Functional Neurosurgery

Evaluation of Interstitial Fluid Volume and Diffusivity in Patients With Idiopathic Normal Pressure Hydrocephalus Using Spectral Diffusion Analysis

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In a retrospective cohort Ishida *et al.* from the University hospitals—centres in Tokyo, (e.g., Tokyo Metropolitan Geriatric Center) published in the *Journal of Magnetic Resonance Imaging* to compare interstitial fluid volume fraction (Fint) and diffusivity (Dint), derived via spectral diffusion analysis, between idiopathic normal pressure hydrocephalus (iNPH) patients and healthy controls (HCs). In iNPH patients, spectral diffusion analysis revealed increased Fint and Dint in periventricular hyperintensity (PVH) regions of the centrum semiovale (CSO) and frontal white matter (FWM), while regions outside PVH did not differ from HCs 1).

Critical Review

* Strengths:

  • Utilizes advanced spectral diffusion with non‑negative least squares to separate Interstitial Fluid Dynamics an innovative approach.
  • Well‑defined region‑based ROI analysis including CSO, FWM, lenticular nucleus (LN).
  • Robust statistical treatment via Kruskal–Wallis with Dunn’s test; Spearman’s for correlations.

* Limitations & Concerns:

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Management of patients discharged from the hospital after VPS surgery

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In a Letter to the Editor Lu et al. published in the Journal of Neurosurgery to discuss ventriculoperitoneal shunt management strategies for discharged patients 1).

Critical Appraisal

– Strengths:

  1. Highlights a clinically important gap—post-discharge VPS care.
  2. Sparks important discussion on outpatient monitoring and follow-up protocols.

– Limitations:

  1. Absence of abstract/data: no study design, patient numbers, follow-up length or outcomes described.

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Multi‑institutional recommendations on the use of 7T MRI in deep brain stimulation

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Middlebrooks EH et al. Mayo Clinic, Jacksonville; Amsterdam UMC; University of Minnesota, Minneapolis; Western University, London (ON)

Published in the Journal of Neurosurgery 1)

A Consensus/Technique article presenting multi-institutional expert consensus on the clinical application and technical optimization of 7‑Tesla MRI in deep brain stimulation (DBS) planning.

7T MRI enables superior visualization of DBS targets—subthalamic nucleus, globus pallidus internus (GPi), and thalamus—due to increased spatial resolution, enhanced contrast, and higher signal-to-noise ratio.

The paper outlines:

  • Standardized imaging sequences
  • Distortion correction methods
  • Artifact mitigation strategies
  • Post‑processing workflows

All recommendations are grounded in experience across >1000 DBS cases.

🔍 Critical Appraisal

➕ Strengths

  • Extensive real‑world experience from multiple high‑volume centers (>1 000 cases)
  • Provides reproducible and practical imaging protocols
  • Addresses technical pitfalls specific to ultrahigh‑field MRI (e.g., geometric distortion, susceptibility artifacts)
  • Multi‑institutional consensus improves external validity

➖ Weaknesses

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Post-traumatic hydrocephalus after decompressive craniectomy: a multidimensional analysis of clinical, radiological, and surgical risk factors

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In a retrospective observational cohort study Romualdo et al. from the Department of Neurosurgery Faculty of Medicine, Technische Universität Dresden University Hospital Carl Gustav Carus published in the Neurosurgical Review to identify clinical, radiological, and surgical risk factors associated with the development of shunt-dependent posttraumatic hydrocephalus (PTH) in patients who underwent decompressive craniectomy following severe traumatic brain injury (TBI). Shunt-dependent post-traumatic hydrocephalus (PTH) occurred in 27% of patients after decompressive craniectomy for severe TBI. Independent risk factors included older age, basal cistern subarachnoid hemorrhage, post-traumatic ischemic infarcts, transcalvarial herniation, subdural hygroma, and progressive contusion hemorrhages. Surgical parameters were not predictive. Patients requiring shunt placement had significantly worse neurological outcomes 5).

🚨 The Illusion of Multidimensionality Despite claiming a “multidimensional” analysis, the study delivers a monotonous list of obvious associations—many of which have been reported in the literature for over a decade. Subarachnoid hemorrhage, infarction, hygroma, contusion progression… yes, thank you, we knew that. What’s new? Almost nothing.

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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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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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High activity of human cytomegalovirus in patients with Sjögren’s disease

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In a cross-sectional observational study using immunohistochemistry and serology to assess human cytomegalovirus (HCMV) activity in salivary gland tissue and serum samples, Pantalone et al. (Karolinska Institutet, Stockholm; Turku University, Finland) — published in Clinical Immunology — investigated the presence and potential role of HCMV in patients with Sjögren’s disease (SD).

