Intracranial epidermoid cysts are rare, benign tumors. Nevertheless, the microsurgical removal of these cysts is challenging. This is due to their capacity to adhere to the neuro-vascular tissue as well as the associated difficulties in micro-surgically peeling off their capsular wall hidden in dead angles. To better understand the rate of recurrence after surgical intervention, we have performed pre- and postoperative volumetric analysis of epidermoid cysts allowing the estimation of their growth rate after resection. Imaging data from 22 patients diagnosed and surgically treated for an intracranial epidermoid cyst between 2000 - 2022 was retrospectively collected from two European neurosurgical centers with microsurgical expertise. Volumetric analysis was performed on magnetic resonance imaging (MRI) data. Average cyst volume at diagnosis, prior to any surgery, measured in 12 patients, was 28877.6 ± 10250.4 mm³ (SEM). Estimated growth rate of incompletely-resected epidermoids after surgery was 1630.05 mm³ ± 729.95 (SEM). Assuming linear growth dynamics and normalizing to postoperative residual volume, the average postoperative growth rate corresponded to 61.5 ± 34.3% (SEM) of the postoperative residual volume per year. We observed signs of recurrence during a radiological follow-up period of 6.0 ± 2.8 years (SD) in more than 50% of our patients. Due to their slow-growing nature, epidermoid cysts can often reach a complex multicompartmental size before resection, even in young patients, thus requiring complex approaches with challenging capsular resection which implies a high risk of nerve and vascular injury per se. Tumor recurrence may be predicted based on postoperative volumetry.

In the cerebral cortex, establishing the precise relationship between functional areas and the macroscopic anatomy of gyri and sulci has a paramount importance for the field of neuroimaging and neurosurgical interventions. The anatomical orientation should start with the identification of anatomical landmarks to set the anatomo-functional boundaries. The human central sulcus region stands out as a well-defined structural and functional unit housing the primary motor and sensory cortices and is considered as key region to be identified during brain surgery. While useful anatomical landmarks have been discovered, especially in the axial plane, the identification of this region in the sagittal plane remains sometimes difficult. Using cadaveric whole brains and multi-modal analysis of MRI brain scans, we systematically observed a tuning fork–shaped sulco-gyral configuration centred around the gyral continuum bridging the pre-central gyrus with the middle frontal gyrus. We provide evidence that this ‘Fork sign’ is a consistent morphological feature visible on the lateral surface of the brain and a reliable radioanatomical landmark for identifying central sulcus region structures on sagittal MRI images, including the motor hand area.

Background/Objectives: Sacral chordomas are rare, locally invasive tumors that pose significant surgical and oncological challenges due to their anatomical complexity, proximity to critical structures, and resistance to conventional therapies. Methods: A literature search focused on contemporary multidisciplinary management of sacral chordoma was conducted. An illustrative case of such a multidisciplinary approach is presented. Results: Achieving optimal outcomes necessitates a multidisciplinary approach that balances en-bloc resection with negative margins and preservation of biomechanical stability and neurological function. Negative resection margins are a key determinant of long-term survival and reduced recurrence, particularly for tumors involving the upper sacrum (S1–S2). While postoperative radiation therapy provides adjunctive benefits, precision in surgical planning and execution remains paramount. Emerging technologies, such as augmented reality and 3D-printed anatomical models, are enhancing surgical precision, while the role of multidisciplinary surgical teams in improving outcomes requires further study. Conclusions: This review highlights the complexities of sacral chordoma management, focusing on surgical strategies, functional trade-offs, and future directions to optimize oncological and functional outcomes.

Background: Isolated inferior rectus muscle palsy is a rare entity and even more rarely induced by an anatomical conflict. We report here a clinical case of third cranial nerve (CN III) compression in its cisternal segment by an idiopathic uncal protrusion in a patient presenting an isolated inferior rectus muscle palsy. Case Description: We report a case of an anatomical conflict between the uncus and the CN III in the form of a protrusion and highly asymmetrical proximity of the uncus and asymmetrically thinned nerve diameter deviated from its straight cisternal trajectory on the ipsilateral side were supported by an altered diffusion tractography along the concerned CN III. Clinical description, review of the literature, and image analysis were done including CN III fiber reconstruction using a fused image from diffusion tensor imaging images, constructive interference in steady state, and T2-fluid-attenuated inversion recovery images on a dedicated software (BrainLAB AG). Conclusion: This case illustrates the importance of anatomical-clinical correlation in cases of CN deficits and supports the use of new neuroradiologically based interrogation methods such as CN diffusion tractography to support anatomical CN conflicts.

The preservation of the human self-a fundamental yet underexplored aspect of neurosurgical practice-has gained increasing attention in recent years. How can neural correlates of self-consciousness be identified, monitored, and protected during brain tumor surgery, and how might this reshape the concept of "onco-functional balance"? This review synthesizes emerging evidence from neuroimaging, neuropsychology, and intraoperative neurophysiology to build a framework for integrating the concept of self into modern neurosurgical practice. We describe the anatomical and functional basis of bodily and cognitive self-awareness, highlighting the roles of interoception, multisensory integration, and higher-order cortical networks such as the medial prefrontal cortex, insula and temporoparietal junction. We outline perioperative tools for clinical assessment, including validated scales for anosognosia and disownership, as well as the Self-Other Voice Discrimination (SOVD) paradigm and Heartbeat-Evoked Potentials (HEPs), which offer quantifiable markers of self-processing. We argue for a reconceptualization of "eloquent" cortex to include regions critical for the preservation of self. As neurosurgery advances toward precision-guided, patient-centered care, protecting the self must become an explicit goal alongside motor, sensory, and language preservation. Future directions include real-time intraoperative monitoring of HEPs, development of functional risk maps for self-related structures, and broader implementation of personalized, neurocognitive surgical planning.Ultimately, this work proposes a shift from an "onco-functional" to an "onco-functional-identity" paradigm-where the integrity of the patient's personality, agency, and awareness becomes a measurable, preservable endpoint of neurosurgical care.