Objective: : Acoustic neuromas, or vestibular schwannomas, pose significant surgical challenges due to their proximity to critical cranial nerves, particularly the facial nerve. The primary goal in their surgical treatment is to achieve maximal tumor removal while preserving neurological function. Recent advancements in surgical technology have introduced neuroendoscopy as an adjunctive tool that can enhance visualization during surgery. This study aimed to evaluate the efficacy of integrating neuroendoscopy with intraoperative electrophysiological monitoring in near-total resection surgeries for acoustic neuroma. Methods: : We conducted a retrospective cohort study comparing 71 patients who underwent neuroendoscopy-assisted microsurgery technique with 68 patients who received standard care group technique. Both groups underwent the suboccipital retrosigmoid sinus approach for tumor resection with intraoperative electrophysiological monitoring. Surgical outcomes, including residual tumor size, facial nerve function, audiological outcomes, and complication rates, were compared between the two groups. Results: : The neuroendoscopy-assisted group demonstrated a significantly smaller residual tumor size, improved immediate and 1-year postoperative House-Brackmann grades, and a higher facial nerve preservation rate compared to the standard care group (p<0.05). There was no significant difference in operation time, blood loss, cerebrospinal fluid leakage, or complication rates between the groups. Word recognition scores after a year were significantly higher in the neuroendoscopy-assisted group (p<0.05). Conclusion : The integration of neuroendoscopy-assisted microsurgery technique in acoustic neuroma surgery improves facial nerve function and residual tumor size without increasing surgical complications. These findings support the utility of this combined approach in enhancing surgical outcomes for patients with acoustic neuroma.

Objective: : To identify sex-specific risk factors for postoperative urinary retention (POUR) in patients undergoing spine surgery with total intravenous anesthesia (TIVA) and explore differences between male and female patients. Methods: : A retrospective chart review was conducted on 446 adult patients (268 males, 178 females) who underwent spine surgery with TIVA from January 1, 2019 to December 31, 2023. Propensity score matching was applied to adjust for confounding variables, resulting in 328 matched patients (164 males and 164 females). Multivariable logistic regression analyses were performed to identify independent risk factors for POUR. Residual urine volume ≥300 mL was used to define POUR. Results: : Male patients had a higher incidence of POUR compared to female patients. Significant risk factors for POUR in males included myelopathy (adjusted odds ratio [aOR], 5.17; 95% confidence interval [CI], 1.11–24.15), benign prostatic hyperplasia (BPH) (aOR, 2.63; 95% CI, 1.02–6.78), and prolonged anesthesia time ≥240 minutes (aOR, 2.54; 95% CI, 1.13–5.72). No significant risk factors were found in female patients. Myelopathy and prolonged anesthesia were associated with an increased risk of POUR across the overall population. Conclusion : Male sex, myelopathy, BPH, and prolonged anesthesia time are significant risk factors for POUR following spine surgery with TIVA. Given these findings, particular attention should be paid to myelopathy, a history of BPH, and anesthesia time in male patients.

Subarachnoid hemorrhage (SAH) is a stroke subtype with high mortality and poor functional outcomes. Prompt occlusion of a ruptured aneurysm at an early stage is crucial to prevent rebleeding, which can result in even higher mortality and more severe disabilities. The most critical initial decision in SAH management is the choice of treatment method with surgical clipping or endovascular coiling. We aimed to develop an evidence-based clinical guideline to select the optimal initial treatment in patients with SAH. We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer two population, intervention, comparison, outcome questions comparing clipping and coiling. The risk of bias was assessed using ROB 2.0 and the Newcastle-Ottawa Scale. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcome and mortality. We included six randomized control trials (RCTs) and 58 observational studies. Meta-analysis of RCTs showed that coiling improved functional outcomes compared to clipping (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.86–0.97). No significant mortality difference was observed in RCTs (OR, 1.38; 95% CI, 0.91–2.09), but non-RCTs favored clipping for reduced mortality (OR, 0.77; 95% CI, 0.69–0.86). However, it is difficult to generalize these findings to all clinical situations, as patients with SAH have a highly variable clinical course. Final treatment decision should be tailored to the individual patient’s status, including aneurysm location, morphology, and the expertise available at the treatment center. Such decisions are best made by specialists such as a board-certified physician and should be explained to the patient and their caregivers, along with the rationale for selecting the most appropriate treatment at the given hospital. Korea has many certified endovascular neurosurgeons, cerebrovascular surgeons, and certified cerebrovascular centers. Proper selection of the most suitable treatment method by certified physicians and centers would greatly benefit patient outcomes and healthcare professionals.

