in patients undergoing unilateral modified radical mastectomy. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2300077956; https://www.chictr.org.cn/showproj.aspx?proj=77956). Registered on November 24, 2023. Principal investigator: Guanghong Xu.
This study evaluated the clinical effects of enteral nutrition nursing combined with gastrointestinal function monitoring in neurosurgical patients receiving enteral nutrition. This single-center retrospective cohort study included 120 neurosurgical patients who received enteral nutritional support from June 2023 to June 2025. Sixty patients received routine enteral nutrition nursing (control group), and 60 received routine care plus dynamic gastrointestinal function monitoring (combined nursing group). Outcomes included gastric retention, abdominal distension, nausea and vomiting, overall gastrointestinal intolerance, enteral nutrition interruption, aspiration/reflux, nutritional delivery, gastrointestinal recovery, hospital and intensive care unit (ICU) stay, nutritional tolerance, and nursing satisfaction. Logistic regression was used to identify factors associated with gastric retention. Baseline characteristics were comparable between groups (all P > .05). Gastric retention occurred less frequently in the combined nursing group than in the control group (15.0% vs 30.0%), although the difference did not reach statistical significance (P = .053). The combined nursing group had lower incidences of abdominal distension (16.7% vs 36.7%, P = .011), nausea and vomiting (11.7% vs 26.7%, P = .038), and overall gastrointestinal intolerance (20.0% vs 43.3%, P = .006). Time to achievement of enteral nutrition targets, gastric residual volume, time to recovery of bowel sounds, and time to first defecation were also more favorable (all P < .001). Enteral nutrition interruption was less frequent (8.3% vs 23.3%, P = .022), and hospital and ICU stays were shorter (both P < .01). Good nutritional tolerance and nursing satisfaction were more frequent in the combined nursing group (both P < .05). Multivariable analysis showed that the combined nursing model was associated with lower odds of gastric retention. Enteral nutrition nursing combined with gastrointestinal function monitoring was associated with improved gastrointestinal tolerance, more efficient nutritional delivery, earlier gastrointestinal recovery, and shorter hospital and ICU stays. A lower observed incidence of gastric retention was also noted, and adjusted analysis suggested an association with reduced odds of gastric retention.
Postoperative sleep disturbance (PSD) is common after surgery and is characterized by insomnia, fragmented sleep, altered sleep-wake patterns, and excessive daytime sleepiness. Stellate ganglion block (SGB) modulates sympathetic activity and may improve sleep through autonomic, analgesic, and anti-inflammatory mechanisms. We searched eight Chinese and international databases from inception to January 1, 2025, and included 10 randomized controlled trials involving 734 participants, predominantly from China. Compared with placebo, routine care, or active control, SGB was associated with lower subjective sleep scores on the night of surgery (standardized mean difference [SMD], - 2.09; 95% confidence interval [CI], - 3.36 to - 0.83), postoperative day 1 (SMD, - 2.27; 95% CI, - 2.85 to - 1.68), postoperative day 3 (SMD, - 1.12; 95% CI, - 1.70 to - 0.55), and 4 weeks after surgery (SMD, - 1.16; 95% CI, - 1.55 to - 0.77). The 4-week effect remained statistically significant; however, no formal interaction test was performed, and the numerical differences between time points should not be interpreted as evidence of a statistically significant temporal decline. SGB also increased total sleep time by approximately 72 min (mean difference, 71.76 min; 95% CI, 51.51-92.01). The estimate for sleep efficiency was based on only two studies and showed substantial heterogeneity (mean difference, 11.45% points; 95% CI, 1.79-21.11; I² = 86%). Substantial heterogeneity for subjective sleep quality (I² = 90%) and the limited geographic diversity of the included trials reduce the certainty and generalizability of the findings. SGB may improve postoperative sleep, particularly during the early postoperative period, but larger multicenter randomized controlled trials are required.
Child's nervous system : ChNS : official journal of the International Society for Pediatric NeurosurgerySergio Cavalheiro, Marcos Devanir Silva da Costa, Fernando Seiji Suzuki, Patrícia Alessandra Dastoli, Diego Pereira de Melo Oliveira, Rocio Ester Gómez Verges,…
PURPOSE: MPDZ syndrome is a rare autosomal recessive disorder caused by biallelic pathogenic variants in MPDZ (9p23) and typically managed with ventriculoperitoneal shunting (VPS). Recent characterization of MPDZ-related hydrocephalus as an obstructive process-driven by diencephalosynapsis and third ventricle atresia-provides theoretical grounds for endoscopic third ventriculostomy (ETV), yet no primary ETV treatment has previously been reported in a genetically confirmed, liveborn patient. METHODS: We report a female infant with prenatally diagnosed obstructive ventriculomegaly, subsequently confirmed as MPDZ syndrome by whole-exome sequencing, who was treated with ETV as the primary surgical intervention, and we review the literature on the neurosurgical management of MPDZ-related hydrocephalus. RESULTS: Fetal MRI demonstrated diencephalosynapsis and third ventricle atresia with secondary occlusion of the aqueduct of Sylvius. A ventriculo-amniotic shunt was placed at 29 weeks of gestation; the infant was born at 36 weeks and 1 day and underwent ETV on the fifth day of life without complications. At 2 years and 5 months of age, she developed intermittent symptoms of intracranial hypertension due to late stoma occlusion at the level of the Liliequist membrane, successfully managed with endoscopic stoma revision. At the most recent follow-up (4 years and 5 months), she remains free of ventriculoperitoneal shunting, with age-appropriate neurodevelopment. A systematic review of the literature identified no prior report of ETV used as primary treatment in a genetically confirmed, liveborn patient with MPDZ syndrome. CONCLUSIONS: This case provides proof of concept that ETV is both mechanistically justified and clinically effective in selected patients with MPDZ-related obstructive hydrocephalus, potentially avoiding lifelong shunt dependency. Patient selection should nonetheless remain individualized, based on ventricular anatomy, third ventricular floor thickness, and associated structural anomalies.
