This Week in Neurosurgery — Aug 19, 2026

Welcome to This Week in Neurosurgery. This week we're covering 10 notable papers spanning operative technique and positioning, neurovascular decision-making from thrombectomy timing to flow diversion antiplatelets, and outcome prediction across trauma, skull base, and pediatric vascular surgery. Let's dive in.

We'll start in the operating room, where two papers ask whether how we position and how we access changes what we achieve. In Neurosurgery, Rychen and colleagues report a randomized, single-blind superiority trial from a Swiss tertiary center comparing the semisitting position against the supine position during endoscopic endonasal trans-sphenoidal pituitary surgery. Fifty-six patients were analyzed, the great majority with pituitary neuroendocrine tumors, and the torso in the intervention arm was elevated thirty degrees with the legs raised. Mean intraoperative blood loss fell by about ninety millilitres, roughly a third less than supine, and the number of interruptions for suctioning or hemostasis dropped by about a fifth. Venous air embolism, the obvious worry, occurred in three patients in the semisitting arm and none supine; all three events were hemodynamically insignificant and resolved spontaneously, and the difference was not statistically significant. This is a small single-center trial and it was not powered for air embolism, so the honest reading is that semisitting buys you a cleaner field and a smoother workflow at the cost of needing precordial Doppler monitoring and a team that knows what to do if the Doppler changes. [1] Staying operative, World Neurosurgery carries a retrospective comparison from Zhang and colleagues of mini-craniotomy neuroendoscopic evacuation against double burr-hole drainage for septated chronic subdural hematoma, fifty-five patients over five years. The endoscopic approach took longer in theatre but achieved better hematoma clearance and better midline shift correction, and functional scores were superior even after adjusting for baseline function and Markwalder grade. Complications were roughly a third in the burr-hole group versus under one in ten with endoscopy. Recurrence and mortality were numerically lower with endoscopy but not statistically different, and hospital stay and costs were comparable. For the septated hematoma specifically, where a burr hole simply cannot reach the loculations, this supports escalating the approach, but it is a small retrospective series with a hint of selection bias toward healthier endoscopy patients. [9]

Turning to neurovascular practice, three papers push on questions we face weekly. In the Journal of Clinical Neuroscience, Ge and colleagues report a propensity-matched single-center cohort of anterior circulation large vessel occlusion treated with thrombectomy, comparing the standard six to twenty-four hour window against patients treated beyond twenty-four hours. After matching, forty-two pairs, functional independence at three months was essentially identical, around fifty-five percent in each arm, with no significant differences in successful reperfusion, symptomatic hemorrhage, or complications. The message is not that the clock is irrelevant; it is that in a highly selected imaging-triaged population, a very late presentation should not by itself close the door. The authors are explicit that this needs randomized confirmation. [3] Alongside it, in the same journal, Rajiv and colleagues looked at what happens after the clot comes out, analyzing two-hourly blood pressures over the first twenty-four hours in two hundred and sixty-eight thrombectomy patients. It was not the mean pressure that mattered but the swing: a systolic coefficient of variation of ten or more was independently associated with worse three-month function, alongside high presenting stroke severity and recanalization status. Notably, no clear association was demonstrated between systolic pressure and symptomatic hemorrhage; diabetes and high presenting severity predicted that instead. The practical implication is that a stable pressure may matter more than an aggressively low one. [4] The third neurovascular paper, in Neurosurgery, addresses antiplatelet choice after flow diversion with newer surface-modified stents. Roy and colleagues pooled a hundred and seventy-one patients from six North American institutions on aspirin plus either ticagrelor or clopidogrel. After propensity-score weighting, in-stent stenosis, stroke or transient ischemic attack, and hemorrhagic complications were all statistically indistinguishable between the two regimens. In-stent stenosis occurred in about one in seven patients overall. The authors read this as support for keeping clopidogrel first line, with ticagrelor a safe fallback in clopidogrel resistance rather than a bleeding liability. And from World Neurosurgery, a cautionary note on intracranial stenting: Zhang and colleagues studied two hundred and nineteen patients stented for symptomatic M1 or basilar atherosclerotic stenosis and found that the relationship between residual stenosis and thirty-day stroke or death was nonlinear. Event rates were about thirteen percent when residual stenosis was under ten percent, about six percent in the ten to twenty percent band, and eighteen percent above twenty percent, although adjusted comparisons were not significant. In perforator-rich territory, chasing an angiographically perfect result may not be protective. [5] [6]

