Background: Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings. Methods: We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions. Results: Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury. Discussion: Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI. Conclusions: We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.

Background: Local delivery after resection of high-grade glioma, particularly glioblastoma (GBM), aims to increase intratumoral drug exposure while limiting systemic toxicity. The only U.S. Food and Drug Administration (FDA)-approved implantable intracranial chemotherapy is the carmustine (1,3-bis[2-chloroethyl]-1-nitrosourea; BCNU)-impregnated polyanhydride wafer (Gliadel wafer), indicated for newly diagnosed high-grade glioma and recurrent GBM. More than two decades of clinical use and randomized data show that intracavitary chemotherapy is feasible and confers a modest survival benefit in carefully selected patients. Nevertheless, Gliadel wafer has not altered the overall poor prognosis of GBM because of biological resistance to nitrosoureas, constrained brain-parenchymal pharmacokinetics, and device-related adverse effects. Objective: The aim is to synthesize clinical and preclinical evidence defining the current limitations of Gliadel wafer and to outline strategies for next-generation local delivery systems, with emphasis on GBM within the broader high-grade glioma setting. Methods: A narrative review of randomized and observational clinical studies, pharmacokinetic studies, and preclinical investigations evaluating Gliadel wafer and potential next-generation local delivery systems in GBM and other high-grade gliomas was performed. Results: The literature delineates key limitations of Gliadel wafer: short diffusion distances and burst-weighted carmustine release, high tumor cell resistance to carmustine due to heterogeneity, and device-related side effects. Emerging approaches to address these limitations include (i) multidrug systems with synergistic effects against GBM cells; (ii) advanced biomaterials that enable controlled and sustained release; and (iii) targeted agents with minimal off-target effects. Testing newer generations of local drug-delivery systems in more predictive translational models, such as patient-derived organoids and spontaneous large-animal glioma models, is essential to maximize the translatability of preclinical studies to human studies. However, broader adoption of spontaneous large-animal glioma models is constrained by ethical oversight, animal-welfare considerations, cost, and limited availability compared with rodent platforms. Conclusions: Next-generation local drug-delivery systems should include multiple synergistic tumor-selective drugs that can be released in a controlled, sustained manner deep into the residual tumor. Preclinical testing of these systems should be conducted in clinically relevant animal models that are more translatable than those used in early Gliadel wafer studies.

Minimally invasive (MI) tubular decompression seeks to reduce soft‑tissue trauma compared with open laminectomy for lumbar spinal stenosis (LSS). We performed a PRISMA‑compliant systematic review and meta‑analysis of comparative studies (2015–April 2025) identified in PubMed, Embase, and CENTRAL. Adults with symptomatic degenerative LSS undergoing MI tubular decompression or open laminectomy were included. Evaluated outcomes included surgical parameters (e.g., overall complications; dural tears, surgical site infections, reoperation), perioperative and postoperative complications, patient-reported outcome measures (PROMs), and hospital length of stay (LOS). Heterogeneity was measured using I². Random-effects models were primary; PROMs were also analyzed in a common-effect sensitivity analysis. Nine studies involving ten cohorts and a total of 2,860 patients were analyzed from 2,853 records. Random-effects models pooled odds ratios (OR) and mean differences (MD); PROMs were additionally examined with a common-effect model as a sensitivity analysis. MI tubular surgery was associated with fewer overall complications (OR 0.42, 95% CI 0.21–0.86), fewer surgical site infections (OR 0.28, 95% CI 0.11–0.69), lower EBL (MD − 46.65 mL, 95% CI − 80.89 to − 12.41), and shorter LOS (MD − 1.39 days, 95% CI − 1.99 to − 0.79). Reoperation, operative time, dural tears, and PROMs did not differ significantly. Overall, our results suggest that MI tubular-assisted decompression may offer advantages over open surgery for lumbar spinal stenosis. It was associated with lower perioperative morbidity and resource utilization – including lower overall complication rates, fewer surgical-site infections, reduced blood loss, and shorter hospital stays – while achieving similar patient-reported outcomes. Given between-study heterogeneity and the predominance of retrospective cohorts, these results should be interpreted with appropriate caution; nevertheless, when feasible and in appropriately selected patients and settings, tubular-assisted decompression may be considered a preferable option.