Wrong-site surgery (WSS) is a rare but preventable sentinel event with significant patient, professional, and organizational consequences. Despite longstanding safety standards, including the Universal Protocol, WSS continues to occur across procedural settings. This case report examines a wrong-side nerve block that occurred during a nonemergent orthopedic procedure. The case is discussed in the context of known patterns, contributing factors, and system failures associated with WSS. Key issues identified include deviations from established workflows, communication gaps, interruptions, incomplete verification of laterality, and failures to consistently apply policies and procedures at critical points in care. Although elements of the verification process were completed, the case highlights vulnerabilities in execution and timing, particularly before the initiation of a nerve block. Implications for perioperative nursing practice emphasize adherence to standardized processes, vigilance during workflow changes, effective team communication, and proactive system-level safeguards to reduce the ongoing risk of WSS.
Neurosurgical focusCatherine M Garcia, Shane Shahrestani, Sohrab Gollogly, Wouter I Schievink, Corey T Walker
Spontaneous intracranial hypotension (SIH) is most commonly caused by spinal CSF leaks, with ventral dural defects frequently requiring surgical repair when conservative measures fail. Endoscopic transforaminal approaches have emerged as minimally invasive alternatives to traditional open techniques, but the physiological consequences of continuous irrigation in the presence of a dural defect remain poorly understood. The authors report the case of a 36-year-old woman with recurrent SIH due to a persistent ventral T11-12 CSF leak despite prior laminectomy, revision repair, and multiple targeted interventions. She underwent transforaminal endoscopic discectomy and ventral dural repair. During the procedure, under continuous gravity-assisted irrigation, she developed sudden, severe, and reproducible hypertension with her systolic blood pressure reaching 275 mm Hg, refractory to anesthetic deepening and multiple antihypertensive agents. Irrigation cessation resulted in immediate hemodynamic normalization, while irrigation reintroduction led to recurrence of the hypertensive response. The procedure was completed after minimizing irrigation, and the patient stabilized postoperatively without further hemodynamic instability. The authors propose that this phenomenon reflects direct transmission of irrigation-induced epidural pressure into the intrathecal space through the persistent dural defect, resulting in acute intracranial pressure elevation and sympathetic activation. In contrast to standard endoscopic cases, chronic CSF leak states may create a compartmentalized and fibrotic epidural environment with reduced compliance and impaired outflow, predisposing the epidural space/operative field to rapid pressure accumulation even under low-pressure irrigation systems. This case highlights a previously underrecognized mechanism of intraoperative hemodynamic instability during endoscopic spine surgery and underscores the importance of considering altered pressure dynamics in patients with CSF leaks. Surgeons should maintain a high index of suspicion for irrigation-related complications in this population and consider strategies to minimize inflow pressure, optimize outflow, and promptly interrupt irrigation in the setting of unexplained physiological changes. These findings have important implications for surgical planning, intraoperative management, and the safe expansion of endoscopic techniques in CSF leak repair.
Mymensingh medical journal : MMJM S A Siddique, M S Hossain, M K Hossen, K Hassan, M S Uddin
Cutaneous horn or sebaceous horns are rare form of lesion consisting of keratotic material resembling that of an animal horn. The shape is conical or cylindrical Hyperkeratosis of variable size. The lesion typically occurs in sun exposed areas. Herewith we report a case of cutaneous horn in the scalp praieto occipital region with underlying bony erosion and intracranial extension. A 60-year-old male patient presented to the neurosurgery department in February 2024 with altered consciousness, a history of chronic headaches, blurred vision, and scalp swelling. Under general anaesthesia the outer fungating part of the lesion was excised initially followed by craniotomy and internal decompression of the lesion done by suction and cauterisation, the central part of the lesion was nearly avascular and was cheezy white. Then the poorly vascularised thick membrane was excised by gentle traction and cauterisation from the sorrounding adjacent gliotic area of left parietal lobe laterally, from the falx medially and from corpus callosum inferiorly. With meticulous hemostasis wound closure done by scalp rotation flap keeping cranioplasty in situ.