The final thread is prognostication and risk stratification. In Neurosurgery, Lubillo and colleagues studied forty-five adults with moderate to severe traumatic brain injury who underwent secondary decompressive craniectomy for refractory intracranial hypertension, all with continuous intracranial pressure and brain tissue oxygen monitoring. Two thirds of patients achieved a favourable six-month outcome, and those patients had spent far less time hypoxic, a median of seven and a half hours versus fifteen, and had a dramatically lower hypoxic burden, about thirteen percent of monitored time versus seventy percent. A composite ischemic burden metric multiplying pre-operative intracranial pressure by the proportion of time with brain tissue oxygen below fifteen millimetres of mercury discriminated outcome well, and a rising brain tissue oxygen after admission independently predicted a good result. It is retrospective and small, but it argues that oxygen, not pressure alone, should inform when we decompress. [2] Two papers refine surgical counselling. In Neurosurgery, Zhang and colleagues report long-term nervus intermedius dysfunction after retrosigmoid vestibular schwannoma resection in two hundred and sixty-two patients, and the incidence is striking: close to half of patients had persistent dysfunction, most commonly dry eye in about forty-four percent, with hypogeusia in about one in six. Larger tumours, longer operations, trigeminal hypoesthesia, and especially poor facial nerve function, which raised the odds roughly eightfold, were independent predictors, and their nomogram discriminated well on internal validation. The actionable point is corneal protection and ophthalmology referral in high-risk patients rather than waiting for symptoms. [8] And in the Journal of Neurosurgery: Pediatrics, Jung and colleagues reviewed a hundred and twenty-nine children with completely resected brain arteriovenous malformations at the Hospital for Sick Children. Recurrence after angiographic cure occurred in about eleven percent, at a mean of two and a half years, with the latest at nearly twelve years. Deep venous drainage was the dominant independent predictor, raising the hazard nearly tenfold, with larger size trending the same way; age, hemorrhagic presentation, and prior embolization were not associated. Pediatric angiographic cure is not permanent cure, and these children need long-term surveillance imaging. [7] Rounding out this theme, Operative Neurosurgery publishes a phase-based framework from Kim and colleagues for interpreting lateral spread response during microvascular decompression for hemifacial spasm across three hundred and ninety-eight consecutive patients. Only about half of cases followed the textbook course of immediate disappearance after separation; the rest were spread across nonelicitable responses, pre-separation disappearance, delayed disappearance, reappearance, and persistence. At one year, about ninety-five percent of patients did well overall, and while persistent response at the end of the case was associated with a higher rate of unfavourable outcome, around fourteen percent versus five percent, the majority of those patients still did well. The lesson is to treat the monitoring signal as context, not as a mandate to keep exploring. [10]

If you only have time for one paper this week, make it the randomized trial of semisitting versus supine positioning for endoscopic endonasal pituitary surgery in Neurosurgery. It is the only randomized evidence in this week's set, it addresses a decision every pituitary surgeon makes at the start of every case, and the safety signal it raises is one you can manage with monitoring you already have. [1]

Here are the key takeaways from this week in Neurosurgery. First, the semisitting position reduces bleeding and interruptions during endonasal pituitary surgery, but commit to precordial Doppler monitoring if you adopt it. Second, after thrombectomy, blood pressure stability over the first day tracked better with recovery than any particular target, and very late presentation beyond twenty-four hours does not automatically exclude a well-selected patient from intervention. Third, for flow diversion with surface-modified stents, clopidogrel remains a reasonable first choice, and ticagrelor is a safe alternative when clopidogrel fails. Fourth, in intracranial stenting of perforator-rich arteries, the lowest residual stenosis was not the safest result. Fifth, brain tissue oxygen burden, combined with intracranial pressure, may sharpen selection and timing for secondary decompressive craniectomy. And finally, counsel your patients on the long tail: close to half of vestibular schwannoma patients develop lasting nervus intermedius dysfunction, and roughly one in nine children recur after an angiographically cured arteriovenous malformation, sometimes a decade later.

That's your roundup for This Week in Neurosurgery. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.