Citations

Abstract Neuroanatomy remains a core competency in neurosurgical training, particularly in skull base education, where learners must integrate three‐dimensional spatial understanding, radiologic correlation, and stepwise procedural knowledge. Cadaveric dissection remains foundational, but adjunctive digital tools may strengthen repeated visualization and anatomical review. We describe the educational rationale and implementation of integrating stereoscopic teaching, a stepwise digital application, photogrammetry, and virtual reality within an established neurosurgical skull base curriculum. Within the Mayo Clinic cranial base course embedded in a broader longitudinal curriculum, four postgraduate year 4 neurosurgery residents participated in transcranial and endoscopic cadaveric dissections supported by stereoscopic lectures, workstation‐based tablet guidance, and immersive review using photogrammetry, virtual reality, and computed tomography/magnetic resonance imaging correlation. The integrated design aligned these modalities with course objectives in anatomical landmark recognition, operative corridor planning, radiologic‐anatomic translation, and stepwise procedural rehearsal. The educational contribution of this model lies in the intentional integration of digital adjuncts around cadaveric dissection rather than in a single technology alone. This multimodal sequence may support spatial understanding, procedural preparation, and competency‐oriented skull base training while extending review beyond the laboratory. Current evaluation is best interpreted as preliminary program evaluation rather than definitive learner‐outcome evidence. This model may offer a transferable approach for programs seeking to complement cadaveric education with emerging digital tools and provides a basis for future prospective evaluations using multiple low‐stakes assessment data points across the broader curriculum.

BACKGROUND AND OBJECTIVES: Endoscopic transnasal surgery offers a minimally invasive alternative to transcranial approaches for accessing midline skull base lesions involving the petrous apex and petroclival region. However, lateral access, particularly behind the petrous internal carotid artery (ICA), remains limited. The contralateral transmaxillary (CTM) approach provides a more direct surgical trajectory, more parallel to the petrous ICA. Yet, lateral access through this approach can be restricted by anatomic barriers, including the pterygoid process and lateral buttress of the maxillary sinus. We aimed to evaluate the contralateral transmaxillary-transpterygoid (CTMP) approach, with and without the lateral buttress removal (CTMP-LBR), to determine whether these modifications could enhance surgical access to the petroclival region. METHODS: Ten sides from 5 formalin-fixed, latex-injected cadaveric specimens were dissected to compare CTM, CTMP, and CTMP-LBR approaches. Petrous bone drilling was directed posterolaterally behind the petrous ICA toward the region medial to the cochlea. In addition, 30 sides from computed tomography angiography scans were analyzed to obtain radiographic measurements for each approach. RESULTS: Compared with CTM, both CTMP and CTMP-LBR significantly increased access for retrocarotid petrous bone drilling ( P < .001) and yielded a wider surgical angle relative to midline ( P < .001), in both cadaveric and radiographic analyses. In dissections, 20% of sides required CTM only, 50% benefited from CTMP, and 30% required CTMP-LBR to achieve adequate lateral access. Radiographic analysis revealed that CTMP required a median of 4 mm of pterygoid drilling, whereas CTMP-LBR required 9 mm and enabled a trajectory parallel to the petrous ICA with only 11 mm of soft tissue displacement. Patients with smaller angles between the petrous ICA and the horizontal plane were significantly more likely to benefit from CTMP over CTM ( P = .005). CONCLUSION: Modification of the CTM approach with pterygoid drilling and optional LBR improves retrocarotid access. Preoperative evaluation of the petrous ICA angle may help optimize patient-specific planning in endoscopic petroclival surgery.