Journal of applied clinical medical physicsVictoria Bry, Angelia Tran, Tamara Egan, Eric Ford, Juergen Meyer
BACKGROUND: Surface Guided Radiation Therapy (SGRT) has become an increasingly important tool that complements x-ray imaging to improve patient safety for setup, respiratory tracking, and motion monitoring. As SGRT is integrated into clinical workflows, its complexity can introduce potential risk of process-related errors. These risks may depend on workflow design, system integration, equipment configuration, and technology specific features. As SGRT continues to expand across a wider range of treatment sites and clinical applications, comprehensive evaluation of institutional workflows is recommended to support safe and effective implementation. PURPOSE: This study aimed to identify and evaluate safety risks associated with the clinical use of SGRT using Failure Mode and Effects Analysis (FMEA). Emphasis was placed on workflow processes, system integration, and equipment-specific characteristics within a clinical environment to inform risk mitigation strategies and support safe implementation. METHODS: A multidisciplinary team performed an FMEA of SGRT related procedures and workflows. A process map was developed to define the scope of clinical applications, including tattoo free setup, free-breathing and deep-inspiration breath-hold (DIBH) breast treatments, prone patient positioning and real-time motion monitoring for stereotactic body radiation therapy (SBRT) patients across body sites. For each process step, team members identified potential failure modes associated with the clinical workflow and environment, including the integration of a C-RAD SGRT system with Elekta linear accelerators. Scoring was performed according to AAPM TG-100 guidelines, using severity (S), occurrence (O), and detectability (D) to calculate the Risk Priority Number (RPN). Failure modes were then ranked by RPN, and those with scores greater than or equal to 100 were selected for further analysis and development of mitigation strategies. RESULTS: Thirty-eight failure modes were identified, with nine having RPN scores greater than or equal to 100 (S = 5-8, O = 2-5, and D = 5-9). High risk failure modes were most associated with the DIBH workflow, particularly respiratory trace acquisition, respiratory trace configuration, and x-ray image verification. Additional high risk failure modes were identified in treatment preparation and system quality assurance processes, including manual data import, template selection, calibration, and daily QA procedures. These risks were primarily associated with workflow-dependent processes involving user interaction and coordination between integrated clinical systems. CONCLUSIONS: This FMEA identified workflow, system integration and equipment related vulnerabilities associated with SGRT implementation. The findings emphasize the importance of risk assessments tailored to specific clinical workflows and treatment environments and support the development of targeted mitigation strategies for safe clinical use.
Acta anaesthesiologica ScandinavicaSara Marija Abu-Bakr Christensen, Mathilde Fredensborg, Birgitte Brandstrup, Ann Merete Møller
BACKGROUND: Effective pain control is critical in pediatric gastrointestinal surgery to support recovery and improve postoperative outcomes. Regional anesthetic techniques have gained increasing interest, with the quadratus lumborum block (QLB) emerging as a promising option. As its use expands, this scoping review aimed to map the available evidence on QLB in pediatric gastrointestinal surgery. Specifically, it examined its application, gastrointestinal procedures involved, reported outcomes, and potential advantages and disadvantages. METHODS: This scoping review followed PRISMA-ScR guidelines and a published protocol with four predefined research questions. The PCC framework was used to define the review scope: Population, pediatric patients; Concept, QLB; Context, gastrointestinal surgery. A systematic search was performed in PubMed, Embase, and Cochrane CENTRAL. Studies investigating QLB in pediatric gastrointestinal surgery were included. Two reviewers independently conducted screening and data extraction. RESULTS: Twenty-nine studies were included. QLB was predominantly performed using the posterior approach (55%). The administered anesthetic dose varied from 0.3 to 1 mL/kg. No studies measured the plasma concentrations of local anesthetics or assessed dermatomal coverage. The block was applied across various gastrointestinal procedures, most frequently inguinal hernia repair (76%). Outcomes from different abdominal surgeries were often reported in aggregate (59%). Postoperative pain was the primary outcome, evaluated using six different measures, with variability in pain scales, analgesic protocols, and rescue analgesia thresholds. Pain scores were the most common measure, assessed most often using the Face, Legs, Activity, Cry, Consolability scale (76%). Few studies compared different QLB approaches (10%). QLB offered superior or comparable analgesia compared to other techniques. CONCLUSION: QLB appears effective for pediatric gastrointestinal surgery. However, the literature reveals considerable heterogeneity in outcome measures and study designs. Knowledge gaps remain regarding dose-related safety, dermatomal coverage, optimal dosing, and comparative efficacy of QLB approaches and gastrointestinal procedure-specific effectiveness. These findings may guide future research to optimize QLB use.
Journal of applied clinical medical physicsDespoina Stasinou, Kalliopi Platoni, Vasiliki Margaroni, Kyveli Zourari, Emmanouil Zoros, Niko Papanikolaou, Evangelos Pappas
BACKGROUND: Single-isocenter stereotactic radiosurgery enables efficient treatment of multiple brain metastases (SI-MBM SRS), but demands high geometric accuracy. Plan complexity metrics are increasingly used as indicators for quality assurance (QA) performance, however their applicability to SRS remains uncertain, particularly in the context of multi-institutional variability. PURPOSE: This study evaluated the relationship between plan complexity, target geometry, and end-to-end dosimetric QA outcomes for SI-MBM SRS across multiple institutions. METHODS: Forty-two SI-MBM SRS plans from different centers and platforms were delivered to polymer gel phantoms, providing high-resolution 3D dose measurements. Gamma passing rates (GPRs) were calculated under 3%/2 mm, 5%/2 mm and 5%/1 mm criteria and were correlated with eleven established complexity metrics calculated per plan. Geometric factors, including target equivalent diameter and distance-to-isocenter, were analyzed. Receiver-operating-characteristic (ROC) analysis was performed to identify optimal thresholds for predicting QA pass/fail (≥90% GPR). RESULTS: No statistically significant differences between the different linacs and treatment planning systems were found, nor strong or consistent correlations between complexity metrics and GPRs. In contrast, geometric parameters were more influential: off-axis distance and target size significantly affected QA performance, with the largest differences observed for far-off-axis lesions. ROC analysis identified optimal thresholds of 34.9 mm for distance-to-isocenter and 4.8 mm for equivalent diameter in predicting QA outcomes (AUC∼0.60-0.65), although the predictive performance remained modest. CONCLUSIONS: In this multi-institutional, gel-based end-to-end study of SI-MBM SRS, target geometry was a stronger QA performance predictor than complexity metrics. These findings emphasize the importance of geometry-aware QA strategies and the need for further standardized, multi-institutional evaluations to clarify the interplay between complexity, geometry, and machine performance in SRS.
