Editorial Board

Sodium MRI in Pediatric Brain Tumors

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In a narrative review Bhatia et al. from the Children’s Hospital of Philadelphia, Radiological Sciences Laboratory, School of Medicine, Stanford University, published in the American Journal of Neuroradiology to explore the potential of sodium-23 MRI (^23Na-MRI) as a noninvasive imaging modality to assess physiological and biochemical changes in pediatric brain tumors and concluded that is a promising, noninvasive imaging modality capable of providing unique physiological and biochemical information that is not accessible through conventional MRI techniques

This narrative review attempts to position ^23Na-MRI as a frontier imaging technique for pediatric brain tumors. It lauds the modality’s potential to reveal sodium-dependent physiological alterations — but quickly devolves into technological evangelism with minimal clinical anchoring. The piece is high on optimism, low on pragmatism, and entirely devoid of data-supported clinical outcomes.

🧠 1. Conceptual Inflation: “Promise” Without Proof

The article enthusiastically describes the theoretical virtues of sodium MRI — sensitivity to cell integrity, ionic gradients, extracellular space — but offers no compelling clinical cases, no comparative metrics, and no outcome data. What remains is a speculative wish list, presented as a roadmap. The authors confuse imaging potential with diagnostic utility, a common pitfall in radiology reviews driven by physics rather than patient care.

“Exciting” is not a scientific category.

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Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas – a multicenter experience

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In a retrospective multicenter cohort study Lim et al. from the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Departments of Neurosurgery, Radiology, Bioinformatics, and Canon Stroke and Vascular Research Center, Gates Vascular Institute, Albany Medical Center, Icahn School of Medicine at Mount Sinai, New York, University of South Florida Morsani College of Medicine, Tampa, Florida, USA – Department of Neurosurgery and Brain Repair Yale University, New Haven, Connecticut, USA – Department of Molecular Biophysics and Biochemistry published in the Journal of NeuroInterventional Surgery to o evaluate the combined effectiveness of the Subdural Evacuating Port System (SEPS) and Middle Meningeal Artery Embolization (MMAE) in chronic subdural hematoma treatment (cSDH). Specifically, the authors aimed to assess: How well the combination of SEPS + MMAE reduces hematoma volume, The safety profile of this combined approach, Predictive factors influencing drainage success and recurrence rates, and concluded that the combined use of SEPS and MMAE is a safe and effective treatment option for patients with chronic subdural hematomas (cSDH). It resulted in significant hematoma volume reduction and a relatively low recurrence rate. Several clinical and radiographic factors were identified as predictors of treatment success

📉 1. The Myth of Innovation-by-Combination

Pairing two well-known procedures—SEPS and MMAE—does not inherently create innovation. Yet, the authors present this as a groundbreaking paradigm, despite:

  • No control group (e.g., SEPS alone, MMAE alone),
  • No randomization,
  • No comparative outcome measures beyond radiographic volume.

It’s procedural layering disguised as progress.

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High-Resolution MR Imaging of the Parasellar Ligaments

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In a anatomic-imaging correlation study with a single-case MR + dissection design Mark el al. 1) from the Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurosurgery, University of Valencia and Fundación Instituto Valenciano de Oncología (IVO), Valencia, Spain publiseh in the American Journal of Neuroradiology (AJNR) to determine whether high-resolution T2-weighted MRI can visualize the parasellar ligaments, which have previously only been described in cadaveric dissection or intraoperative findings, and to correlate these MRI findings with anatomical dissection in the same specimen. The authors report that parasellar ligaments can be identified on high-resolution T2-weighted MRI as T2-hypointense, bandlike structures originating from the medial wall of the cavernous sinus. They claim that identifying these ligaments may be relevant, given that resection of the medial wall of the cavernous sinus has been associated with better outcomes in functioning pituitary adenoma surgery.

This study is a prime example of technological overreach dressed up as discovery. It takes a single cadaver, applies ultra-high-resolution MRI, and then retrofits a minor fibrous band into a clinical “finding.” The result is a beautifully imaged, clinically irrelevant piece of anatomical embroidery that contributes nothing actionable to radiology, neurosurgery, or pituitary surgery.

