Anuraag Punukollu

Background: Trigeminal neuralgia (TN) is a debilitating craniofacial pain disorder commonly caused by neurovascular compression (NVC). Microscopic microvascular decompression (MI-MVD) remains the gold-standard surgical treatment; however, its linear field of view may limit visualization of offending vessels. Endoscopic microvascular decompression (EN-MVD) offers enhanced illumination and panoramic visualization, potentially improving decompression completeness and reducing complications. However, comparative data remains inconsistent. This study compares the efficacy and safety of EN-MVD versus MI-MVD through a systematic review and meta-analysis. Methods: Following PRISMA guidelines, PubMed, Embase, and Web of Science were searched for comparative studies. Outcomes included pain relief, recurrence, complications, operative time, and length of hospital stay. Pooled estimates were calculated using a random-effects model, with heterogeneity assessed using I ² -statistic. Results: Ten studies encompassing 1,051 patients (465 EN-MVD, 586 MI-MVD) were included. Adequate pain relief was comparable between approaches at all time points. However, complete long-term pain freedom favored EN-MVD (OR 2.72, p < 0.01). Recurrence was significantly lower with EN-MVD (OR 0.51, p = 0.02). Overall complications were reduced (OR 0.48, p < 0.001), particularly postoperative headache (OR 0.28, p < 0.001), whereas other complications were comparable. EN-MVD more frequently detected multiple offending vessels (OR 1.99, p = 0.035), with marginal differences in operative time (+ 6.4 min, p < 0.05) and decompression time (-2.8 min, p < 0.05). Conclusion: EN-MVD appears to provide pain relief comparable to that of MI-MVD, with studies suggesting possible advantages at long-term complete pain relief, recurrence, and postoperative headache. Studies being non-randomized, and with low certainty, these associations cannot establish superiority or a causal effect of the endoscopic approach. Therefore, these findings should be hypothesis-generating and require confirmation in prospective, standardized ideally randomized or well-adjusted multicenter studies with long-term follow up.

BACKGROUND AND OBJECTIVE: Transfemoral access (TFA) is the standard for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Transradial access (TRA) is a feasible alternative. Despite advances, no recent systematic review or meta-analysis exists, highlighting the need for updated evidence. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases were searched up to February 2024 for articles comparing TRA with TFA for MT in AIS. Studies were included if they reported at least one outcome, with at least 10 patients per group. Random-effects models were applied, with odds ratios (ORs) used for dichotomous outcomes and mean differences (MDs) for continuous outcomes. RESULTS: Our analysis included 763 TRA patients and 3527 TFA patients, with one randomized study and nine observational studies. We found no significant differences in successful recanalization (OR 0.88, 95% CI: 0.59-1.32), complete recanalization (OR 1.15, 95% CI: 0.92-1.43), first pass effect (OR 0.83, 95% CI: 0.68-1.01), puncture-to-recanalization time (MD −1.67, 95% CI: −7.48 to 4.13), access site complications (OR 0.70, 95% CI: 0.28-1.76), symptomatic intracranial hemorrhage (OR 0.93, 95% CI: 0.62-1.39), crossover (OR 1.71, 95% CI: 0.75-3.92), number of passes (MD 0.17, 95% CI: −0.08-0.41), length of hospitalization (MD −0.59, 95% CI: −1.28-0.09), and favorable outcomes at 3 months (OR 0.85, 95% CI: 0.58-1.23). Trial sequential analysis showed that successful recanalization, puncture-to-recanalization time, and first pass effect did not reach the required information size, indicating inconclusive results, whereas access complications analysis suggested a high probability of similarity between the two treatments. CONCLUSION: TRA is a viable alternative to TFA for MT in AIS, with comparable safety and efficacy. Although current evidence does not support widespread adoption, the introduction of radial-specific devices and advancements in operator training could improve outcomes. Further randomized trials with larger sample sizes are needed to clarify TRA's role and optimize neurointerventional practices compared with TFA.

Rathke’s cleft cysts (RCCs) are benign, cystic lesions that account for less than 5% of cases in the pediatric population. While asymptomatic RCCs often require only conservative management, symptomatic cases may necessitate surgical intervention. Advances in surgical techniques have improved the safety of these procedures. This comprehensive review and single-arm meta-analysis evaluates the outcomes of surgical management in pediatric patients. PubMed, Embase, and Web of Science were systematically searched for studies documenting RCC resection in pediatric patients (< 18 years). Outcomes of interest included symptomatic improvement (headache, visual impairment, endocrinopathy), postoperative complications, postoperative diabetes insipidus (DI), recurrence, and reoperation rate. Heterogeneity was assessed using I² statistics, and a random-effects model was adopted. Twelve studies were included in the final analysis. The pooled proportion of headache improvement was 84% (95% CI: 73%-91%), with 65% of patients achieving complete resolution. Improvement of visual symptoms occurred in 87% of cases (95% CI: 63%–96%). The rate of improvement of endocrinopathy after surgery had an overall pooled rate of 48% (95% CI: 29%-69%). The rate of postoperative complications was 8% (95% CI: 4%-13%), and the incidence of new postoperative DI was 28% (95% CI: 18%-40%). The pooled incidence of cyst recurrence was 16% (95% CI: 11%-23%), while the incidence of reoperation was 14% (95% CI: 8%-24%).Surgery for RCC in pediatric patients offers high rates of symptomatic improvement for headaches and visual impairments, though improvement for endocrinopathy tends to be moderate. The procedure generally has a low risk of postoperative complications, but the incidence of new-onset DI is notable. While many patients experienced complete headache resolution, surgery should not be solely indicated for headache management. Surgical decisions must prioritize objective clinical factors, such as cyst characteristics, neurological impact, and endocrine dysfunction. Additionally, recurrence and reoperation rates are observed, highlighting the need for careful consideration of potential risks and individualized treatment planning. Future research should focus on refining surgical techniques and assessing long-term outcomes to optimize treatment strategies for pediatric RCC patients.