Angelo Franzini

Background: Postoperative epileptic seizures are a recognized complication after superficial temporal artery–middle cerebral artery (STA–MCA) bypass for Moyamoya angiopathy (MMA), but their determinants remain incompletely understood. We aimed to identify clinical, radiological, and perioperative factors associated with early postoperative seizures following adult STA–MCA bypass. Methods: We retrospectively analyzed 75 hemispheric revascularization procedures performed in adult MMA patients between 2005 and 2023, with each operated hemisphere treated as an independent analytical unit. The primary outcome was the occurrence of at least one in-hospital postoperative seizure; the primary exposure was cerebral hyperperfusion syndrome. Univariate and multivariable Firth penalized-likelihood logistic regression was used to account for the small sample size and rare outcome. Results: Postoperative seizures occurred in 14 of 75 procedures (18.7%). Hyperperfusion was identified in 6 procedures (8.0%) and showed the strongest univariate association with seizures (OR 10.20), followed by diabetes mellitus (OR 6.05). Right-hemispheric procedures showed a protective effect in the univariate analysis (OR 0.24). In separate multivariate adjusted models, hyperperfusion (OR 10.28) and diabetes mellitus (OR 5.70) remained associated with postoperative seizures (OR 10.28 and OR 5.70, respectively). Pre-existing epilepsy, antiepileptic treatment, and preoperative EEG abnormalities were not associated with seizure risk. Conclusions: Early postoperative seizures after direct STA–MCA bypass in adult MMA were most consistently associated with postoperative cerebral hyperperfusion in our cohort, while pre-existing epilepsy and preoperative EEG abnormalities showed no statistically significant associations. Early recognition of hyperperfusion may support risk-stratified postoperative surveillance and individualized management.

1. While several pharmacological and noninvasive treatment options are available for patients with chronic craniofacial pain disorders, a subset of patients remains refractory to current optimal co...

BACKGROUND: Vagal-glossopharyngeal neuralgia (VGPN) represents a rare and often misdiagnosed condition. Compared to the more common trigeminal neuralgia, its clinical picture is more heterogeneous due to the multiple functions exerted by the rootlets involved; indeed, presentation may include dysphagia, dysphonia, syncope, bradycardia, and paroxysmal cough alongside the typical, sharp, unilateral pain. Neurovascular conflict at the root entry zone of the lower cranial nerves (CNs) is often considered the underlying cause. OBSERVATIONS: The authors present the case of a 50-year-old female with a 3-year history of recurrent dysphagia-associated pain on the right side of the throat and tongue as well as episodic wheezing and progressive dysphonia. MRI revealed a high-riding posterior inferior cerebellar artery (PICA), causing distortion of the lower CNs. Microvascular decompression was performed through a retrosigmoid approach. Intraoperative findings confirmed the anomalous course of the PICA between CNs IX and X. LESSONS: At 6 months, the patient reported resolution of all symptoms. This case is presented along with a 2D operative video illustrating the surgical technique, followed by a comprehensive literature review discussing the diagnosis, treatment, and outcomes of VGPN. https://thejns.org/doi/10.3171/CASE25726

Introduction: Gamma knife radiosurgery (GKRS) is an established effective treatment for medically intractable trigeminal neuralgia (TN), but outcome predictors remain controversial. Notably, the influence of neurovascular conflict (NVC) evident on magnetic resonance imaging on the outcomes of radiosurgery is debated. This study aimed to evaluate whether an NVC with the trigeminal nerve in the posterior fossa influences pain and sensory outcomes after primary GKRS for TN. Methods: A retrospective review of our GKRS database identified 148 patients who underwent GKRS as the initial treatment for medically intractable TN between 2014 and 2024. The retrogasserian part of the trigeminal nerve was targeted. Background medical history, treatment outcomes and complications, and dosimetric data were collected through chart review. NVC was graded based on high-resolution magnetic resonance images obtained prior to treatment, according to a 4-tier severity scale. Results: After GKRS, 132 (89%) patients achieved Barrow Neurological Institute (BNI) grade IIIb or better pain relief. At a median follow-up of 39 months, pain recurred in 27 (20%) patients, and 47 (32%) developed facial sensory disturbances, which were bothersome in 18 (12%). Estimated rates of pain relief at 1, 3, 5, and 7 years were 77%, 72%, 68%, and 64%, respectively. The median maximum dose was 85 Gy. The presence and severity of NVC did not predict pain or sensory outcomes after GKRS, whereas facial sensory disturbances were associated with long-term pain relief. Conclusion: GKRS is an effective treatment for medically intractable TN but may lead to facial sensory disturbances. The presence or severity of NVC with the trigeminal nerve in the posterior fossa did not influence the outcomes of primary GKRS.