Journal of applied clinical medical physicsZeinab A Chahrour, Nour F Obeid, Ali El-Zaart, Wassila El Kanawati, Abbas Mkanna, Rida Assaf, Bilal H Shahine
BACKGROUND: Accurate CT/MR registration is important in stereotactic brain radiotherapy, where small spatial errors may affect target localization and treatment planning. In many clinical settings, registration quality is still assessed primarily through manual visual inspection. However, time and workflow constraints may limit the consistency and depth of manual evaluation. PURPOSE: This study aimed to develop a 3D convolutional neural network (3D CNN)-based quality assurance (QA) method for rigid brain CT/MR registration using paired sub-volumes and a registration-level mean probability score (μ). The proposed method classifies local CT/MR registration quality, while the final registration-level assessment is based on μ across the sampled sub-volumes. METHODS: The study included 209 patients. Of these, 202 comprised the primary cohort and were divided patient-wise into 128 training, 33 validation, and 41 test patients. For each patient, 25 skull-based CT/MR sub-volumes of 42 × 42 × 42 voxels were used as a two-channel CNN input. High-quality examples were obtained from clinically approved registrations, while low-quality examples were generated using rigid perturbations of the complete MR volume. The mean predicted probability across the 25 sub-volumes was used as the registration-level score μ, and the validation-derived threshold of 0.5871 was fixed for testing. Seven additional patients, separate from the 202-patient cohort, were evaluated after model development and threshold selection were completed using registrations before and after physician correction. RESULTS: On the held-out test set, patch-level accuracy was 85.90%, with an ROC AUC of 0.929 and average precision of 0.920. At the registration level, accuracy was 97.56% and ROC AUC was 0.999. All 41 low-quality registrations were correctly flagged, while 39 of 41 high-quality registrations were correctly accepted. In the additional clinical evaluation, all seven initial registrations requiring correction were classified as low quality, while six of seven corrected registrations were classified as high quality, resulting in an overall accuracy of 92.86%. CONCLUSIONS: The proposed method combined local CNN predictions into a registration-level μ score and showed strong performance on held-out and clinical cases. It may provide a quantitative screening measure for rigid brain CT/MR registration QA while maintaining clinical review as the final decision step.
Journal of applied clinical medical physicsKurtis H Dekker, Jennifer A Everaars
BACKGROUND: Single-isocenter multiple-target stereotactic radiation treatments delivered on C-arm linear accelerators are increasingly common due to practical advantages in both accessibility and speed compared to multiple isocenter treatments. Optimization of high-quality treatment plans can be a time-consuming process requiring substantial manual effort. In our institution, the planning workflow for these treatments was entirely manual and involved the generation of optimization structures and repeated recalculation and input of optimization objectives during the iterative optimization process. Although commercial automated planning solutions are available, their implementation may impose operational constraints, including reliance on specific immobilization and image/surface guidance hardware, motivating the development of an immobilization-independent automation tool for cranial stereotactic treatment plan optimization. PURPOSE: To develop and implement a treatment planning optimization tool for multiple-target cranial stereotactic treatments in the Varian Eclipse treatment planning system, to reduce manual planner input and planning time while improving plan quality. METHODS: A software tool was written using the Varian Eclipse Scripting Application Programming Interface to automatically generate target-specific ring structures and facilitate the iterative process of plan generation. Twenty cases were retrospectively re-planned with this tool and compared with the corresponding clinical plans to evaluate plan quality using qualitative and quantitative metrics of conformality and complexity. Automated plans were verified using portal dosimetry to ensure clinical deliverability. For ten cases, a timing study was performed to compare optimization time between the software tool and manual re-optimization. RESULTS: The automatic optimization tool produced plans with similar modulation and complexity, but consistently lower dosimetric falloff metrics (R50% and Paddick Gradient Index) than the corresponding clinical plans. All plans passed patient-specific QA (portal dosimetry) following institutional practice. For the ten cases included in the timing study, the software had a mean runtime of 5.8 min (range: 2-12 min), with variation depending on case characteristics such as number of targets and arcs employed. In comparison, manual plan generation required 21.5 min on average (range: 4-49 min). DISCUSSION: The automated planning tool produced clinically acceptable, deliverable plans with better dose falloff compared to the previous manual planning approach. The tool is estimated to save an average of 15 min of optimization time per plan. CONCLUSIONS: A treatment planning optimization tool has been developed that provides improvement in both dosimetric plan quality and treatment planning efficiency for single-isocenter multiple-target cranial stereotactic treatments.
Neurosurgical focusDong Hwa Heo, Sang Hyub Lee, Choon Keun Park
In conventional biportal endoscopic spine surgery, active surgical manipulation is primarily performed through the working portal using the dominant hand, while the endoscopic viewing portal serves a passive role limited to visualization. Although the biportal approach provides superior optical advantages, the functional potential of the endoscopic viewing portal remains underused. The aim of this technical note was to describe a bimanual technique using an endoscopic self-retractor mounted on the endoscopic trocar to expand the operative role of the endoscopic viewing portal. The nondominant hand actively controls the endoscopic self-retractor through finger-based manipulation, while the dominant hand performs surgical maneuvers through the working portal, enabling two-handed manipulation. This technique allows surgeon-controlled retraction, dissection, and tissue protection and can be applied to a wide range of operative situations, including soft tissue dissection, ligamentum flavum resection, dural and nerve root protection, epidural lesion removal, and hemostasis. The bimanual technique with an endoscopic self-retractor was used in 396 cases (33 cervical, 8 thoracic, and 355 lumbar). It was applied in various procedures such as foraminotomy, discectomy, laminectomy, and fusion. No endoscopic self-retractor-related complications or adverse events were observed. By transforming the endoscopic viewing portal into an active auxiliary operative channel, the bimanual technique enhances surgical precision, safety, ergonomics, and autonomy in biportal endoscopic spine surgery.