❌ Critical Flaws

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Effectiveness of 2-methoxyestradiol in alleviating angiogenesis induced by intracranial venous hypertension

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In a Preclinical Experimental Study Zou et al. 1) from the Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China, evaluated in the Journal of neurosurgery the antiangiogenic effect of 2-methoxyestradiol (2-ME) in a rat model of intracranial venous hypertension, used as a proxy to study dural arteriovenous fistula formation. Specifically, the authors aimed to determine whether 2-ME could reduce angiogenesis in the dura mater by modulating the HIF-1α and ID-1 pathways, which are implicated in hypoxia-induced neovascularization, and concluded that 2-ME could potentially serve as a therapeutic agent to modulate angiogenesis caused by intracranial venous hypertension — a process they consider central to DAVF development.

🚩 1. Flawed Model: DAVF Without DAVF

Despite the title and clinical framing, this study does not model dural arteriovenous fistulas (DAVFs).

No arteriovenous shunt is demonstrated.

No hemodynamic assessment is performed.

No imaging or functional endpoints validate that the model reflects DAVF pathophysiology.

👉 What the authors present is not a DAVF model, but a crude simulation of dural angiogenesis via venous outflow obstruction. Calling it a DAVF model is scientifically misleading.

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Preoperative Nomogram-Based Assessment to Identify GBM Patients Who Do not Derive Survival Benefit From GTR Compared to STR

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In a retrospective prognostic modeling study, He et al. from Sichuan Provincial People’s Hospital published in the Academic Radiology a preoperative nomogram to identify glioblastoma patients who do not derive a survival benefit from gross total resection (GTR) compared to subtotal resection (STR), and concluded that patients with nomogram scores below 55 or above 95 gain limited survival advantage from GTR, supporting a more individualized surgical strategy 16).

🎯 Takeaway Message for Neurosurgeons

Don’t let a nomogram tell you not to operate. This study reduces complex glioblastoma surgery to a score — ignoring tumor location, function, biology, and patient context. Use it, at best, as background noise. Surgical judgment, not predictive modeling, should guide the extent of resection. Maximal safe resection remains the standard — not because of scores, but because leaving tumor behind costs lives.

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Comparison of survival benefit and safety profile between lenvatinib and donafenib as conversion therapy in patients with hepatocellular carcinoma 

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In a retrospective comparative cohort study, Hou et al. 1) published in the American Journal of Translational Research, the authors—affiliated with the Department of Oncology, Department of Gynaecology and Obstetrics, and Department of Neurosurgery at Shijiazhuang People’s Hospital (Hebei, China), as well as Beijing Water Conservancy Hospital—compared the survival benefit and safety profile of lenvatinib versus donafenib as conversion therapy in patients with hepatocellular carcinoma (HCC) at China National Liver Cancer (CNLC) stages I–III.

Lenvatinib demonstrated significantly superior survival outcomes—both in overall survival and progression-free survival—compared to donafenib. It also showed better tolerability, with fewer grade ≥3 adverse events.

❌ 1. Study Design: Retrospective = Weak Evidence

This is yet another retrospective single-center analysis, plagued by inherent biases—selection, reporting, and confounding—that no amount of statistical massaging can resolve. No randomization, no blinding, and no control for treatment timing or physician discretion. In oncology, where treatment nuances matter, such designs should be considered hypothesis-generating at best, not guidance for clinical practice.

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Fighting the Fracture Cascade: Early and Repeated Balloon Kyphoplasty as a Bridge Until the Effects of Osteoporosis Treatment Become Apparent in a Super-Aged Patient

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In a case report by Tanaka et al., published in Cureus in May 2025, and authored by clinicians from the Departments of Neurosurgery at the International University of Health and Welfare Narita Hospital (Narita), Shiroishi Kyoritsu Hospital (Shiroishi), Shojima Neurosurgery (Saga), Imari Arita Kyoritsu Hospital (Arita), and the Department of Neurology at Shiroishi Kyoritsu Hospital, the authors describe the management of an 87-year-old patient with a cascade of adjacent osteoporotic vertebral fractures. The purpose of the report is to highlight the role of early and repeated balloon kyphoplasty (BKP) as an effective bridging strategy to preserve mobility, spinal alignment, and independence in super-aged patients, until the delayed therapeutic effects of pharmacologic osteoporosis treatments, such as teriparatide, become evident 1)

1. Overinterpretation of a Single Case

The fundamental flaw of this report is its excessive generalization from a single anecdotal case. No matter how long the follow-up, one patient’s trajectory cannot justify broad clinical recommendations, especially regarding a high-cost and procedure-intensive strategy like repeated BKP.

