Background: The management of large (≥10 mm) and giant (≥25 mm) intracranial aneurysms remains clinically challenging due to their elevated rupture risk, morbidity, and procedural complications, which pose a dilemma for both intervention and conservative management. Flow diversion (FD) has emerged as a promising endovascular approach, although its comparative safety and efficacy versus Coiling remain unclear. Methods: Following PRISMA guidelines, studies published between January 2000 and March 2025 were identified across PubMed, EMBASE, Scopus, and Web of Science. Outcomes assessed included aneurysm recurrence, complete occlusion, favorable clinical outcomes, procedure-related complications and mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and heterogeneity and publication bias were assessed. Results: A total of 1893 patients (1256 FD, 637 Coiling) and 1915 aneurysms across 33 studies were included. FD significantly reduced recurrence compared to Coiling (8% vs. 27%; p = 0.0001) and showed a trend toward a higher rate of complete occlusion (p = 0.0571). However, FD had a modestly increased rate of hemorrhagic complications (p = 0.0495). No other significant differences were found in clinical outcomes, major complications, ischemic events, delayed rupture, or mortality. Conclusions: Both FD and Coiling are effective and generally safe for large and giant intracranial aneurysms. FD is associated with lower recurrence and a trend toward a higher rate of complete occlusion, with similar overall safety but slightly higher hemorrhagic risk. FD is emerging as a preferred first-line option for large and giant unruptured aneurysms, while coiling remains important for ruptured aneurysms or when anatomical constraints limit the use of FD.

Purpose: To describe the inter-sternohyoid median (ISM) anterior cervical spine approach and report anatomical validation and early clinical outcomes with a matched historical comparator. Methods: We performed anatomical and radiological studies to define the novel ISM surgical corridor. Subsequently, we retrospectively reviewed 25 cases operated with the ISM approach for cervical spine surgery. A matched historical cohort of 75 patients treated with standard anterolateral approaches was included (1:3 matching by sex, age ± 3 years, and number of operated levels). Outcomes included operative time, postoperative length of stay, Numeric Pain Rating Scale (NPRS), modified Rankin Scale (mRS), 1-month dysphagia (Dysphagia Outcome and Severity Scale [DOSS] ≤ 6), complication rate, and recurrence. Results: Anatomical and radiological assessment confirmed that the ISM corridor can provide access to selected subaxial levels. In the preliminary clinical application, corridor creation required 7–10 min. No complications were registered in either group at 30-day follow-up. Dysphagia at 1 month showed an absolute risk difference of − 8.0% (95% CI − 14.7 to − 2.7), a hypothesis-generating finding in this exploratory matched historical comparison. Matched-set mean differences (ISM-controls) were small for operative time (− 0.29 min), length of stay (− 0.76 days), NPRS at 1 month (− 0.47 points), and mRS at 1 month (− 0.14 points). Conclusion: In selected patients, the ISM approach provides a short, medial, relatively orthogonal corridor to the subaxial cervical spine with feasible exposure and encouraging preliminary feasibility findings. The present exploratory analysis does not establish clinical superiority; prospective studies with larger comparative cohorts, objective anatomical measurements, and longer follow-up are warranted.

Across surgical disciplines, second victim reactions emerge as a common and predictable occupational hazard rather than a rare exception, particularly in high-risk specialties such as neurosurgery. These reactions often overlap with professional grief after a patient death or catastrophic complications. Trainees and early-career surgeons, individuals with perfectionistic traits or preexisting burnout, and surgeons working in punitive or unsupportive institutional cultures appear particularly vulnerable. Triggers include unexpected intraoperative deaths, perceived preventable complications, adverse outcomes in young or pediatric patients, and events entangled with medicolegal conflict. Coping strategies range from adaptive approaches, such as structured reflection, learning-focused case review, and seeking peer support, to maladaptive patterns, including emotional withdrawal, avoidance of high-risk cases, defensive medicine, and thoughts of leaving surgical practice. Surgery-specific peer-support programs and debriefing models have been developed and are generally well received, although rigorous outcome data remain limited. Emerging literature in neurosurgery and neurointervention suggests that the second victim phenomenon is especially salient where small technical decisions may determine irreversible neurological harm. Neurosurgeons report a substantial emotional burden, features consistent with posttraumatic stress after catastrophic complications, and high levels of moral distress and moral injury around end-of-life decisions and perceived unbeneficial treatment. The purpose of this narrative review is to examine the second victim phenomenon in surgery and its relevance for neurosurgical practice, with an emphasis on recognizing that such experiences are intrinsic to the work and that integrating education, structured debriefing, peer-support processes, and a supportive institutional culture are critical to sustaining humane, high-quality care across a career.