OBJECTIVE Communicating hydrocephalus may occur following stereotactic radiosurgery (SRS) for vestibular schwannomas (VSs), yet identifying individual patient risk factors associated with this post-SRS complication remains a challenge. This study examined predictors of nonobstructive ventricular enlargement and symptomatic communicating hydrocephalus following primary SRS treatment for VS via a single-center institutional cohort review and meta-analysis of the literature. METHODS A retrospective single-institution cohort study and systematic literature review and meta-analysis examining post-SRS communicating hydrocephalus in VS was performed. RESULTS The institutional cohort consisted of 634 patients who received primary SRS as treatment for VS. The cohort was 51.6% female, with a median age of 64 (range 18–89) years. Following SRS treatment, 364 patients (57.4%) experienced tumor shrinkage, 218 (34.4%) had no change in the size of their lesion, and 52 (8.2%) experienced tumor growth. Nonobstructive ventricular enlargement was observed in 23 patients (3.6%) following SRS treatment, of whom 9 (39.1%) remained asymptomatic and 14 (60.9%) required placement of a ventriculoperitoneal (VP) shunt, with a median time to shunt placement of 8 months. In the multivariate analysis, patients ≥ 65 years old (p = 0.038), SRS target volume ≥ 5 cm 3 (p < 0.001), maximum SRS dose ≥ 26 Gy (p = 0.015), and tumor growth at the most recent follow-up (p = 0.002) were associated with an increased risk of post-SRS ventricular enlargement. Similarly, patients with older age (p = 0.049), increased SRS target volume (p = 0.002), and tumor growth (p = 0.016) were at an increased risk of symptomatic communicating hydrocephalus requiring VP shunt placement. Twenty-nine studies, including the cohort in this study, met inclusion criteria in the meta-analysis. Of the pooled 7825 patients, the overall incidence of hydrocephalus following SRS was 5%, and a subanalysis of 7081 patients demonstrated the incidence of symptomatic hydrocephalus requiring a VP shunt to be 4%. In this subanalysis, the overall shunting rate in patients who experienced post-SRS ventriculomegaly was 92%. Among individual studies in the literature, increased tumor size was most commonly found to be a statistically significant risk factor for post-SRS hydrocephalus. CONCLUSIONS Approximately 5% of patients may experience nonobstructive ventricular enlargement following primary SRS treatment for VS. However, not all patients may be symptomatic and require shunting. Patients who are older (≥ 65 years), those with larger tumor volumes, and those with post-SRS tumor growth may be at increased risk of communicating hydrocephalus and may benefit from closer clinical monitoring.

Objective To assess the impact of renal replacement therapy in people with lupus nephritis (LN)–associated end‐stage kidney disease (ESKD) and support the development of the 2024 American College of Rheumatology LN treatment guidelines. Methods We conducted a systematic literature review and meta‐analysis to address three Population, Intervention, Comparison, and Outcome (PICO) questions related to renal replacement therapy for ESKD due to LN, including comparisons of kidney transplant versus dialysis, hemodialysis versus peritoneal dialysis, and preemptive kidney transplant versus no preemptive kidney transplant. Outcomes of interest included mortality, cardiovascular (CV) events, infections, lupus flares, disease‐related damage, graft failure, and quality of life. We conducted a meta‐analysis and analyzed hazard ratios for time‐to‐event analyses and risk ratios for dichotomous outcomes, as well as absolute risk estimates. Results Sixteen comparative observational studies addressed at least one of the three PICO questions. Kidney transplant was found to reduce the risks of all‐cause mortality, CV mortality, infection‐related mortality, and CV events compared with dialysis (high certainty). Dialysis modality (peritoneal vs hemodialysis) was not associated with mortality (high certainty) or with other outcomes of infection, CV complications, and systemic lupus erythematosus flares (low certainty). Preemptive kidney transplant was associated with lower risks of graft failure and mortality (low certainty). Conclusion This systematic review identified improved outcomes with kidney transplant versus dialysis for people with LN‐associated ESKD and potential benefits of preemptive kidney transplant. This evidence supports the use of kidney transplant as a preferred renal replacement therapy for people with LN‐ESKD.

Objective To provide evidence‐based and expert guidance for the treatment and management of non‐renal systemic lupus erythematosus (SLE); treatment and management of lupus nephritis are addressed in a separate guideline. Methods Clinical questions for treatment and management of SLE were developed in the PICO format (population, intervention, comparator, and outcome). Systematic literature reviews were developed for each PICO question, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess evidence quality and formulate recommendations. The Voting Panel achieved a consensus of ≥70% agreement on the direction (for or against) and strength (strong or conditional) of each recommendation. Results We present recommendations and ungraded, consensus‐based good practice statements for the treatment and management of SLE that are applicable to pediatric and adult patients. Recommendations emphasize uniform treatment with hydroxychloroquine, limiting duration of glucocorticoid use, and early introduction of conventional and/or biologic immunosuppressive therapies to achieve and maintain control of SLE inflammation (remission or a low level of disease activity), reduce SLE‐related morbidity and mortality, and minimize medication‐related toxicities. Conclusion This guideline presents direction regarding treatment and management of SLE and provides a foundation for well‐informed, shared clinician–patient decision‐making. These recommendations should not be used to limit or deny access to therapies, as treatment decisions may vary due to the unique clinical situation and personal preferences of each person with SLE.

Objective To provide evidence‐based and expert guidance for the treatment and management of non‐renal systemic lupus erythematosus (SLE); treatment and management of lupus nephritis are addressed in a separate guideline. Methods Clinical questions for treatment and management of SLE were developed in the PICO format (population, intervention, comparator, and outcome). Systematic literature reviews were developed for each PICO question, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess evidence quality and formulate recommendations. The Voting Panel achieved a consensus of ≥70% agreement on the direction (for or against) and strength (strong or conditional) of each recommendation. Results We present recommendations and ungraded, consensus‐based good practice statements for the treatment and management of SLE that are applicable to pediatric and adult patients. Recommendations emphasize uniform treatment with hydroxychloroquine, limiting duration of glucocorticoid use, and early introduction of conventional and/or biologic immunosuppressive therapies to achieve and maintain control of SLE inflammation (remission or a low level of disease activity), reduce SLE‐related morbidity and mortality, and minimize medication‐related toxicities. Conclusion This guideline presents direction regarding treatment and management of SLE and provides a foundation for well‐informed, shared clinician–patient decision‐making. These recommendations should not be used to limit or deny access to therapies, as treatment decisions may vary due to the unique clinical situation and personal preferences of each person with SLE.

