This Week in Neurosurgery — Sep 2, 2026

Welcome to This Week in Neurosurgery. This week we're covering 10 notable papers spanning meningioma classification and skull base surgery, cerebrovascular decision-making from thrombectomy hardware to subarachnoid haemorrhage imaging, and perioperative risk management including thromboprophylaxis and intraoperative monitoring. Let's dive in.

We'll start with meningiomas, which dominate this week's pool, and with a question that goes to the heart of how we counsel patients: what actually predicts progression. In Neurosurgical Focus, Karamani and colleagues report a single-centre experience applying routine methylation profiling to 106 meningioma resections alongside standard World Health Organization grading. Roughly three quarters of the tumours were grade 1 by histology, but epigenetic classification disagreed with the histological grade in 18 of 74 classifiable cases. The important signal is this: over follow-up, tumour progression tracked significantly with the methylation class and with tumour volume, but not with World Health Organization grade. The practical problem is logistical. Nearly three in ten tumours could not be classified at all, and the epigenetic report landed a median of 23 days after surgery, while the tumour board had already made its decision at around day eight. So methylation profiling looks like the better prognosticator, but in real-world workflow it remains a complement to histopathology rather than a replacement — and notably, progression-free survival in the unclassifiable tumours mirrored the intermediate group, which is a useful default assumption when the result comes back uninformative [1]. Alongside this, Neurosurgical Focus carries a review from Peyre and colleagues on progestin-associated meningiomas, pulling together the epidemiological, clinical, biological and histopathological features of tumours linked to synthetic progestins and to pregnancy. For anyone running a meningioma clinic, a medication history is now part of the diagnostic workup, not an afterthought [2].

Three further papers address meningiomas in anatomically hostile locations, and together they make a consistent argument for function-first surgery. In the Journal of Clinical Neuroscience, Madheshiya and colleagues examined 37 patients with tuberculum sellae meningioma who came to surgery already blind or with non-serviceable vision in at least one eye — a group often written off. Immediate postoperative visual improvement occurred in just under 40 percent of patients, and by a mean follow-up of nearly four years, close to 60 percent of patients had improved, with some crossing back from non-serviceable to serviceable vision. On multivariable analysis, younger age, use of the supraorbital keyhole approach, and optic canal unroofing were each associated with long-term visual improvement — and the middle two are surgeon-modifiable. The message is that severe preoperative visual loss is not, by itself, a reason to withhold operation [3]. In Neurosurgical Focus, Matsushima and colleagues describe a function-prioritised workflow for 26 jugular foramen meningiomas, combining compartment-based anatomical classification, selective preoperative embolisation, and continuous vagus nerve monitoring. Every patient was extubated immediately after surgery, and just over three quarters of patients resumed oral intake within a week. At one year, swallowing and voice were still subjectively worse in about half of patients, but almost all of those cases were mild, and crucially no patient required tracheostomy, gastrostomy, long-term tube feeding, or phonosurgery. Simpson grade IV resection accounted for around seven in ten cases, but that residual was mostly intrajugular or extracranial rather than intradural, and only three patients needed salvage stereotactic radiosurgery over a median follow-up of about four and a half years. That is a deliberate trade of extent of resection for lower cranial nerve function, backed by surveillance [4]. Also in Neurosurgical Focus, Li and colleagues propose an imaging-based stratification system for parasagittal meningiomas involving the superior sagittal sinus, applied to 62 consecutive single-surgeon resections. Their grading correlated strongly with the established Sindou classification and with venous patency, and as grade rose so did operative time, blood loss, and fluid requirement. High-involvement tumours were far less likely to achieve a Simpson grade I resection — the odds of settling for a Simpson II or III strategy were more than twelvefold higher. Complication rates did not differ between groups, and with a mean follow-up of only about 13 months there were no recurrences, so this is a preoperative planning tool for anticipating exposure and sinus handling, not yet a validated predictor of outcome [5].

