Neurosurgery

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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Intraoperative ICG-VA with FLOW800 and multimodal fusion neuro-navigation for the resection of arteriovenous malformation with reduced blood loss

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In a retrospective cohort study, Yang et al. from The First Affiliated Hospital of Soochow University (Suzhou, Jiangsu) and Beijing Tiantan Hospital, Capital Medical University (Beijing, China), published in World Neurosurgery, evaluated the safety and effectiveness of combining intraoperative indocyanine green video angiography (ICG-VA) with FLOW800 and multimodal fusion neuronavigation in the microsurgical resection of brain arteriovenous malformations (AVMs).

The combined use of ICG-VA, FLOW800, and multimodal neuro-navigation was associated with:

Reduced intraoperative blood loss

Improved functional outcomes

Lower rates of postoperative complications and reoperation

→ Enhancing both the safety and efficacy of AVM microsurgery.

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A flashy mix of fluorescence imaging, hemodynamic mapping, and navigation overlays is presented as a major leap forward in AVM surgery. Ninety patients, split into two groups. Outcomes like hemoglobin drop and mRS are tracked. Sounds solid. Until you actually read it.

⚠️ Fatal Methodological Flaws Retrospective Bias Parade: No randomization. No matching. No controls for AVM grade, eloquence, or preoperative hemorrhage. The groups may as well be different species.

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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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