Their findings showed:

  • SD patients had significantly higher expression of HCMV proteins in salivary gland tissue:
    1. HCMV-IE: 88.9%
    2. HCMV-LA: 69.2%
    3. HCMV-pp65: 45.8%
  • HCMV-specific IgM was more frequent in SD patients than in controls (32.1% vs. 13.4%, p = 0.04)
  • HCMV-IgG titers were significantly elevated in the SD group (p < 0.0001)

These results suggest a possible role of active or latent HCMV infection in the pathogenesis of Sjögren’s disease, although a causal relationship has not been established.

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🧠 Takeaway Message for Neurosurgeons

While Sjögren’s disease is primarily a rheumatologic condition, this study provides important implications for neurosurgeons:

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Challenges in Pulmonary Management after Traumatic Brain and Spinal Cord Injury

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In a review Zhou et al. published in Neurosurgery clinics of North America the most common pulmonary complications following traumatic brain injury (TBI) and spinal cord injury (SCI) — such as neurogenic pulmonary edema, Acute Respiratory Distress Syndrome, Ventilator-Associated Pneumonia, and thromboembolic events — and summarize current understanding of their pathophysiology and treatment, with the goal of guiding early recognition and management to improve outcomes in neurotrauma patients 3)

🧨 Verdict: ❝A clinically themed PowerPoint stretched into ten pages. No risk. No depth. No new thought.❞

⚠️ Fundamental Flaws No Original Contribution → This is not a review — it’s a recitation. The article contributes zero new data, no expert algorithm, and no provocative insight into managing a leading cause of secondary injury in neurotrauma.

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Fever in the Neurocritically Ill Patient

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In a review Kitagawa et al. from McGovern Medical School at the University of Texas Health Science Center at Houston published in Neurosurgical Clinics of North America to review fever etiology in neurocritically ill patients, assessed current pharmacologic and mechanical strategies for temperature control, and evaluated the existing evidence on whether these interventions improve clinical outcomes. The goal was to inform clinical decision-making in the neuro ICU setting. They concuded that fever is common in neuro ICU patients and is associated with worse outcomes. While several interventions effectively reduce body temperature, the literature remains inconclusive regarding their impact on prognosis. Management should be individualized, weighing the potential benefits against adverse effects. Further research is needed to clarify the clinical value of temperature control in this population 4)

Another polished yet pointless review, safely orbiting the surface of a real clinical problem without offering a single actionable insight. If you’ve spent time in a Neuro-ICU, you already know everything this article says. And if you haven’t — reading it won’t help you survive your next febrile crisis.

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Multi‑omics analysis of druggable genes to facilitate Alzheimer’s disease therapy: A multi‑cohort machine learning study

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In a computational, multi-omics, machine learning study, Hu et al., published in the Journal of Prevention of Alzheimer’s Disease, aimed to identify druggable genes associated with Alzheimer’s disease (AD) by integrating multi-omics data from brain and blood samples and applying advanced machine learning and Mendelian randomization techniques to facilitate the development of effective therapeutic targets.

They concluded that LIMK2 is a promising druggable gene target for Alzheimer’s disease (AD), as its expression is significantly associated with key AD biomarkers — including Cerebrospinal fluid amyloid-beta, p-tau, and hippocampal atrophy — across both brain and blood datasets.

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Takeaway Message for a Neurosurgeon

Despite its computational complexity, the study by Hu et al. offers no clinically actionable insight for neurosurgeons. While it identifies LIMK2 as a statistically associated gene in Alzheimer’s pathology, there is no mechanistic evidence, no surgical relevance, and no translational pathway that justifies changing diagnostic or therapeutic strategies. Use it as a reminder: Data mining ≠ disease understanding. For neurosurgeons, especially those navigating cognitive decline in surgical candidates, CSF biomarkers and omics correlations remain tools — not decisions.

1. Conceptual Inflation Disguised as Innovation

The article by Hu et al. promises a “multi-cohort, multi-omics, machine learning” roadmap to druggable targets in Alzheimer’s disease (AD), but ultimately delivers a statistical Rube Goldberg machine — impressive in complexity, hollow in clinical consequence. The central narrative is built around the identification of “druggable genes” like LIMK2, but without a mechanistic framework, experimental validation, or translational bridge. The result is computational theater masquerading as biological discovery.

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