Background: Trigeminal neuralgia (TN) is a debilitating pain that affects the dermatomes associated with the trigeminal nerve (V1, V2, and V3). Unfortunately, many medical treatments and surgical procedures fail to sufficiently modulate the pain associated with this condition. Case Description: This study presents two extreme cases of refractory TN (RTN) that progressed to atypical facial pain and describes successful mitigation of the neuralgia of said cases by percutaneous implantation of upper cervical spinal cord stimulation (SCS). The SCS was designed to target the descending spinal trigeminal tract. Conclusion: Together, these cases collaborate with the limited literature and further delineate the use and potential advantages of SCS in the treatment of RTN.

Background: Primary intracranial sarcomas (PIS) are rare tumors with mesenchymal origins. These tumors have a heterogeneous clinical presentation and are associated with a poor prognosis. Case Description: This report highlights the complexities associated with PIS by focusing on a 26-year-old male with recurrent tumor growth facing unique challenges regarding diagnosis and treatment options . A high-grade spindle-celled neoplasm with sarcomatous features characterized the patient’s tumor. There were additional morphologic changes, including multinucleated giant cells and rare foci with eosinophilic spheroids. Genomic analysis revealed a DICER1-associated PIS. Treatment involved endovascular embolization, multiple surgical interventions, intrathecal etoposide injections, and oral pazopanib with adjuvant radiation therapy. Conclusion: This case additionally highlights an unusual association between PIS and anomalous hypervascularity, refractory hemorrhage, and subdural effusions, a presentation that is increasingly being reported in this type of tumor.

Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based on a two-stage method that aims to improve the visualization and excision of the tumor. In the first case, we utilized a combined endoscopic endonasal approach and a staged modified pterional, pretemporal, with extradural clinoidectomy, and transcavernous approach to successfully remove a giant pituitary adenoma. In the second case, we performed a modified right-sided pterional approach with pretemporal access and extradural clinoidectomy. This was followed by a transcortical, transventricular approach to excise a giant anterior clinoid meningioma. These cases demonstrate the importance of performing staged operations to address the challenges posed by these giant tumors.

BACKGROUND AND OBJECTIVES: Despite a substantial body of literature describing the efficacy of revascularization compared with conventional management of moyamoya disease (MMD), the impact of the timing of revascularization relative to stroke onset remains inadequately characterized. The aim of this review was to synthesize existing research to guide clinicians in the optimal timing of revascularization in symptomatic MMD. METHODS: A comprehensive literature review was performed to identify studies reporting on timing of revascularization. Studies were divided into revascularization within 3 months of stroke, between 3 and 6 months of stroke, or >6 months from stroke event. RESULTS: A total of 3049 cases and 3151 treated cerebral hemispheres were included. There were 91 individuals (2.98%) in the 3 months to intervention cohort, 152 (4.92%) individuals in the 3 to 6 months to the intervention cohort, and 2806 (92.0%) individuals in the >6 months to the intervention cohort. The average follow-up time was 43.8 ± 35.19 months. Clinical improvement was reported in 83.4% of cases overall. The 3-to-6-month poststroke preoperative interval has the highest frequency of clinical improvement (90.2%), followed by the >6-month preoperative interval (83.4%). The preoperative interval of <3 months had the lowest frequency of clinical improvement (76.5%). Comparison of average treatment effect in the treated demonstrated reduced frequency of improved clinical outcome (Mean difference: −22.6, SE: 9.15, P = .013) and increased frequency of worse clinical outcome (Mean difference: 20.1, SE: 7.38, P = .006) in the 6 months cohort was found to be associated with a reduced frequency of worse clinical outcome (Mean difference −1.81, SE: 0.349, P = .001). CONCLUSION: The findings of this meta-analysis suggest that, in cases where it is clinically feasible to delay revascularization following an acute neurological event in patients with MMD, postponing intervention is warranted.

Optic chiasm decompression for preservation of vision is often the primary surgical goal for patients with pituitary tumors. Descent of the diaphragma sellae (DS) is an intraoperative surrogate marker of adequate chiasm decompression. DS may not always descend in an obvious or symmetrical manner, leaving uncertainty to whether the operation was successful. We propose a technique of intentionally incising the DS to ensure adequate chiasm decompression. Here we present patients with pituitary tumors who underwent transsphenoidal surgery and DS incision when the DS was not easily identified and/or did not descend. The approximately 3-mm incision under endoscopic guidance allowed for direct visualization of the suprasellar cistern and optic chiasm. Cerebrospinal fluid (CSF) leak was repaired using a nasoseptal flap in 4 cases, while intradural substitute and thrombin glue were utilized in another case. Five patients with pituitary macroadenomas (average size: 6.4 cm³) had endoscopic endonasal transsphenoidal resection. Vision improved in all cases postoperatively. There were no postoperative complications or CSF leaks at 1 year. Diaphragma sellotomy ensures chiasm decompression with minimal risk to the patient with current reconstructive techniques and without the need for intraoperative magnetic resonance imaging (iMRI) and reduction of the need for repeated surgical intervention.

Spinal cord stimulation (SCS) is an established therapy for refractory back and leg pain, traditionally utilizing laminectomy-placed paddle leads or percutaneous cylindrical leads. Although percutaneous systems reduce soft tissue injury, they suffer higher migration rates and less precise dorsal column targeting. Minimally invasive surgical (MIS) techniques using tubular retractors combine the stability of paddle electrodes with reduced surgical trauma. Here, we describe a paramedian METRx tubular technique designed to minimize disruption of the posterior tension band while preserving paddle lead advantages. From January 2024 to April 2025, the senior author implanted paddle leads in 130 patients undergoing an SCS trial. Six patients (five men and one woman; mean age 67.7±6.4 years; mean BMI 34.9±4.7 kg/m²) underwent definitive paddle lead placement via a 3 cm paramedian incision and sequential dilation to a 22 mm METRx working channel. Neurosensory monitoring (somatosensory evoked potential (SSEP)/motor evoked potential (MEP)) was maintained throughout. Docking was performed at T7-T11 (four at T8-T9, one at T7-T8, and one at T10-T11). Under direct microscopic/endoscopic visualization, hemilaminectomy and flavectomy expose the dorsal epidural space. Boston Scientific paddle leads (Marlborough, Massachusetts, United States) were fluoroscopically confirmed, anchored to the interspinous ligament, tunneled subfascially to the gluteal pocket, and connected to an implantable pulse generator. All six paddle leads were successfully positioned without intraoperative complications. The mean estimated blood loss was 25 mL, and the mean operative time was 56.0±10.6 minutes. At the first postoperative follow-up (mean 2.9±3.1 months), no lead migrations, revisions, or infections were observed. The average Visual Analog Scale (VAS) pain score improved to 4.5±1.3. Importantly, with the paramedian approach, the midline supraspinous and interspinous ligaments were preserved, thereby reducing the osteoligamentous insult compared to midline or open microdissection techniques. The paramedian METRx tubular technique for paddle lead SCS placement is safe, efficient, and reproducible, with minimal blood loss and operative time. By sparing key posterior tension band structures, it may enhance postoperative recovery and preserve spinal stability. Prospective, controlled studies comparing paramedian versus midline MIS approaches are warranted to further elucidate clinical benefits and long-term outcomes.