Objective: : A twig-like middle cerebral artery (T-MCA) is a rare condition characterized by steno-occlusion of the M1 segment of the middle cerebral artery (MCA) with nearby collateral arterial networks. Despite unclear pathophysiology, it is often classified as a congenital anomaly caused by failure of fusion of the plexiform MCA arterial plexus. We aimed to improve understanding of the pathophysiology of T-MCAs by analyzing incidental T-MCA findings and their natural history. Methods: : A retrospective chart review was performed between January 2011 and December 2023 at three medical centers treating both ischemic and hemorrhagic strokes. Patients with suspected MCA lesions were selected through radiology reports from computed tomography, magnetic resonance angiography, and digital subtraction imaging. Results: : We identified 51 T-MCA cases from a radiology report search spanning 13 years across three medical centers. The study included 9875 patients with ischemic stroke and 2097 with hemorrhagic stroke. Of the 51 T-MCA cases, incidental findings accounted for 25 (49.0%), ischemic stroke for 18 (35.3%), and hemorrhagic strokes accounted for eight cases (15.7%). T-MCA related ischemic and hemorrhagic strokes accounted for 0.18–0.38% of all strokes. The RNF213.R4810K mutation was identified in seven of 15 patients (46.7%) tested. We found three cases of a de-novo T-MCA that progressed from a normal MCA architecture. Conclusion : T-MCAs may represent an acquired secondary anomaly rather than a congenital lesion, followed by steno-occlusion of the focal MCA with new arterial network formation. Both Moyamoya angiopathy and chronic atherosclerosis likely contributed to disease progression. Formation of a microaneurysm, dilatation of the lenticulostriate artery, and hemodynamic stress can lead to stroke.

Objective: : The indications for repeated brain computed tomography (CT) for delayed intracranial hemorrhage (DICH) remain inconclusive. This study aimed to identify the risk factors for DICH in patients with severe trauma. Methods: : Patients with blunt trauma, admitted to a level I trauma center between January 2018 and June 2020, were retrospectively reviewed. Patients who underwent repeat brain CT but had a normal initial brain CT were included. The patients were divided into the DICH and normal groups, and their general characteristics and outcomes were compared. Multi-logistic regression analysis was performed to identify the risk factors. Patients with DICH were also interviewed. Results: : Of 784 patients, 37 (4.7%) were included in the DICH group. The DICH group presented with more severe injury. In multi-logistic regression, age over 65 years (odds ratio [OR], 2.681; 95% confidence interval [CI], 1.250–5.753; p=0.011), lowest systolic blood pressure under 90 mmHg during resuscitation (OR, 2.678; 95% CI, 1.247–5.750; p=0.012), severe abdominal injury (OR, 2.667; 95% CI, 1.213–5.864; p=0.015) and cervical spine fracture (OR, 2.408; 95% CI, 1.084–5.351; p=0.031) were associated with DICH. Among the 37 patients with DICH, one patient underwent an invasive procedure, and no mortality was reported. Conclusion : The incidence of DICH may be higher in patients with severe trauma and repeat brain CT could be considered in selected high-risk cases, even when the initial scan is normal.

