Background/Objective: Craniosynostosis, the premature fusion of one or more cranial sutures, is the second most common craniofacial defect and poses significant diagnostic and therapeutic challenges. Our objective was to systematically evaluate current diagnostic imaging modalities for craniosynostosis and to propose a novel radiation-free ARCANA Protocol as an alternative to conventional screening. Methods: Following PRISMA guidelines, we conducted a systematic review of the literature using PubMed and Cochrane databases from 2015 onwards, restricted to English-language and full-text articles. Inclusion criteria encompassed studies evaluating diagnostic accuracy, radiation exposure, and neurocranial outcomes associated with imaging modalities in craniosynostosis. Quality assessment was performed using QUADAS-2. To evaluate the certainty of evidence supporting each imaging modality, we applied the GRADE framework. Given the extensive number of included studies (n = 70), findings were categorized by diagnostic modality rather than individual studies. Results: Analysis of 70 selected studies demonstrated a continued reliance on 3D computed tomography (3DCT) as the diagnostic gold standard, despite recognized risks of cumulative radiation exposure in pediatric populations. Alternative radiation-free imaging techniques including high-resolution ultrasonography (US), three-dimensional stereophotogrammetry (3DSPG), and advanced magnetic resonance imaging (MRI) have emerged, offering substantial benefits such as eliminating ionizing radiation and providing comprehensive neurocranial assessments. 3DCT demonstrates approximately 90% sensitivity and 90–100% specificity for detecting suture closure; ultrasound achieves 71–100% sensitivity and 86–100% specificity, while advanced MRI techniques such as GA-VIBE report up to 97% sensitivity and 96% specificity. Conclusions: The proposed ARCANA Protocol integrates clinical assessment, 3DSPG, US, and advanced MRI sequences into a unified multimodal framework that eliminates radiation exposure while ensuring comprehensive evaluation of cranial and intracranial anatomy. The protocol emphasizes patient safety and diagnostic accuracy. The main limitations of this study are the heterogeneity of the included studies and the lack of prospective validation, which is essential to confirm diagnostic and clinical effectiveness and to support a potential paradigm shift toward radiation-free assessment of craniosynostosis.

• The neurosurgical postcode lottery reflects global inequity. • Geography and income strongly shape access to neurosurgical care worldwide. • Workforce shortages leave millions without access to lifesaving neurosurgery. • Costs, travel distance, and discrimination deepen treatment inequality. • Equity requires workforce growth, stronger health systems, and fair financing.

Background/Objectives: Spinal dural arteriovenous fistulas (sDAVFs) are the most common spinal vascular malformation and a treatable cause of progressive myelopathy, yet diagnosis and optimal management remain challenging. This study presents a nine-year institutional experience using a multidisciplinary treatment algorithm that prioritizes endovascular embolization, with surgery reserved for unsuccessful or contraindicated cases. Methods: We retrospectively analyzed 15 patients treated between 2015 and 2023, all diagnosed by MRI and confirmed by digital subtraction angiography. Endovascular embolization was attempted as the initial treatment modality in all patients using contemporary liquid embolic agents. Results: Three patients (20%) subsequently required surgical disconnection following unsuccessful or incomplete embolization. Lesions ranged from Th5 to L5, and most patients presented with varying degrees of motor deficits, gait disturbance, paresthesias, or sphincter dysfunction. Neurological improvement occurred in all but one patient, and no treatment-related complications were observed. Prior embolization attempts aided intraoperative localization in surgically treated cases, facilitating precise fistula identification. Conclusions: These findings demonstrate the feasibility and favorable outcomes of a multidisciplinary, stepwise treatment strategy in this single-center experience. Endovascular embolization served as the initial treatment modality, while surgical disconnection provided an effective complementary option in selected cases where embolization was unsuccessful or incomplete.

Introduction: The presence of syringomyelia associated with Dandy-Walker malformation is rarely described in adults. Case report: We report a case of a 28-year-old woman with a history of Dandy-Walker malformation who developed syringomyelia. She had been previously treated in childhood with a ventriculoperitoneal and cystoperitoneal shunt for hydrocephalus, but over time she developed progressive neurological symptoms, including numbness and weakness in the upper extremities. Magnetic resonance imaging revealed a syrinx extending from C4 to T1 associated with large posterior fossa cyst. The patient was treated with cyst fenestration and cystoperitoneal shunts were removed, with complete resolution of symptoms and disappearance of syrinx. Discussion: A literature review revealed only 6 cases of syringomyelia associated with Dandy-Walker malformation in adults. The pathophysiology of this entity is multifactorial and may be related to obstructed cerebrospinal fluid flow, altered pressure dynamics, and formation of arachnoid adhesions. Conclusions: Individualized surgical approaches are essential for optimizing outcomes in this rare condition. Further research is needed to standardize treatment protocols and clarify underlying mechanisms and help to improve the management of these patients.

Introduction: Scaphocephaly, the most common form of craniosynostosis, is caused by the premature fusion of the sagittal suture, resulting in an elongated skull shape and constrained cranial growth. Material and methods: This retrospective study included all consecutive patients with sagittal synostosis who were operated at the Clinic of Neurosurgery, UCCS, in the 20-year period. Detailed patient data were obtained from medical records and neuroradiological diagnostics. The follow-up period for these patients ranged from 6 to 20 years. The acquired data were thoroughly statistically analyzed. Results: There were 93 children with a clear male preponderance. In the majority of children, there were no perinatal complications, and the majority of mothers didn't have any chronic illnesses. Three types of surgical treatment were used, with an almost equal distribution. The mean blood loss during surgery varied across the three operative techniques, with the lowest blood loss observed using the TSEO technique. Successful treatment was observed in only 57.1% patients who underwent strip-suturectomy, 96.6% patients treated with the π procedure, and all patients treated with the TSEO technique. Statistical analysis revealed a significantly higher success rate of the TSEO and π procedure compared to strip-suturectomy. Cranial index remained dolichocephalic in 6/28 children treated with strip-suturectomy alone, while in all cases treated with TSEO and π procedure, cranial index normalized. The majority of operated children had no complications. Conclusion: Successful treatment of scaphocephaly requires a case-specific approach that extends beyond the surgical procedure itself. This series emphasizes the need for individualized treatment plans and a multidisciplinary approach throughout the surgical process.