Journal of applied clinical medical physicsOfformata E Osunkwor, Alois Ndlovu, Roland F Teboh
BACKGROUND: Respiratory motion introduces significant geometric uncertainty in Stereotactic Body Radiotherapy (SBRT) for thoracic and abdominal tumors. Deep Inspiration Breath-Hold (DIBH) mitigates this, but the surface signal alone may not reflect internal target position, supporting the need for real-time internal-anatomy verification during delivery. PURPOSE: To commission a Surface-Guided Radiation Therapy (SGRT) system and validate an integrated SGRT + Image-Guided Radiation Therapy (IGRT) + triggered kV imaging (SITI) workflow for DIBH SBRT. MATERIALS & METHODS: The LAP LUNA 3D SGRT system was commissioned per AAPM TG-302 using phantom-based assessment of static and dynamic localization accuracy, reproducibility, and latency. An end-to-end test using a dynamic phantom validated the SITI workflow. Point dose was measured with an ion chamber under four scenarios: SGRT-only delivery, full SITI delivery, and SITI with induced 1 and 2 mm uncorrected 3D shifts. RESULTS: Static localization accuracy was better than 0.5 mm / 0.3°, with reproducibility within 0.2 mm / 0.1°. Dynamic testing confirmed sub-millimeter spatial accuracy and a 31.6 ms latency, well below the AAPM TG-302 100 ms tolerance. The 1 and 2 mm uncorrected shifts produced point-dose reductions of 0.9% and 2.2% relative to the SITI reference, consistent with the ∼1%/mm local dose gradient. Both shifts were clearly visualized on triggered kV images, confirming detection of sub-tolerance residual displacements undetected by surface guidance alone. CONCLUSIONS: The LAP LUNA 3D system meets the technical requirements for SBRT. The SITI workflow is technically feasible and provides real-time visualization of internal target position during delivery, offering a robust motion-management strategy for DIBH SBRT of mobile thoracic and abdominal targets.
Neurosurgical focusSungjae An, Subum Lee, Younggyu Oh, Jung-Yul Park, Junseok W Hur
OBJECTIVE: Traditional management of symptomatic lumbar spondylolisthesis (SPL) involves interbody fusion (IBF). However, endoscopic unilateral laminectomy with bilateral decompression (E-ULBD) has emerged as a less invasive alternative with growing evidence of effectiveness. The authors aimed to comprehensively compare outcomes between E-ULBD and IBF in grade 1 lumbar degenerative SPL. METHODS: The data of patients who underwent E-ULBD or IBF for symptomatic lumbar SPL by a single surgeon during the same period were retrospectively reviewed. Demographics, SPL characteristics, surgical profiles, pain management, patient-reported outcomes, and surgical/medical complications were analyzed. Surgical complications were classified by location (index vs adjacent level) and analyzed separately from uncomplicated cases. RESULTS: Eighty-one patients (51 E-ULBD, 30 IBF) were included with a mean follow-up of 43.8 months. E-ULBD demonstrated significantly shorter hospitalization, less blood loss, and fewer medical complications. Index-level surgical complications were comparable (35.3% E-ULBD, 16.7% IBF; p = 0.072), whereas IBF had significantly more adjacent-level complications (20.0% vs 3.9%, p = 0.046), resulting in worse pain and Oswestry Disability Index scores at the final follow-up. In the E-ULBD group, segmental instability and facet violation > 10% were significantly associated with symptomatic SPL progression. CONCLUSIONS: For grade 1 lumbar SPL, E-ULBD may provide superior recovery profiles and less clinical burden from complications compared with IBF. Nevertheless, both procedures were associated with surgical complication rates approaching 40%, whereas 60% of uncomplicated cases achieved comparable favorable outcomes. Facet violation > 10% was a significant risk factor for symptomatic SPL progression following E-ULBD.
Neurosurgical focusDong Hwa Heo, Sang Hyub Lee, Dong Chan Lee, Jae-Won Jang
OBJECTIVE: Biportal endoscopic posterior cervical foraminotomy (BE-PCF) has gained popularity as a minimally invasive technique for the treatment of unilateral cervical radiculopathy. Although BE-PCF is expected to reduce tissue injury while providing effective neural decompression, long-term comparative data with minimally invasive microscopic PCF are limited. The aim of this study was to compare clinical outcomes, perioperative parameters, and tissue injury profiles between patients who underwent BE-PCF and those who underwent microscopic PCF with a minimum 2-year follow-up. METHODS: This retrospective comparative study included 126 patients who underwent single-level PCF (69 with BE-PCF and 57 with microscopic PCF). Clinical outcomes were assessed using visual analog scale (VAS) scores for neck and arm pain and the Neck Disability Index (NDI). Perioperative variables, complications, and reoperation rates were analyzed. Muscle and soft tissue injury were evaluated using serum biomarkers, including creatine phosphokinase (CPK) and C-reactive protein (CRP) levels, and MRI-based muscle injury scoring. Radiological assessment included postoperative MRI and dynamic radiography for instability. RESULTS: Both procedure groups showed significant improvement in VAS and NDI scores at the final follow-up. The BE-PCF group demonstrated significantly lower neck pain at postoperative day 1 and at the final follow-up. There were no significant differences in arm pain or functional outcomes between groups. Estimated blood loss was significantly lower in the BE-PCF group. Postoperative increases in CPK and CRP levels were significantly higher in the microscopic PCF group, indicating greater muscle and soft tissue injury. MRI-based muscle injury scores were also significantly lower in the BE-PCF group. Complication and reoperation rates were comparable between the two groups, and no postoperative instability was observed. CONCLUSIONS: BE-PCF provides clinical outcomes comparable with that of microscopic PCF while significantly reducing muscle and soft tissue injury. These findings suggest that BE-PCF is a safe and effective minimally invasive alternative for the treatment of unilateral cervical radiculopathy.
