Tammam Abboud

Background: Intraoperative monitoring of motor-evoked potentials (MEPs) during resection of supratentorial brain tumours under general anaesthesia is done either by transcranial electrical stimulation via scalp electrodes (TES) or by direct cortical stimulation via a strip electrode placed on the precentral gyrus (DCS), but evidence favouring one method over the other is lacking.Methods: TRANSEKT was a multicentre, randomised, double-blind, exploratory trial at six neurosurgical centres in Germany and Switzerland. Adults (18–80 years) with supratentorial tumours adjacent to the corticospinal tract and no or only mild preoperative paresis were randomly assigned to surgery under TES-MEP monitoring with a bihemispheric threshold ratio-based criterion or conventional DCS-MEP monitoring. The primary endpoint was deterioration of motor function by at least one Medical Research Council grade at discharge or 7 days after surgery, analysed as complete cases. This trial is registered with DRKS (DRKS00023256).Findings: Between Dec 3, 2020, and March 14, 2024, 137 patients were randomly assigned and 114 were analysed (54 DCS, 60 TES). Motor function deteriorated in 13 of 54 patients (24%) with DCS and 12 of 60 (20%) with TES (OR 0·77, 95% CI 0·30–1·94; p=0·576). TES met the prespecified non-inferiority criterion for negative predictive value (DCS 86% vs TES 93%; one-sided p=0·021); the positive predictive value did not differ (44% vs 29%; p=0·399). Residual tumour was detected in 33% versus 31% (p=0·789). Intraoperative seizures occurred in four (3%) of 137 patients, and nine (6·5%) died during follow-up.Interpretation: TRANSEKT provides the first randomised evidence comparing bihemispheric threshold ratio-based TES-MEP with conventional DCS-MEP during resection of motor-eloquent supratentorial tumours. Neither modality was superior for postoperative motor outcome, predictive performance, or extent of resection. The findings support individualised selection of TES or DCS according to surgical context, technical feasibility, and local expertise.

Background: Dysthyroid optic neuropathy (DON) is a vision-threatening complication of thyroid-associated ophthalmopathy that may require urgent surgical intervention. We describe a microsurgical two-wall orbital decompression technique designed to achieve effective orbital and optic nerve decompression in extremely severe cases as an additional option. Methods: A frontotemporal extradural approach is used to remove the lateral orbital wall and orbital roof, with optional decompression of the optic canal. Neuronavigation guides bone removal and helps avoid violation of the frontal sinus. The surgical technique, anatomical landmarks, and perioperative considerations are described in detail, and key steps are demonstrated in an accompanying video. Results: Twelve orbits in 7 patients (mean age 60 ± 5 years) underwent microsurgical two-wall orbital decompression for treatment of visual impairment due to DON. The technique allows controlled removal of the lateral orbital wall and orbital roof with excellent visualization of the orbit and optic canal. Adequate orbital volume expansion and optic nerve decompression can be achieved while preserving critical anatomical structures. The procedure is associated with low technical morbidity. Conclusion: Microsurgical two-wall orbital decompression appears to be a clinically applicable and feasible technique for the treatment of visual impairment due to DON. It may be considered in selected patients with severe or refractory disease and persistent visual impairment despite prior decompression.

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BACKGROUND AND OBJECTIVES: This retrospective single-center cohort study evaluated the role of early postoperative computed tomography (EPOCT) after pediatric intracranial tumor resection, a practice that remains controversial. Although EPOCT is frequently used to detect early postoperative complications, evidence supporting its routine use in neurologically stable children is limited, and concerns regarding radiation exposure persist. The aim of this study was to assess the clinical relevance of routine EPOCT after elective intracranial tumor surgery in children and adolescents and to identify clinical and perioperative predictors of abnormal imaging findings and emergency return to the operating room (RTOR). METHODS: We included 240 pediatric patients (0-18 years) who underwent elective intracranial tumor resection and received EPOCT within 4 hours postoperatively. Clinical, surgical, and radiological variables were analyzed for associations with abnormal EPOCT findings and RTOR. Multivariable logistic regression and receiver operating characteristic analyses were performed to assess predictive value. RESULTS: No emergency RTOR was triggered by EPOCT findings alone in neurologically stable patients. Abnormal EPOCT findings were identified in 17/240 patients (7.1%). Emergency RTOR occurred in 12/240 cases (5.0%) unrelated to residual tumor; all were associated with postoperative neurological deterioration. Postoperative neurological deficits showed the strongest association with abnormal EPOCT (odds ratio 15.33). Additional significant predictors included surgical duration, preoperative external ventricular drain placement, ventricular size, and perioperative red blood cell transfusion. Neurological examination demonstrated higher sensitivity (100%) and negative predictive value (100%) for predicting emergency RTOR than EPOCT. CONCLUSION: EPOCT after pediatric intracranial tumor resection provides limited therapeutic benefit in clinically stable patients. Postoperative imaging should be applied selectively, guided primarily by neurological deterioration and supported by specific perioperative risk factors. A selective, clinically driven imaging strategy may reduce unnecessary radiation exposure without compromising patient safety.

Pediatric traumatic brain injury (TBI) is a major cause of disability and long-term sequelae in children and adolescents worldwide. To facilitate understan