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Pituitary apoplexy: surgical or conservative? A meta-analytical insight.

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In a Systematic Review and Meta-Analysis, Xia et al., from the First College of Clinical Medical Science, Three Gorges University & Yichang Central People’s Hospital, Yichang, Hubei, China, published in Frontiers in Surgery. The authors compared recovery outcomes of neurosurgical vs. conservative treatment in patients with pituitary apoplexy, aiming to provide evidence-based guidance for clinical decision-making.

Recovery from ophthalmoplegia improved wih surgery 3).

The authors claim to provide evidence-based guidance for choosing between surgical and conservative treatment in pituitary apoplexy through a meta-analysis of 33 years of literature.

They conclude that surgery significantly improves ocular muscle paralysis but yields no benefit over conservative management for visual acuity, visual field, or endocrine outcomes.

💣 Critical Issues

1. Methodological Superficiality

Despite claiming a rigorous meta-analysis, the study relies on a fixed-effects model—a questionable choice given the expected heterogeneity across decades of heterogeneous, mostly retrospective, observational studies. This choice artificially narrows confidence intervals and potentially overstates precision. No rationale is given for not using a random-effects model, which is standard in clinical meta-analyses dealing with variable populations and treatment protocols.

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Systematic Review of the predictive value of negative brain or low probability brain MRIs in patients with CSF venous fistulas

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The article titled “Systematic Review of the Predictive Value of Negative Brain or Low Probability Brain MRIs in Patients with CSF Venous Fistulas” (American journal of neuroradiology) is a systematic review analyzing data from nine studies (898 patients) to assess how reliably negative brain MRI or low-probability MRI scores (Bern, Mayo) can rule out cerebrospinal fluid (CSF) venous fistulas, a surgically treatable cause of spontaneous intracranial hypotension (SIH) 1).

The authors found that although negative brain MRI has a high negative predictive value (89%), CVFs were still identified in a notable number of patients—especially when using the Mayo score (NPV only 65%).

The authors conclude that negative imaging does not exclude CVF, and invasive spinal imaging (e.g., DSM, dynamic CT myelography) should be considered in cases with strong clinical suspicion. This is especially relevant for neurosurgeons, as surgical ligation of CVFs may be necessary.

All authors are affiliated with Cedars-Sinai Medical Center (Los Angeles), with Dr. Wouter I. Schievink, a neurosurgeon, being a leading expert in the field of CSF leaks.

This so-called systematic review by Tay et al. (AJNR, June 2025) ambitiously sets out to clarify the diagnostic value of negative brain MRI in detecting cerebrospinal fluid venous fistulas (CVFs), yet ends up as a textbook example of how quantitative gloss can’t save a weak clinical premise.

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Temporal trends and risk factors associated with stroke mortality among cancer patients

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In a retrospective cohort study published in the Journal of Clinical Neuroscience, Ahmed et al. with Cleveland Clinic Cerebrovascular Center, West Virginia University participation 1) analyzed data from over 5.9 million patients diagnosed with a first primary cancer, based on the SEER database (2000–2020). The study aimed to quantify the risk of stroke-related death (SD) in cancer patients and to identify temporal trends and associated clinical and demographic risk factors. Stroke-related mortality (SD) among cancer patients has significantly declined over the past two decades across all cancer types and both sexes. However, older age, non-white race, male sex, and specific cancer types—notably nervous system, respiratory, and head and neck cancers—are associated with a higher risk of stroke death. Conversely, patients receiving chemotherapy or radiotherapy had a lower risk of SD compared to those who received no treatment.

⚠️ Fatal Methodological Flaws

No Clinical Stroke Classification

The authors report on “stroke mortality” without differentiating ischemic vs. hemorrhagic strokes, nor providing stroke etiology or timing relative to cancer diagnosis or cancer treatment—rendering any mechanistic or preventative inference purely speculative.

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