Neurosurgical focusHyeong-Ki Shim, Kyung-Chul Choi, Jaeyoung So, Hyojeong Kim, Jeoungin Park
OBJECTIVE: The aim of this study was to compare the clinical outcomes and healthcare costs of full-endoscopic decompression (FED), unilateral biportal endoscopic (UBE) decompression, and microscopic decompression (MD) for single-level lumbar spinal stenosis over a 2-year follow-up period. METHODS: The authors retrospectively reviewed 395 patients (FED, n = 200; UBE, n = 93; MD, n = 102) who underwent single-level decompression between May 2020 and April 2022. Clinical outcomes were assessed using the visual analog scale (VAS) and Oswestry Disability Index (ODI). Economic evaluation included direct costs (surgery, hospitalization, and follow-up care) and indirect costs (productivity loss for both employed and unemployed patients) from a societal perspective. FED and UBE were additionally pooled as endoscopic decompression (ED) for incremental cost-effectiveness ratio (ICER) analysis. Cost-effectiveness was analyzed using quality-adjusted life years (QALYs) and the ICER. RESULTS: Clinical improvements in VAS and ODI were comparable across the three groups at 2 years (p > 0.05). However, the MD group had a significantly longer hospital stay (mean 5.4 days) compared with the FED (mean 3.2 days) and UBE (mean 3.6 days, p < 0.001) groups. Total healthcare costs were significantly higher in the MD group (mean $6586) compared with the FED (mean $5502) and UBE (mean $5515, p < 0.001) groups. Indirect costs were also highest in the MD group due to delayed resumption of household activities and longer hospitalization (p = 0.012). Mean QALY gains were comparable among groups (FED, 0.197; UBE, 0.198; MD, 0.180; p > 0.05), whereas the mean cost per QALY was significantly higher in the MD group ($47,290) than in the FED ($39,060) and UBE ($34,822) groups (p = 0.04). The ICER for ED versus MD was -$60,510 per QALY, indicating that endoscopic techniques were more cost-effective. CONCLUSIONS: In single-level lumbar spinal stenosis, both FED and UBE decompression achieved clinical outcomes comparable with that of MD while demonstrating lower societal costs and more favorable cost-effectiveness profiles. The economic advantage of ED in this study was driven primarily by shorter hospitalization and earlier recovery.
Radiation oncology (London, England)Sebastian Regnery, Rita Pestana, Thomas Mielke, Philipp Hoegen-Saßmannshausen, Hanna Waldsperger, Fabian Weykamp, Friderike K Longarino, Cedric Beyer, Jakob Li…
BACKGROUND: We aim to quantify the dosimetric benefits of daily online adaptive (DOA) carbon ion stereotactic radiotherapy (CISR) in hepatocellular carcinoma (HCC). PATIENTS AND METHODS: 13 patients received 4 × 10.5 Gy (RBE-weighted dose) CISR to 14 HCC lesions in challenging locations (N = 10: liver dome, N = 3: < 1 cm from intestines). All patients underwent daily in-room CT, with forward calculation of the baseline plan. Additionally, four patients were shuttled to a 1.5 Tesla MR scanner in treatment position for MRI simulation. Based on visual review of all data, the physician decided to treat or to perform offline plan adaptation and treat another day. We compare the dosimetry properties of four scenarios per fraction: (1) baseline plan, (2) no adaptation, (3) occasional offline adaptation (OOA), (4) DOA. RESULTS: Baseline planning target volume (PTV) and internal target volume (ITV) coverage by the prescribed dose (median coverage: PTV: 97%, ITV: 100%) significantly decreased for no adaptation (PTV: 87.6%, p = 0.0001; ITV: 97.7%, p = 0.007) and OOA (PTV: 87.8%, p = 0.0001; ITV: 97.7%, p = 0.007), while DOA maintained high PTV coverage (PTV: 95.7%, p = 0.17; ITV: 100%, p = 0.53). Frequent violations of organs-at-risk (OAR) dose constraints occurred for no adaptation and OOA (both 20/52 fractions, 38.5%). They affected the bowel, heart and esophagus up to 6 cm from the PTV. DOA led to considerably fewer (6/52 fractions, 11.5%) and less intense violations of OAR dose constraints. CONCLUSIONS: Daily CT- and MR-guided CISR is feasible in the liver, and demonstrates frequent violations of initial treatment planning objectives when non-adaptive or offline adaptive approaches are followed. DOA could improve target coverage and OAR protection, while particularities of carbon ions such as overdoses far from the target should be considered.