Objective: : The insertion of a surgical paddle lead for spinal cord stimulation (SCS) is a cornerstone therapy for chronic refractory pain, with lower impedance and reduced battery usage than a percutaneous lead. However, the greater invasiveness of this procedure can cause complications. Methods: : This study introduces a novel SCS technique using the unilateral biportal endoscopy (UBE) approach, illustrated through intraoperative images and endoscopic videos. We retrospectively reviewed 14 patients who underwent SCS using the UBE technique. Clinical, surgical, and radiological data were collected from electronic medical records and surgical videos. Results: : A total of 14 patients (five females, nine males) were included in the study. The mean endoscopic operating time was 76.3±22.3 minutes. After the trial period, 13 patients (92.8%, 13/14) improved and underwent permanent implantation. The complication rate was 21.4%, with two cases of thoracic radiculopathy and one case of asymmetrical lead positioning. No lead migration was observed in these 13 patients. Conclusion : This study demonstrated the safety and efficacy of UBE-SCS as a minimally invasive alternative to conventional techniques, with high success rates and acceptable complications. However, further large-scale, long-term comparative studies are needed.

Objective: : This study investigated the relationship between arterial partial pressure of oxygen (PaO2) levels in the first 24 hours of intensive care unit (ICU) admission and clinical outcomes in neurocritically ill brain tumor patients. Methods: : In this single-center retrospective study of 2123 brain tumor patients, we analyzed PaO2 levels from arterial blood gas samples within 24 hours of ICU admission. The primary endpoint was 28-day mortality. Analysis utilized multivariable logistic regression and inverse probability of treatment weighting (IPTW). Results: : PaO2 exceeding 91.5 mmHg was defined as hyperoxia. The non-hyperoxia group showed higher 28-day mortality than the hyperoxia group (15.5% vs. 6.0%, p<0.002), a trend that persisted after IPTW adjustment (10.7% vs. 6.6%, p=0.019). In IPTW-adjusted regression, non-hyperoxia remained significant (adjusted odds ratio [OR], 3.24; 95% confidence interval [CI], 1.82–5.77). Survival analysis demonstrated significantly higher survival rates in the hyperoxia group (p<0.001). Subgroup analysis revealed significant heterogeneity across tumor types (p for interaction <0.001), with protective effects observed in malignant brain tumors (adjusted OR, 3.5; 95% CI, 1.88– 6.51) and brain metastases (adjusted OR, 3.86; 95% CI, 2.31–6.44), but not in benign tumors (adjusted OR, 1.14; 95% CI, 0.22–5.87). Conclusion : Elevated PaO2 levels within the first 24 hours of ICU admission were associated with decreased mortality rates, suggesting oxygenation as a potential therapeutic target in brain tumor patients. The protective effects were most pronounced in patients with malignant brain tumors and brain metastases, supporting a tumor type-specific approach to oxygenation management.

Accurate and early identification of stroke and large vessel occlusion (LVO) in emergency settings is essential for improving patient outcomes and ensuring the efficient allocation of medical resources. This clinical practice guideline systematically reviews domestic and international literature and conducts meta-analyses to evaluate the utility and diagnostic accuracy of stroke assessment tools used in prehospital emergency medical services (EMS). We developed a guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted to evaluate the usefulness of diagnostic EMS assessment tools for diagnosing stroke and LVO. Overall, 70 non-randomized control studies were selected for this study. A meta-analysis was conducted with a subgroup analysis to distinguish between patients with stroke and those with LVO. EMS tools demonstrated high sensitivity but low specificity for diagnosing stroke. In the prehospital setting, using validated EMS stroke assessment tools is recommended for the early identification of stroke and LVO. Upon hospital arrival, stroke specialists should conduct further evaluation and triage to confirm the diagnosis and guide appropriate management. Delays in diagnosing LVO are frequently unacceptable. While experts advocate for the use of EMS assessment tools to facilitate early identification of LVO, these tools alone lack adequate sensitivity. Therefore, further diagnostic evaluations and consultation with stroke specialists upon hospital arrival are recommended.