Introduction: Tumor-related trigeminal neuralgia (TN) is a challenging condition to manage that can be treated with gamma knife radiosurgery (GKRS) by targeting the tumor, the trigeminal nerve, or both. However, data regarding the efficacy of this treatment are somewhat limited. The aim of this study was to report outcomes of GKRS for tumor-related TN from a cohort study. Methods: Retrospective review of our GKRS database identified 41 patients with benign tumor-related TN treated with GKRS between 2014 and 2024. Background medical history, treatment outcomes and complications, and dosimetric data were obtained by chart review. Results: The tumor, the trigeminal nerve alone, or a combination of both was targeted in 28, 7, and 6 patients, for a total of 47 GKRS procedures. Eight (24%) patients had pain control before GKRS targeting the tumor. Thirty (88%) and 11 (85%) patients had pain control after GKRS targeting the tumor and the trigeminal nerve, respectively. After a median follow-up of 63 months, pain recurred in 8 (24%) and 3 (23%) patients in the two groups. After tumor- and nerve-targeted GKRS, estimated rates of pain control at 1, 4, 7, and 10 years were 82%, 69%, 56%, and 56%, and 77%, 67%, 50%, and 50%, respectively. When GKRS targeting the tumor and the trigeminal nerve was considered as part of the same treatment, estimated rates of pain control at 1, 4, 7, and 10 years were 83%, 75%, 71%, and 71%. After tumor- and nerve-targeted GKRS, respectively, 5 (15%) and 3 (23%) patients developed persistent non-bothersome facial hypesthesia. Conclusions: GKRS targeting the tumor is an effective, well-tolerated treatment for patients with tumor-related TN. More durable relief is achieved in some patients with second-stage GKRS targeting the trigeminal nerve but with additional facial sensory disturbances.

Introduction: The treatment of patients with glossopharyngeal neuralgia (GN) refractory to medical therapies is challenging. Gamma knife radiosurgery (GKRS) has emerged as an incisionless treatment option with outcomes reported in a limited number of studies. The aim of this study was to report on the outcomes of GKRS in patients with GN treated at our center. Methods: We retrospectively reviewed all patients with GN who underwent GKRS at our center since 2017. Pain intensity was evaluated using the Barrow Neurological Institute (BNI) pain score modified for GN. Adverse events were recorded. Results: Six patients underwent GKRS for GN at our center between 2017 and 2024. The maximum dose delivered was 85 Gy for 1 patient and 90 Gy for the others. After a median period of 2 weeks from GKRS, all patients experienced pain reduction (BNI I-IIIa). Pain recurred during follow-up in 2 patients after 9 and 3 months, respectively. Both underwent repeat GKRS, which relieved pain in one. No adverse event or neurological deficit occurred. Conclusions: GKRS is an effective, well-tolerated treatment for patients with GN. Pain may recur over time, but more durable pain relief can be achieved with repeat GKRS.

Purpose Gamma Knife radiosurgery (GKRS) has emerged as an effective treatment option for trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). To date, the outcomes of repeat GKRS for patients with TN and MS with recurrent pain have been investigated in a few patients. This study aims to report the outcomes and predictive factors of pain reduction for MS patients undergoing repeat GKRS for recurrent TN. Methods Eighteen patients with MS underwent repeat GKRS for recurrent TN. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, and outcomes of the procedure. Facial pain and sensory function were evaluated using the Barrow Neurological Institute (BNI) scales. Results Fifteen patients achieved a BNI pain score of IIIa or better, indicating pain reduction, within a median period of 21 days after repeat GKRS. The maximum dose for repeat GKRS ranged from 70 to 85 Gy. Pain recurred in 5 patients after a median period of 12 months after GKRS. Percentages of patients with pain reduction at 1, 2, 3, 5, and 7 years were 60%, 60%, 50%, 50%, and 50%, respectively. Older age at repeat GKRS predicted sustained pain reduction (P = 0.01). Seven patients developed facial sensory disturbances, which were bothersome in two patients. Conclusions Repeat GKRS may be used as an effective treatment modality for prolonging the duration of pain reduction time in patients with MS and TN. After repeat GKRS, facial sensory disturbances are common; however, they are often not bothersome.

Background Rosette-forming glioneuronal tumor (RGNT) is a rare slow-growing neoplasm with mixed glial and neurocytic components. Surgical resection is the mainstay of treatment, whereas the role of adjuvant radiation therapies for residual or recurrent tumors has been poorly investigated. Case Presentation We describe the case of a patient with a recurrent fourth ventricular RGNT who was treated with two-staged Gamma Knife radiosurgery (GKRS). GKRS was effective in controlling tumor growth and safe up to seven years from treatment. Conclusions This case suggests that GKRS may be a safe and effective treatment for patients with recurrent or residual RGNT.

Background: The treatment of medically refractory patients with chronic short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is challenging. Stereotactic radiosurgery targeting the trigeminal nerve and sphenopalatine ganglion (SPG) has been used as a less-invasive treatment. The outcomes of this procedure have been described in a few case reports. Objectives: The objective of the study was to report on the effect of Gamma Knife radiosurgery (GKRS) in 5 patients with chronic SUNCT. Methods: Retrospective review of our GKRS database identified 5 patients with chronic SUNCT who underwent GKRS targeted to the trigeminal nerve and SPG. A maximum dose of 80–85 Gy and 80 Gy was, respectively, delivered to the trigeminal nerve and SPG. Pain intensity and facial numbness were evaluated using the Barrow Neurological Institute (BNI) scores. Results: These 5 patients were clinically followed for a mean period of 26.2 months. Within a period ranging from 2 days to 9 months, GKRS was successful in reducing pain attacks and autonomic symptoms in all 5 patients. At the last assessments, BNI pain scores of I, II, and IIIa were achieved in 1, 1, and 3 patients, respectively. Two patients developed nonbothersome facial numbness (BNI facial numbness score II). Conclusions: These 5 cases show that GKRS targeted to both the trigeminal nerve and the SPG is effective in reducing pain and autonomic symptoms of patients with SUNCT, although nonbothersome trigeminal sensory disturbances may occur.