Study Design: Vignette-based cross-sectional study. Objective: Generative artificial intelligence (AI) programs such as large language models (LLMs) are reshaping treatment decision-making, yet applications in minimally invasive spine surgery (MISS) are still scarce. This study examines whether OpenAI’s ChatGPT-5 Pro and Google’s Gemini 2.5 Pro reproduce expert management categories from published MISS cases and measures agreement at procedural and binary triage levels. Methods: We constructed 90 clinical vignettes from published case reports and prompted each LLM to assign 1 or more of ten predefined categories with two-sentence rationales. Agreement with reference was assessed using Jensen–Shannon divergence (JSD), Stuart–Maxwell tests, Cohen’s κ, and McNemar’s test for surgical vs non-surgical triage. Results: Divergence from reference was small, with Jensen–Shannon divergence 0.115 (ChatGPT-5 Pro) and 0.112 (Gemini 2.5 Pro), and smaller between models at 0.073. Paired multinomial tests found differences from the reference (Stuart–Maxwell χ ² (9) = 24.8 and 26.0; P = 0.007 and 0.006) but not between models (14.4; P = 0.108). Case-level agreement was slight for ChatGPT-5 Pro and fair for Gemini 2.5 Pro (κ = 0.146 and 0.245). Collapsing categories to surgical vs non-surgical improved agreement (κ = 0.415 and 0.587 vs reference; 0.692 between models) with no bias in rates ( P ≥ 0.401). Conclusions: LLMs may differentiate between surgical and non-surgical triage, but procedure selection should remain expert-led until systems mature. These findings establish a baseline for integrating LLMs into surgical triage workflows and highlight promise and limitations of generative AI in precision spine care.

Idiopathic intracranial hypertension (IIH) features elevated intracranial pressure (ICP) without a secondary cause. Trigeminal neuralgia (TN), usually attributed to neurovascular conflict (NVC), has been reported only rarely in association with IIH. We reviewed the literature and present three institutional cases to better characterize this association while explicitly acknowledging the limits of case-based causal inference. We systematically searched PubMed, Ovid Medline, Ovid Embase, Scopus, and Web of Science from inception through August 2025, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The core search combined terms for idiopathic intracranial hypertension or pseudotumor cerebri with trigeminal neuralgia, trigeminal neuropathy, and facial pain. Because causal attribution from case reports is limited, we applied a qualitative framework based on temporality, objective evidence of raised ICP, exclusion of more convincing alternative causes, especially definite NVC, and response to ICP-lowering therapy. Methodological quality was appraised using the Joanna Briggs Institute case report checklist. Quantitative summaries were restricted to published TN phenotypes; trigeminal neuropathy without pain and persistent idiopathic facial pain were summarized separately. Out of 1302 records, 12 case reports met the criteria. Nine described TN, two involved trigeminal neuropathy without pain, and one involved a persistent idiopathic facial pain phenotype. Across the nine TN cases, all patients were female (mean age 38.7 ± 12.5 years). Reported opening pressure ranged from 220 to 480 mmH₂O (mean 393.0 ± 89.2 mmH₂O), although diagnostic certainty varied, and not all cases fulfilled the full Friedman criteria for definite IIH. Maxillary (V2) and mandibular (V3) involvement predominated, and multidivisional pain was common. Imaging features of raised ICP and improvement after ICP-lowering therapy were recurrent themes, but standardized high-resolution trigeminal magnetic resonance imaging (MRI) sequences were inconsistently reported, limiting exclusion of coexisting classical TN. We additionally describe three institutional cases: two with documented elevated opening pressure (290 and 320 mmH₂O) and one probable ICP-related case with suggestive imaging but unavailable opening pressure. In the institutional cohort, dedicated Constructive Interference in Steady State (CISS) or Fast Imaging Employing Steady-state Acquisition (FIESTA) assessment was not uniformly available; in one case, venous contact was of uncertain significance, and in another, microvascular decompression was performed without operative confirmation of arterial compression or pain relief. TN associated with IIH is a rarely reported association. Given the limited case-based evidence, the available data should be regarded as hypothesis-generating rather than definitively causal. When objective intracranial hypertension is present, careful evaluation of both ICP-related markers and alternative TN mechanisms, including NVC, is essential. ICP-lowering therapy has been reported to improve pain in some cases and may address a potential contributing mechanism.