Background/Objectives: Surgical clipping remains a fundamental treatment modality for intracranial aneurysms, particularly in complex cases and those not amenable to endovascular approaches. However, it is associated with several technical challenges and potential complications that may compromise patient outcomes. This study aims to identify and analyze the most frequent and critical intraoperative pitfalls encountered during microsurgical clipping. We discuss experience-based strategies for avoiding these complications as well as practical solutions for managing them effectively when they occur. Methods: A retrospective review of our institutional experience with surgically treated intracranial aneurysms is reported. The study includes a comprehensive analysis of complications encountered across a defined series of cases, along with representative clinical cases. Results: Several categories of complications were identified, including aneurysm rupture, incomplete clipping and aneurysm remnant, vessel stenosis and brain ischemia, and new-onset seizures. Specific microsurgical techniques, intraoperative tools (e.g., indocyanine-green angiography, neurophysiological monitoring, micro-Doppler flowmetry evaluation), and decision-making algorithms are discussed to help mitigate these risks. For each scenario, tailored rescue strategies are outlined based on both the literature evidence and our clinical experience. Conclusions: Awareness of the potential pitfalls in aneurysm clipping and a structured approach to their prevention and management are crucial for optimizing surgical outcomes, and for preparing young vascular neurosurgeons. Through a combination of technical refinement and scenario-based preparedness, many complications can be anticipated and effectively addressed.

Background: The treatment of unruptured cerebral aneurysms has evolved through new surgical and endovascular approaches. Its goal is to ensure the patient survival with a good quality of life, so cognitive outcome should be considered a critical factor in the decision-making analysis. This study aimed to investigate the impact of unruptured cerebral aneurysm treatment on cognitive function. Method: This prospective study enrolled 109 patients with unruptured cerebral aneurysms, 65 treated with microsurgery and 44 with endovascular procedures. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) test, anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), and quality of life by the SF-36 questionnaire. Potential risk factors influencing the neuropsychological assessment were recorded. Patients were evaluated before treatment, at discharge and at 6-months, 1-year and 2-years post treatment. Results: Before treatment, 24 patients exhibited a cognitive impairment on the MoCA test. These 24 cases were significantly older and had higher incidence of anxiety or depression under treatment. At 6 months two patients with preoperatively normal cognitive function developed a new deficit: they presented transient post-surgical complications and investigated risk factors. These two patients recovered completely at 12 months. Among those with baseline impairment 10 patients recovered at 6 months and 4 more at 12 months. At 24 months, 99 patients presented with normal MoCA scores and 10 patients showed persistent preoperative deficit. Conclusions: Neither minimally invasive microsurgery nor endovascular treatment was associated with a decline in global cognitive function within two years of follow-up. Anxiety and depression symptoms tended to improve post treatment, while quality-of-life scores remained stable. Transient postoperative complications did not influence long term cognitive outcomes. These findings highlight the importance of recognizing patient and aneurysm related risk factors that may predispose to cognitive decline. Individualized planning and pre-treatment neuropsychological assessment are therefore essential.

Background/Objectives: to compare and characterize the frequency and severity of treatment-related adverse events (TRAEs) experienced by pediatric and adult patients with medulloblastoma receiving the same pediatric-based treatments. Methods: a retrospective comparative study of TRAEs was conducted on 18 adult patients and 45 pediatric patients with medulloblastoma treated at the same institution with craniospinal/local radiotherapy and chemotherapy delivered according to pediatric regimens (i.e., PNET3, PNET4, PNET5 or high-risk protocols). Results: Grade ≥ 3 hematological TRAEs were significantly more frequent in adults (61.1% vs. 33.3%, p = 0.038). Adults also more frequently suffered from weight loss > 10% than children (72.2% vs. 40%, p = 0.018). The incidence of chemotherapy-induced peripheral neuropathy did not differ significantly between the two groups (27.7% in adults versus 22.2% in children, p = 0.65). These findings suggest that adult patients treated with pediatric-derived protocols may benefit from more proactive hematologic and nutritional supportive care to safely maintain treatment intensity. Objective severe ototoxicity was 22.2% and 17.8% in adults and children (p = 0.69), respectively. There were significantly more adults than children who needed a dose reduction (55.6% vs. 28.9% in children, p = 0.042) and who stopped treatment prematurely (44.4% vs. 20.1% in children, p = 0.048). There was no difference in 5-year overall survival between adults and the pediatric population (88.8% vs. 86.7%, p = 0.82). Conclusions: Adults are at an increased risk of hematological and nutritional toxicities when treated for medulloblastoma with identical treatment regimens. These age-related patterns of sensitivity demand protocol modifications (such as more supportive care, nutritional support, and possibly lower dose intensities). Although there were more treatment modifications due to more severe toxicity, adults had the same survival rates as children, suggesting pediatric-based protocols should still be employed with modifications to supportive care.

Objectives: Our objective was to systematically evaluate the role of intraoperative neurophysiological monitoring (IONM) in supratentorial meningioma surgery, focusing on intraoperative changes, surgical decision-making, and postoperative neurological outcomes. Methods: A PRISMA-guided systematic review was conducted across PubMed, Scopus, and Cochrane databases. Nine studies, including 576 supratentorial meningioma (STM) cases identified across the source cohorts, were analyzed. Data extraction included study design, tumor location, monitoring modalities, intraoperative neurophysiological changes, and postoperative outcomes. Risk of bias was assessed using ROBINS-I, the JBI Critical Appraisal Checklist, or QUADAS-2, according to study design. Results: IONM modalities varied widely and included motor and somatosensory evoked potentials, cortical stimulation, and electromyography. Substantial heterogeneity was observed. Postoperative deficits occurred in both monitored and unmonitored patients (5.2–66%), including cases with preserved intraoperative signals, suggesting false negatives. IONM influenced intraoperative decision-making in selected cases, particularly for tumors near motor areas. However, its impact on postoperative outcomes remains unclear. Conclusions: Intraoperative motor cortex identification was the most consistently reported finding with a surgical impact. Available data from the literature are inconclusive about the role of IONM in reducing postoperative neurological morbidity.

A 64-year-old patient presented with signs and symptoms of intracranial hypertension. Imaging studies revealed superior sagittal sinus thrombosis, chronic left transverse sinus (TS) thrombosis and a Cognard type IIA + B dural arteriovenous fistula (dAVF) of the left TS.^1-5 Endovascular treatment was performed through arterial (ascending pharyngeal artery) and venous injection (left TS catheterization via right jugular puncture), enabling selective transvenous closure of the fistulous point with coils and Squid liquid embolic agent. At 6-month follow-up, angiography demonstrated the development of a new Cognard type I dAVF with fistulous points at the torcular Herophili, likely due to angiogenic remodeling induced by the persistence of the TS stenosis. Given the absence of cortical venous reflux and the patient's asymptomatic status, conservative management was chosen. Subsequent angiography 6 months later showed disease progression to a Cognard type IIB, along with complete occlusion of the right TS. The torcula was still opacified by the fistula, but no longer contributed to cerebral venous drainage, which had predominantly shifted anteriorly via the lateral mesencephalic vein toward the cavernous sinus and pterygoid plexuses, and through emissary and diploic veins. Endovascular treatment via the right transjugular vein was unsuccessful due to occlusive stenosis of the distal right TS. The patient underwent microsurgical exclusion of the dAVF. The torcular was disconnected from the straight sinus using a titanium clip, and a deep arterial feeder was coagulated (Video 1). Postoperatively, the patient developed a cerebrospinal fluid leak, which resolved after ventriculoperitoneal shunt placement. This case underscores the importance of multimodal treatment options in managing complex dAVFs.