Intraoperative neurophysiological monitoring (IONM) is a crucial advancement in neurosurgery, enhancing procedural safety and precision. This technique involves continuous real-time assessment of neurophysiological signals, aiding surgeons in timely interventions to protect neural structures. In addition to inherent limitations, IONM necessitates a detailed anesthetic plan for accurate signal recording. Given the growing importance of IONM in neurosurgery, we conducted a narrative review including the most relevant studies about the modalities and their application in different fields of neurosurgery. In particular, this review provides insights for all physicians and healthcare professionals unfamiliar with IONM, elucidating commonly used techniques in neurosurgery. In particular, it discusses the roles of IONM in various neurosurgical settings such as tumoral brain resection, neurovascular surgery, epilepsy surgery, spinal surgery, and peripheral nerve surgery. Furthermore, it offers an overview of the anesthesiologic strategies and limitations of techniques essential for the effective implementation of IONM.

Background: This work aims to review the current literature and our experience on vascular Eagle syndrome (ES) that can present misleading clinical presentations and better understand the possible therapeutic strategies.Methods: We reviewed the existing literature on PubMed from January 1, 2017, to December 31, 2022, including the sequential keywords “vascularANDEagle syndrome,” “vascularANDstyloid syndrome,” “vascularANDelongated styloid process,” “vascularANDstylocarotid syndrome,” and “Eagle syndromeANDcarotid artery dissection.”Results: 38 vascular ES cases, including our experience, were analyzed. The most frequent clinical onset was hemiparesis (n21, 57%), but other regular clinical presentations were aphasia, loss of consciousness, amaurosis, headache, or a combination of the latter. Massive oral bleeding was reported only once in the literature before our case. Twelve patients were treated with only antiplatelet therapy, either single or double. Nine patients were treated with anticoagulation therapy only. In 14 patients, a carotid artery stent was used, associated with anticoagulation or antiplatelet therapy. In 17 cases, a styloid process (SP) resection was performed.Conclusion: ES has many clinical presentations, and carotid artery dissection resulting in oral bleeding seems rare. Literature results and our experience make us believe that when dealing with vascular ES, the best treatment strategy is endovascular internal carotid artery stenting with antiplatelet therapy, followed by surgical removal of the elongated SP to prevent stent fracture.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a benign neurologic condition with treatment response rates ranging only between 30 and 50%. Several studies have attempted to identify clinical or radiological predictive factors of a favorable and sustained response to shunting, with conflicting and inconclusive results. With this report, we aimed to define the role of the Evans index (EI), enlargement of temporal horns, lateral ventricular bulges, and isolated elements of disproportionally enlarged subarachnoid spaces (high-convexity tightness and sulcal focal dilation) in predicting outcomes following ventriculoperitoneal shunt (VPS) placement. Methods: All patients referred to Ospedali Riuniti of Ancona, Italy, from 2010 to 2021 were retrospectively examined for evaluation of iNPH. Clinical notes and neuroimaging were reviewed. After screening, 82 patients undergoing VPS procedures for iNPH were included in this series. Most (82.9%) patients were aged >65, with a male-to-female ratio of 1.92:1. Results: Small baseline EI was associated with a significant improvement in gait apraxia scores (0.36 ± 0.04 vs. 0.40 ± 0.05, P = 0.04) and urinary incontinence episodes (0.38 ± 0.03 vs. 0.40 ± 0.05, P = 0.04). An EI > 0.40 was associated with a reduced likelihood of gait improvement (30.2%) in contrast to symptom stability or worsening (53%, P = 0.03). Similarly, an EI > 0.40 was associated with a reduced likelihood of continence improvement compared to stability or worsening of episode frequency (21.8% vs. 54%, P = 0.004). The presence of moderately compressed or obliterated cortical sulci was associated with a significant improvement of modified Rankin scale (mRS) functional status following surgery compared to patients with no convexity tightness (78% vs. 49.1%, P = 0.02 and 39.1% vs. 16.9%, P = 0.03, respectively). A large preoperative EI was predictive of poor response in the domains of gait apraxia (odds ratio [OR] = 0.001, 95% confidence interval [CI]: 0.001–0.4, P = 0.004) and urinary continence (OR = 0.001, 95% CI: 0.001–0.3, P = 0.003). The strongest predictors of improved mRS performance status were moderately (OR= 3.72, 95% CI: 1.22–11.35, P = 0.02) or severely compressed cortical sulci (OR= 3.15, 95% CI: 1.07–9.26, P = 0.03). Conclusion: The EI is a significant parameter predictive of enhanced gait function and urinary continence postsurgery. Furthermore, noteworthy evidence supports the association of high-convexity tightness with improved overall functional scores following surgical intervention.