Turning to cerebrovascular work, two papers challenge the reflex to do more. In Neurosurgery, Chacon and colleagues asked whether the newer superlarge-bore aspiration catheters actually outperform standard large-bore catheters in mechanical thrombectomy. Across 34 international centres and more than two thousand patients treated with frontline aspiration, with propensity matching to balance the groups, first pass effect was essentially identical — around 55 percent in both arms. Ninety-day functional independence, successful recanalisation, time to reperfusion, intraprocedural complications, symptomatic haemorrhage, embolisation to new territory, and mortality were all comparable, and the findings held in the subgroup restricted to internal carotid and M1 occlusions. Using a prespecified 10 percent margin, standard large-bore catheters were non-inferior for both recanalisation and first pass effect. The caveat is that only 107 patients received the superlarge-bore devices, so this is not a definitive verdict — but there is currently no outcome-based argument for paying more for the bigger bore [6]. Also in Neurosurgery, Preuss-Hernández and colleagues addressed repeat angiography after perimesencephalic subarachnoid haemorrhage, reviewing 279 consecutive patients across two tertiary centres over more than two decades. Vascular pathology was found in exactly one patient — about one in 250 — and only after clinical deterioration prompted repeat angiography. Meanwhile, procedure-related ischaemic complications occurred in seven patients, roughly one in 40, leaving one patient with a permanent deficit. In other words, the harm rate exceeded the diagnostic yield. In patients meeting strict perimesencephalic criteria with a negative high-quality computed tomography angiogram, routine repeat digital subtraction angiography looks hard to justify. The authors also identified a haemorrhage volume threshold of 13 millilitres that separated poor from favourable discharge outcome with high specificity and a negative predictive value of about 97 percent — promising for early risk stratification, but needing validation [7].

Two technical papers round out the week. In World Neurosurgery, Jin and colleagues report on superficial temporal artery to middle cerebral artery bypass combined with a pedicled temporoparietal fascial flap onlay in 55 adults with moyamoya disease, with 23 patients who declined surgery serving as an observational comparison. Direct bypass patency was 98 percent, perfusion imaging improved in over 90 percent of patients at one week, and 85 percent achieved Matsushima grade A collateralisation on latest angiography. Non-surgical management carried a substantially higher stroke hazard — roughly seven times higher in the adjusted analysis — but the authors are appropriately explicit that this was a self-selected comparison that cannot establish causation, and superiority over other combined techniques was not tested [8]. And in World Neurosurgery, Le and colleagues describe fully endoscopic microvascular decompression for hemifacial spasm in 18 consecutive patients, using both the familiar lateral spread response and the Zhong-Lee response, elicited by direct stimulation of the neurovascular conflict. The lateral spread response was detectable in about eight in ten patients, whereas the Zhong-Lee response was present in every patient before decompression and disappeared in every case afterward. Immediate symptom resolution occurred in just over three quarters of patients, with the remainder resolving later. This is a small, single-series report, but the second modality appears genuinely useful when the lateral spread response is absent, disappears too early, or when multiple candidate vessels complicate identification of the true culprit [9].

Finally, the Journal of Clinical Neuroscience publishes a scoping review from Woon and colleagues on venous thromboembolism prophylaxis in neurosurgery, which underpinned a consensus guideline across five New Zealand centres. Reported thromboembolism rates in neurosurgical patients range enormously, from under one percent to about a third, with higher rates in cranial surgery, malignancy, traumatic brain injury, prolonged immobility, and prior events. Intermittent pneumatic compression reduces risk with a favourable safety profile, and low molecular weight heparin started between 24 and 72 hours postoperatively — or after stable neuroimaging in head injury — consistently reduced events without a corresponding rise in major bleeding. The comparison between low molecular weight and unfractionated heparin remains inconclusive [10].

If you only have time for one paper this week, make it the perimesencephalic subarachnoid haemorrhage study in Neurosurgery [7]. It is a large, clean dataset that directly quantifies harm against yield for a procedure many of us still order out of habit, and it should change your imaging pathway on Monday.

Here are the key takeaways from this week in Neurosurgery. First, after a strictly perimesencephalic bleed with a good-quality computed tomography angiogram, routine repeat catheter angiography exposes patients to more risk than it uncovers. Second, superlarge-bore aspiration catheters did not improve first pass effect, reperfusion, or outcomes over standard large-bore devices. Third, methylation profiling predicts meningioma progression better than World Health Organization grade, but a slow turnaround and a high unclassifiable rate mean it complements rather than replaces histology today. Fourth, in skull base meningiomas, accepting intrajugular residual to preserve lower cranial nerves, and unroofing the optic canal even in eyes with non-serviceable vision, are both defensible function-first choices. And fifth, mechanical prophylaxis plus low molecular weight heparin started at 24 to 72 hours appears safe across most neurosurgical patients, but individualised assessment beats a rigid protocol.

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.

If this weekly briefing is useful, follow the show in your podcast app so new episodes arrive automatically. And if it saves you time, a quick rating in your podcast app helps other physicians find the show.

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