BACKGROUND Glossopharyngeal neuralgia (GPN) is a rare disorder characterized by severe, episodic pain along the sensory distribution of cranial nerve (CN) IX. Bilateral GPN presents unique challenges for consideration of microsurgical treatment due to potential risks of postoperative dysphagia and cardiac arrhythmias associated with resection of bilateral CN IX/X. Here, the authors describe successful staged bilateral microsurgical rhizotomy of CN IX and upper CN X rootlets to treat bilateral GPN. OBSERVATIONS A 54-year-old female presented with right GPN and underwent a right retrosigmoid craniotomy with rhizotomy, resulting in complete resolution of pain. During the following year, the patient developed left GPN and was considered for the same surgical intervention. However, prior to pursuing surgical intervention, evaluation of her swallowing function was conducted to stratify her risk of pharyngeal sensory denervation or dysphagia, and to confirm her suitability for left-sided rhizotomy. Given the patient’s normal oropharyngeal swallowing function on videofluoroscopic swallow study, she underwent left retrosigmoid craniotomy with rhizotomy. At the 3-month follow-up, the patient described complete resolution of pain and normal swallowing function. LESSONS With the use of comprehensive patient evaluation between surgical stages, staged bilateral microsurgical rhizotomy is a feasible and safe treatment option for carefully selected patients with bilateral GPN. https://thejns.org/doi/10.3171/CASE25359

Abstract Professor Albert J. Rhoton Jr., MD, is renowned for his groundbreaking dissections, marking a monumental achievement in the field of neuroanatomy. Alongside his anatomical contributions, he also passed on his knowledge and skills to numerous fellows, leaving behind a profound legacy. Despite the widespread recognition of his influence, little quantitative work has been done to characterize the scholarly impact of his alumni. Data were collected on Rhoton fellows, including fellowship years, country of origin, current institutions, and titles, practice settings, and leadership roles. Scholarly productivity was evaluated by assessing publication counts, including publications before and after the fellowship, and publications focused on surgical anatomy. Additionally, H-indices and citation counts were recorded. Other variables analyzed included ownership of a surgical anatomy laboratory, and participation in organizing hands-on courses. We analyzed 118 alumni from diverse countries. There was a significant increase in publication output following the fellowship, with publications rising from an average of 7 to 76 (p < 0.001). Fellows from high-income countries had higher research productivity than those from middle-income countries, with greater average H-index (p = 0.003), publication count (p = 0.01), and citation score (p = 0.003). Overall, 65% of fellows pursued academic practice, with 18% owning a laboratory and 30% involved in hands-on courses. Dr. Rhoton's mentorship has shaped a generation of neurosurgeons who continue his legacy. His fellows have established careers worldwide, leading in academia, professional organizations, and surgical training. Their global impact underscores the lasting value of structured mentorship in neurosurgery.

Abstract Cadaveric dissections, which are considered the most realistic model to study neuroanatomy, are expensive and not readily available in all centers. Given the surge of technological advances, incorporation of three‐dimensional (3D) scanning technologies and 3D models has gained popularity, both in the educational and clinical settings. We present our institutional experience in creating high‐fidelity neuroanatomical 3D models using three 3D scanning techniques: structured light 3D scanning, “manual” photogrammetry with a single DSLR camera, and “automatic” photogrammetry using a scanner equipped with five vertically arranged DSLR cameras and an automatic turntable within a square box. A survey study was conducted with 20 neurosurgical residents to assess the quality of the three resulting 3D models. In the study, “manual” photogrammetry was determined to be the most cost‐effective technique, while “automatic” photogrammetry was the most time‐effective and user‐friendly technique. The best visual quality was obtained using “manual” photogrammetry, as determined from survey results of 20 neurosurgical residents. While structured light 3D scanning had the lowest quality of resolution of the texture map, this technique was the most accurate to use for determining measurements, with a fixed accuracy of 0.05 mm. Overall, “manual” photogrammetry can allow for the most detailed 3D models and is the most cost‐effective strategy, while structured light 3D scanning is most suitable for obtaining clinically relevant measurements given the high degree of structural accuracy. Alternatively, “automatic” photogrammetry can serve as a hybrid between obtaining relatively high‐quality models in a time‐effective and user‐friendly manner.