Postoperative seizures are a recognized complication following intracranial surgery, with implications for neurologic recovery, length of stay, and quality of life. Despite decades of investigation, the role of routine seizure prophylaxis after craniotomy remains debated. Early trials supported short-term phenytoin use, while recent evidence and guidelines question its necessity in seizure-naïve patients. This review summarizes current data regarding the incidence, risk factors, and prevention of post-craniotomy seizures, with emphasis on the comparative efficacy of antiepileptic agents and the appropriate duration of prophylaxis. Levetiracetam has largely replaced phenytoin in modern practice due to improved tolerability, though neither has shown clear superiority in preventing late seizures. Most data support selective, rather than routine, prophylaxis limited to the immediate postoperative period in high-risk populations. Future work should focus on individualized risk stratification and standardized institutional protocols.

Background: Relative value units (RVUs) remain the dominant metric for quantifying physician productivity in the United States. While they effectively standardize procedural effort and reimbursement, RVUs primarily capture transactional work and miss activities essential to long-term value creation. In neurosurgery, where academic, operational, and strategic contributions by physicians underpin departmental sustainability, this narrow focus may incentivize short-term productivity at the expense of enduring value. Methods: This editorial reviews the conceptual foundations of value creation through the lens of enterprise management theory, particularly the “blue line” versus “red line” management framework described by Kaiser and Young in The Blue Line Imperative . It examines how current RVU-based systems align, or misalign, with principles of sustainable value creation and explores models from business and academic medicine that could inform more comprehensive performance frameworks. Results: Evidence suggests that RVU-centric compensation structures can create systemic distortions by rewarding immediate procedural output while undervaluing education, leadership, innovation, and quality improvement. This dynamic mirrors “red line” management, where short-term gains can erode long-term organizational value creation. Emerging frameworks, such as academic RVUs and value-based incentive models, offer examples of hybrid systems that incorporate multidimensional measures of value. Conclusion: RVUs remain a useful foundation for measuring clinical effort, but neurosurgery must evolve beyond them. Integrating clinical, educational, operational, and strategic metrics into a broader “Neurosurgical Value Index” could better align incentives with sustainable value creation, ensuring that what is measured and rewarded reflects the long-term health of patients, providers, and institutions.

Background: Craniopharyngiomas are rare Sellar and suprasellar tumors that can cause significant visual, endocrine, and hypothalamic morbidity. Treatment decisions in older adults are complicated by higher comorbidity burden, reduced physiological reserve, and limited data especially for the very elderly. Because most studies group all patients ≥65 together, the survival impact of surgery and radiotherapy in elderly subgroups remains unclear. Methods: A retrospective cohort study was conducted using SEER 17 (2000–2022). Patients aged ≥50 years with histologically confirmed craniopharyngioma were categorized as non-elderly (50–64), elderly (65–79), or very elderly (≥80). Demographic and clinical characteristics were compared using Chi-square tests and two-sample t-tests. Overall survival (OS) was evaluated using Kaplan–Meier analyses and multivariable Cox proportional hazards models. Results: A total of 1259 patients met inclusion criteria. OS decreased with age. In the 50–64 cohort, subtotal resection (STR) and gross total resection (GTR) significantly improved survival, and radiotherapy provided additional benefit. In the 65–79 cohort, neither resection nor radiotherapy significantly influenced OS. In the ≥80 cohort, STR was associated with worse survival relative to no resection (HR 2.21; p = 0.0349), while GTR and radiotherapy did not improve outcomes. Conclusions: The effect of craniopharyngioma treatment varies by age. Surgery and radiotherapy benefit younger patients, whereas adults aged 65–79 may gain symptomatic but not survival advantages. In patients ≥80, STR may reduce survival, underscoring the need for individualized treatment plans aligned with patient goals and physiological reserve.

Background/Objectives: Spinal ependymoma is the most common intramedullary spinal cord tumor in adults, and maximal safe resection is the cornerstone of treatment. Patients aged 75 years and older are underrepresented in surgical neuro-oncology cohorts. We sought to characterize treatment patterns and identify predictors of overall survival in very elderly patients with spinal ependymoma. Methods: We performed a retrospective cohort study of patients aged 65 years or older with spinal ependymoma using the National Cancer Database. The primary cohort was patients aged 75 years or older (very elderly); patients aged 65–74 years served as a comparison cohort. Multivariable Cox proportional-hazards models were fit within each cohort, and a surgery-by-age-cohort interaction was tested. Results: Of 1497 eligible patients aged 65 years or older with spinal ependymoma, 422 patients (28.2%) met criteria for the final analytic cohort. Intramedullary versus extramedullary tumor status was not available in the NCDB PUF and therefore could not be characterized. Very elderly patients were less likely to undergo surgery than the comparison cohort (70% vs. 85%; p < 0.001) despite similar tumor characteristics. Among very elderly patients, median overall survival was 59.7 months without surgery and 106.0 months with surgery, an approximately 46-month difference favoring surgery. Surgery was independently associated with lower mortality (HR 0.46; 95% CI, 0.24–0.89; p = 0.021). Increasing age (HR 1.15 per year; 95% CI, 1.07–1.22; p < 0.001), Charlson–Deyo score ≥ 2 (HR 4.41; 95% CI, 1.65–11.79; p = 0.003), and increasing tumor size (HR 1.02 per mm; 95% CI, 1.01–1.04; p < 0.001) were also independently associated with worse survival. In the 65–74 cohort, no significant association between surgery and overall survival was detected (HR 1.23; 95% CI, 0.54–2.81; p = 0.623), though statistical power was limited by only 7 deaths in the no-surgery arm. The surgery-by-age-cohort interaction was significant (HR 0.37; p = 0.043). Conclusions: Surgical resection was independently associated with improved overall survival in very elderly patients with spinal ependymoma despite lower utilization. Chronological age alone may be an imperfect basis for excluding older adults from surgical consideration.

Purpose: Mechanical thrombectomy (MT) has improved outcomes for acute ischemic stroke (AIS); however, patients with renal failure remain at elevated risk for adverse events. Sex-based differences in outcomes following thrombectomy have been reported in heterogeneous stroke populations, but data specific to renal failure patients are limited. Understanding whether sex influences in-hospital mortality and discharge disposition in this high-risk subgroup is clinically important.Materials and Methods: We conducted a retrospective cohort study using the 2019–2022 National Inpatient Sample to identify renal failure patients undergoing MT for AIS. Patients were stratified by sex. Multivariable logistic regression was used to assess associations between sex and in-hospital mortality and non-routine discharge, adjusting for demographic, socioeconomic, clinical, and hospital-level covariates.Results: The study included 3,280 unweighted hospitalizations (1,675 males; 1,605 females). After adjustment, female sex was independently associated with higher odds of non-routine discharge (adjusted odds ratio [OR] 1.536, 95% confidence interval [CI] 1.391–1.696; P<0.001) but not with in-hospital mortality (adjusted OR 0.953, 95% CI 0.874–1.038; P=0.266). Increasing age and select comorbidities were associated with both outcomes.Conclusion: Female sex was associated with increased odds of non-routine discharge but not in-hospital mortality among renal failure patients undergoing MT. These findings support equitable application of thrombectomy across sexes while highlighting the importance of sex-aware discharge planning in this high-risk population.