Journal of applied clinical medical physicsHilla Magga, Henri Korkalainen, Tuomas Virén, Janne Heikkilä, Jan Seppälä, Akseli Leino
BACKGROUND: Deep learning-based (DL) approaches have gained interest in predicting dose distributions in radiotherapy of prostate cancer treated with volumetric modulated arc therapy and intensity-modulated radiation therapy. Meanwhile, research on predicting dose distributions in high-precision stereotactic radiotherapy treatments has remained relatively underrepresented. PURPOSE: We aimed to expand the previous studies by developing a DL-based framework for predicting dose distributions for robotic, stereotactic prostate cancer radiotherapy. METHODS: We harnessed a U-Net-based convolutional neural network for predicting clinically achievable dose distributions based on CT images, delineated structures, and distance information from the planning target volume. A dataset of 462 patients treated with CyberKnife (Accuray Inc.) utilizing an Iris collimator was divided into training (70%, n = 323), validation (10%, n = 46), and test (20%, n = 93) sets. RESULTS: In the independent test set, the mean absolute error between the mean doses of predictions and clinical plans was 0.63 Gy for the rectum and 1.04 Gy for the bladder. CONCLUSIONS: The proposed U-Net-based model demonstrated the ability to learn and reproduce characteristic dose distributions in CyberKnife prostate cancer radiotherapy. The model may provide patient-specific dose estimates for setting initial planning objectives to assist in automating treatment planning and improving inter-planner consistency.
BMJ openJin Li, Nianlan Zhou, Saiquan Lu, Xi Yang, Wangjun Yan, Zhengfei Zhu, Mo Cheng
INTRODUCTION: Immunotherapy in combination with chemotherapy has been recommended as the first-line treatment of driver gene-negative advanced non-small cell lung cancer (NSCLC), but the efficacy is reduced in NSCLC patients with bone metastases due to the immunosuppressive microenvironment. Both nuclear factor kappa-B ligand (RANKL) inhibitors and stereotactic body radiation therapy (SBRT) have been shown to modulate the tumour immune microenvironment. Therefore, narlumosbart, a monoclonal antibody targeting RANKL, in combination with SBRT, may exert synergistic effects and improve efficacy of first-line chemoimmunotherapy in this population. METHODS AND ANALYSIS: This single-arm, single-centre phase II clinical trial will enrol driver gene-negative advanced NSCLC patients with bone metastases who have not received any systemic therapy. Eligible patients will receive narlumosbart (120 mg subcutaneously every 4 weeks) and SBRT to bone target lesions (24 Gy/3 fractions for spinal metastases and 30-35 Gy/5 fractions for non-spinal lesions), followed by standard first-line chemoimmunotherapy. The primary endpoint is the objective response rate of non-radiotherapy lesions. Secondary endpoints include safety and tolerability, progression-free survival, overall survival, bone-related events, pain score and quality of life. Sample size was calculated using the Simon's Two-Stage method (α=0.05, power=0.8, H₀=25%, H₁=50%). Nine patients will be enrolled in stage 1. If ≥2 patients achieve complete response (CR)/partial response (PR), an additional 15 patients will be enrolled in stage 2. If fewer than two patients achieve CR/PR, the trial will be terminated. 27 subjects will be enrolled in this project, considering the dropout rate of 10%. ETHICS AND DISSEMINATION: This study was approved by the Medical Ethics Committee of Fudan University Shanghai Cancer Center (approval number 2411308-15) on 6 December 2024. The trial registration number is NCT06738160 at clinicaltrials.gov, sponsored by Fudan University, and registered in December 2024 before the enrolment of the first participant in February 2025. The trial will be conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Written informed consent will be obtained from all participants prior to enrolment. Results will be published in a peer-reviewed journal.
Journal of applied clinical medical physicsEdward A Opalko, Dheerendra Prasad, Matthew B Podgorsak
PURPOSE: The purpose of this study was to evaluate the ability of the GammaPlan treatment planning system used in the Gamma Knife Icon and Esprit machines to automatically correct large interfractional shifts in hypofractionated frameless treatments using a custom 3D printed phantom. METHODS: A custom 3D printed insert was created to modify a commercial head phantom. The water equivalence of polylactic acid (PLA) was determined by comparing optical densities of film using solid water and PLA as buildup. Lesions of varying size, shape and location were created on images of the phantom to replicate several clinical scenarios. Seven 5-fraction plans were generated using typical dose objectives. Six combinations of headrests/masks were created to simulate different setup positions. Masks were changed between fraction measurements to simulate interfractional shifts. The composite dose distributions of the corrected plans were measured using Gafchromic film and compared to the original dose distribution using Gamma Analysis. RESULTS: The average deviation for Coverage, Paddick Conformity Index and Gradient Index across all plans remained unchanged between the corrected plan and the original plan. No deviation was greater than 0.01 between the three metrics. Compared to the original plans, the measured dose distributions produced an average Gamma Passing Rate of 98.3% for 3%/1mm, 99.6% for 2%2mm, 96.3% for 2%1mm and 92.7% for 1%/1mm. All but two dose distributions produced passing rates above 90%. For the dosimetric analysis of PLA, the optical densities at various MU values were found to be equivalent for solid water and PLA. CONCLUSION: The correction algorithm was able to produce a corrected plan almost identical to the original plan in terms of plan statistics and dose distributions. The algorithm could accurately correct for extreme interfractional shifts beyond what is seen clinically. The results of this study also show the potential for PLA phantoms to be used as dosimetry tools.
