Background: Brain metastases are a major driver of cancer-associated morbidity and mortality, occurring in 20–40% of all malignancies. Objective: Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), or observation after resection of 1–4 brain metastases. Methods: PRISMA-compliant search of Embase and MEDLINE from inception to August 2024. Overall survival (OS), cognitive decline (CD), surgical bed control (SBC), and intracranial control (IC) were assessed by pooling hazard ratios (HR) or 12-month post-SRS odds ratios (OR) via meta-analysis of proportions with random-effects modeling. Results: Of 1319 unique, English-language abstracts, 37 underwent full-text review, and 7 were included, representing 812 patients in three paired comparisons: WBRT vs. observation (4 RCTs, n = 545), WBRT vs. SRS (2 RCTs, n = 253), and SRS vs. observation (1 RCT, n = 132). Pooled HR were not significant for OS (WBRT vs. observation, HR = 1.01, 95% CI = 0.87–1.18; WBRT vs. SRS, 0.77, 95% CI = 0.47–1.26) or CD (WBRT vs. observation, HR = 0.98, 95% CI = 0.81–1.17; WBRT vs. SRS, 1.31, 95% CI = 0.48–3.60). Pooled OR favored WBRT over both observation and SRS with respect to SBC (SBC: WBRT vs. observation, OR = 1.35, 95% CI = 1.05–1.74; WBRT vs. SRS, OR = 1.46,95% CI = 1.00–2.13) and IC (IC: WBRT vs. observation, OR = 1.22, 95% CI = 1.06–1.40; WBRT vs. SRS, OR = 1.22, 95% CI = 1.03–1.59). GRADE assessment demonstrated very low to moderate certainty for all reported outcomes. Conclusions: Even among RCTs, the best available evidence regarding adjuvant treatment for oligometastatic brain disease is heterogeneous, imprecise, and inconclusive. WBRT improves SBC and IC, but not OS. SRS may decrease CD risk, which requires validation in double-blind RCTs incorporating precise neurocognitive metrics.

Purpose Flow diversion has emerged as a key strategy in the treatment of intracranial aneurysms. However, its safety and efficacy in distal middle cerebral artery (MCA) aneurysms remain inadequately characterized. This study aims to update and synthesize the current literature by evaluating occlusion rates, procedural complications, and clinical outcomes associated with flow diversion in this subset.Methods A systematic review and meta-analysis were conducted according to the PRISMA guidelines. Relevant studies published through 2025 were identified through searches of major databases using predefined criteria. A random-effects proportional meta-analysis using R (version 4.4.2) was performed to assess pooled occlusion and complication rates. Heterogeneity was evaluated via I² statistics, and publication bias was assessed via funnel plots.Results Ten studies comprising 128 distal MCA aneurysms treated with flow diverter stents were included. The pooled complete occlusion rate was 87% (101/120; 95% CI: 80–93%), with no observed heterogeneity (I² = 0.0%, p = 0.7997). A sensitivity analysis excluding two large studies revealed an occlusion rate of 81% (48/61; 95% CI: 71–91%), with low heterogeneity. The overall complication rate was 14% (21/128; 95% CI: 8–21%), with the most frequent complications being thromboembolic events, in-stent stenosis, and hemorrhagic complications. Funnel plots did not reveal evidence of publication bias.Conclusion Flow diversion appears to be a promising treatment option for distal MCA aneurysms, offering high rates of complete occlusion with an acceptable complication profile. However, the data remain limited and heterogeneous. Larger prospective studies with standardized outcome reporting are needed to establish its definitive role in this challenging vascular territory.

The field of neurosurgery in the Caribbean has long been shaped by systemic limitations in infrastructure, training opportunities, and gender representation. Despite these challenges, a small group of pioneering women have broken through traditional barriers to become leaders in Caribbean neurosurgery. This narrative review highlights the contributions and career trajectories of female neurosurgeons across the region, offering historical and contemporary perspectives on their clinical, academic, and leadership roles. Through a combination of literature review and direct outreach, we document the stories of the first female neurosurgeons in Curaçao, Trinidad and Tobago, Jamaica, Guyana, Saint Lucia, the Dominican Republic, Cuba, and Puerto Rico. Their achievements span advanced surgical innovations, including the introduction of percutaneous transforaminal endoscopic discectomy in the Caribbean, establishment of local neurosurgical departments, and leadership in academic and global neurosurgery initiatives. The article also examines persistent disparities in neurosurgical training and representation, particularly among women and underrepresented minorities. These stories underscore the critical importance of resilience, mentorship, and advocacy in driving progress in a traditionally male-dominated field. By documenting these contributions, we aim to amplify the visibility of Caribbean female neurosurgeons and inspire further efforts to promote equity and diversity in neurosurgery, both regionally and globally.