Background/Objectives: Preservation of critical white matter (WM) pathways is essential for maximizing surgical safety in neuro-oncology and functional neurosurgery. Constrained spherical deconvolution (CSD) offers superior modeling of complex fiber architecture compared to diffusion tensor imaging (DTI). This case series evaluates the clinical utility of CSD in surgical planning and intraoperative navigation. Methods: A retrospective review of 20 patients (15 brain tumors, 5 functional disorders) treated between September 2022, and September 2024 was performed. All patients underwent preoperative MRI with CSD-based reconstruction of eloquent WM tracts. Clinical presentation, tract involvement, surgical strategy, and postoperative outcomes were analyzed. Results: CSD reliably reconstructed CST, AF, IFOF, OT, and DRTT depending on tumor location or DBS target. Compared with standard DTI, CSD provided improved delineation of tract extent and tumor–tract interfaces. Gross total resection (GTR) was achieved in all tumor patients without new neurological deficits. DBS cases showed precise correlation between stimulation thresholds, side effects, and CSD-predicted distances to critical WM tracts. DRTT targeting resulted in marked clinical improvement in Holmes tremor. Conclusions: CSD enhances anatomical accuracy in WM tract visualization, supporting safer resections in eloquent areas and improving DBS targeting. Its integration into routine workflow may optimize neurosurgical outcomes.

Curvularia species are melanized dematiaceous molds widely distributed in soil, plants, and decaying organic matter. Human infections are uncommon and typically involve the paranasal sinuses, skin, cornea, or respiratory tract, whereas central nervous system (CNS) involvement is rare. We report a locally invasive sino-cranial infection caused by Curvularia spicifera in a 20-year-old immunocompetent man with chronic sinusitis and features consistent with allergic fungal rhinosinusitis (AFRS). Brain magnetic resonance imaging revealed acute-on-chronic sinusitis complicated by a frontal sinus mucocele with orbital and intracranial extension. Management involved urgent neurosurgical source control followed by endoscopic sinonasal surgery. C. spicifera was repeatedly isolated from independent deep surgical specimens. The isolate was identified as Curvularia spicifera using a polyphasic approach integrating morphological, proteomic (MALDI-TOF MS), and molecular evidence. Histopathological examination demonstrated mixed neutrophilic and eosinophilic inflammation consistent with AFRS. Antifungal treatment was initiated with liposomal amphotericin B plus voriconazole; amphotericin B was subsequently discontinued because of severe hypokalemia, whereas voriconazole was continued under therapeutic drug monitoring. At the time of writing, the patient had completed three months of voriconazole therapy, with progressive clinical improvement and good tolerability, and was awaiting further radiological follow-up to guide the decision on treatment duration. Review of published cases indicates that contiguous spread from chronic sinonasal disease represents a frequent pathogenic mechanism of CNS Curvularia infection and that severe disease may occur even in the absence of overt immunosuppression. This case highlights the importance of early multidisciplinary management, aggressive surgical source control, accurate microbiological identification, and prolonged mold-active antifungal therapy with careful monitoring for treatment-related toxicity.