Biomedical physics & engineering expressSali Di, Brandon VanGenderen, Marcus Sonier, Joseph Awotwi-Pratt
Stereotactic body radiotherapy (SBRT) for prostate cancer often uses high-energy photon beams, which can produce photoneutrons through interaction in the linac head, raising concerns regarding neutron-related exposure. Therefore, it is important to estimate neutron dose equivalent in SBRT plans when comparing beam energies and treatment delivery techniques. BD-PND fast neutron detectors were used in this study to quantify neutron dose equivalent in prostate SBRT plans. We performed dosimetry measurements using a Varian TrueBeam Linac and assessed neutron production at energies of 2.5 MV, 6 MV, 6 MV flattening filter free (FFF), 10 MV, 10 MV FFF and 15 MV. Bubble counts were converted to neutron dose equivalent using the manufacturer-provided calibration factor. The measured neutron dose equivalent was highest at the centre and decreased at peripheral measurement locations farther from the primary beam. Significant differences in neutron dose equivalent were found between flattening filter (FF) and FFF beams at the central beam position after multiple comparison correction. In contrast, peripheral positions showed no statistically significant differences. Additionally, low bubble counts were observed under 6 MV and 6 MV FFF beams, suggesting a low-level detector response under the present measurement conditions. Overall, beam energy, FF or FFF delivery and measurement positions all affect the measured neutron dose equivalent in prostate SBRT. The low-energy observation should be interpreted as preliminary, and additional work is needed, including repeated measurements, different detector types and more clinically relevant measurement locations.
Anticancer researchFederico Ampil, Robert Brown, Michelle Norton
BACKGROUND/AIM: Hippocampal brain metastases are uncommon, and evidence regarding their management and outcomes remains limited. This study evaluated the efficacy and safety of whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) for hippocampal brain metastases at a single institution. PATIENTS AND METHODS: We retrospectively reviewed 21 patients treated for hippocampal brain metastases over a 20-year period. Clinical characteristics, treatment approaches, intracranial tumor control, treatment-related toxicity, and survival were analyzed. Eleven patients received WBRT and 10 received SRS. RESULTS: The mean patient age was 60.7 years. Most patients were symptomatic (86%), had multiple brain metastases (71%), and had extracranial metastatic disease (76%). Memory impairment was documented in one patient. Among patients receiving WBRT, contralateral hippocampal avoidance was not feasible in five (45%) because of multiple brain metastases. The mean follow-up was 17.2 months. Intracranial tumor control was achieved in 18 patients (86%), and radionecrosis occurred in one patient (5%). The overall median survival was four months, and the estimated one-year survival rate was 42%. Intracranial tumor control rates were 91% after WBRT and 80% after SRS (p=0.49); the corresponding median survival times were one and five months, respectively (p=0.29). No acute or chronic treatment-related toxicity was documented, although post-treatment neurocognitive function was not systematically assessed. CONCLUSION: WBRT and SRS provided high rates of intracranial tumor control with limited observed toxicity in this small cohort of patients with hippocampal brain metastases. However, overall survival remained poor. Larger studies incorporating standardized neurocognitive assessment are needed to clarify the comparative benefits and long-term safety of these treatment approaches.
Acta neurochirurgicaSergio Corvino, Giuseppe Corazzelli, Tamara Ius, Giuseppe Catapano
BACKGROUND: Meningioangiomatosis is a formidable neurosurgical challenge due to its heterogeneous nature and anatomical localization which often make impossible gross total resection. Surgery is reserved for drug-resistant epileptic seizures aiming their control. METHOD: We describe a case of meningioangiomatosis of the right sylvian fissure involving the M1-M2 segments of right middle cerebral artery. A subtotal lesion resection, completed with disconnection surgery through multiple subpial circumferential transections was performed. CONCLUSION: To underline the efficacy of the disconnection surgery and the pivotal role of intraoperative electrophysiologic assessment for tailoring the surgical resection at the presumed ictal onset zone.
Journal of applied clinical medical physicsNabaa Mohammed Alsiraj, Haydar Hamza Alabedi, Mustafa Salih Almusawi, Moneer K Faraj, Rozilawati Ahmad, Sura Abdulkareem Madlool Alzuabidi
BACKGROUND: An accurate assessment of the radiotherapy plans requires an accurate dose to the target and efficient confinement of the doses. However, present indices do not completely cover these aspects in a single framework. PURPOSE: To develop a unified, dimensionless metric that integrates geometric conformity and dosimetric efficiency for evaluating stereotactic and fractionated radiotherapy plans aims to reduce QA workload by providing a rapid, quantitative estimate of plan acceptability, allowing early prediction of treatment plan performance. METHODS: In this study, the Nabaa Efficiency Index η N a b a a is introduced and defined as the product of the Conformity Index (CI) and a Dose-Efficiency Ratio (DER), evaluated at 50% and 90% isodose levels ( η 50 % N a b a a , η 90 % N a b a a ). We analyzed theoretical behavior against normalized dose-volume ratios and compared η N a b a a with established indices of conformity, homogeneity, and the Paddick efficiency index ( η 50 % P a d d i c k ) . Clinical validation used 100 plans (50 Gamma Knife, 50 VMAT-SRS). Statistics included ANOVA, correlations, ROC/AUC, and decision-curve analysis. RESULTS: η 50 % N a b a a and η 90 % N a b a a were monotonic, bounded, and dimensionless. η 50 % N a b a a distinguished gradient/halo efficiency between stereotactic and linac plans (p < 0.001). η 90 % N a b a a most strongly reflected prescription-dose conformity (pooled AUC = 0.94) and outperformed the Paddick Efficiency Index ( η 50 % P a d d i c k ) in discrimination and interpretability. CONCLUSION: η N a b a a unifies geometric and dosimetric assessment across modalities. Its simplicity, physical interpretability, and software-ready formulation support integration into automated QA and treatment-planning pipelines.