An Assessment of Exposure and Maneuverability to the Upper Parapharyngeal Space Through the Multiport Endoscopic Endonasal Transpterygoid and Anterior Transmaxillary Techniques Leonardo Tariciotti, Alejandra Rodas, Youssef M. Zohdy, J. Manuel Revuelta Barbero, Erion Jr De Andrade, Jackson Vuncannon, Roberto Soriano, Edoardo Porto, Garzon‐Muvdi Tomas, Camilo Reyes, C. Arturo Solares, Gustavo Pradilla Head and Neck, 2026 Background Treating tumors that extend into the upper parapharyngeal space (UPPS) is challenging, given the region's anatomical complexity and its proximity to the parapharyngeal carotid artery (ppICA) and the middle cranial fossa. Endoscopic techniques offer optimal surgical outcomes while also reducing morbidity related to open approaches. Methods Exposure and maneuverability were evaluated toward the UPPS using a multiportal endoscopic technique combining the anterior transmaxillary (TMA) and endonasal transpterygoid approaches. Bilateral stepwise dissections were performed in four specimens. Measurements of linear trajectories, angles of exposure, and surgical corridor volumes were obtained. Results The TMA provided superior maneuverability around the uppermost ppICA portion within the UPPS, while the endonasal corridors offered a more direct trajectory to its lowest segment. Conclusion Combining the TMA and endonasal transpterygoid approaches enhances surgical control over critical neurovascular structures within the UPPS by addressing the limitations of each technique used independently.
The visuo-operative angle: computational 3D assessment of surgical trajectories toward irregular target areas in skull base corridors Leonardo Tariciotti, Alejandra Rodas, Youssef M. Zohdy, Juan M. Revuelta Barbero, Erion Junior De Andrade, Biren Patel, Edoardo Porto, Justin Maldonado, Jackson R. Vuncannon, Roberto Soriano, Camilo Reyes, Tomas Garzon-Muvdi, C. Arturo Solares, Gustavo Pradilla Journal of Neurosurgery, 2026 OBJECTIVE The aim of this study was to introduce the visuo-operative angle (VOA) as a novel neuroanatomical metric for quantifying surgical exposure and visibility in skull base microsurgery. The VOA measures the alignment between surgical trajectories and target exposure areas in 3D space. Additionally, the authors explored its implementation in 3D photogrammetry of cadaveric models and 3D-segmented presurgical imaging models to assess the feasibility of VOA in experimental and clinical settings. METHODS Five latex-injected human cadaveric specimens were used to evaluate various endoscopic and microscopic approaches. The VOA was calculated as the angle formed by the surgical trajectory line and the plane of the target exposure area. Photogrammetry was used to generate high-resolution 3D models of the dissected regions and replicate the measurement virtually. Finally, a clinical exploratory trial was conducted in a patient undergoing an endoscopic endonasal approach for a pituitary neuroendocrine tumor (PitNET) with clival erosion. Three-dimensional–rendered preoperative imaging was used to define and measure the target clival region and its VOA, and intraoperative neuronavigation validated the measurement. RESULTS VOA showed excellent interrater agreement across 36 target areas (bias ≤ 1°, within-subject coefficient of variation 1%–6%). Endoscopic and microscopic findings were consistent with prior literature using different exposure metrics and expert opinion while adding surgically relevant detail on trajectory visibility and instrument direction toward deep targets (e.g., an endoscopic transorbital approach [ETOA] vs a transmaxillary approach to Meckel’s cave and the anterolateral triangle; subtemporal vs translabyrinthine/retrosigmoid approaches to the internal acoustic canal; frontotemporal-orbitozygomatic approach vs ETOA at the clinoid triangle). Photogrammetry yielded measurements highly concordant with cadaveric data. Presurgical estimates (VOA approximately 52.7°) aligned with intraoperative values (53.5°), supporting the feasibility of the VOA as an analytical tool for approach analysis and modeling. CONCLUSIONS The VOA is a simple, reproducible geometrical metric (in degrees) that relates the surgeon’s line of sight and instrument path to the target plane, adding directional detail not captured by conventional metrics. Integrated with photogrammetry and 3D-segmented imaging, the VOA enables the quantitative comparison of corridors and approach variants, as well as supporting regional anatomy modeling. Early results are promising, but larger cadaveric series and multicase clinical studies are needed to establish the accuracy, robustness, and applicability of this metric across anatomical research, surgical planning, and intraoperative calculations.
Comprehensive Comparison of Visual Outcomes in Macro and Giant Prolactinoma Cohorts Managed With Medical Versus Surgical Treatment Justin Maldonado, Biren Patel, Tianwen Ma, Youssef M. Zohdy, Leonardo Tariciotti, Travis Atchley, Erion de Andrade, Hithardhi Duggireddy, Karen Salmeron Moreno, Asmita Indurkar, Khaled Altaroor, Samir Lohana, Michael Dattilo, Nyrene Ahmed Haque, Adrianna Ioachimescu, Gustavo Pradilla, Tomas Garzon-Muvdi Neurosurgery, 2026 BACKGROUND AND OBJECTIVES: Macro (>1 cm) and giant prolactinomas (>4 cm) are large prolactin-secreting tumors associated with chiasmal compression and vision loss. Although most patients are treated medically, select cases with severe acute vision loss may be considered for urgent surgical treatment. The purpose of this study was to determine whether first-line dopamine agonist therapy or surgery offered superior visual outcomes for patients with macro and giant prolactinomas using retinal nerve fiber layer (RNFL) thickness and logarithm of minimum angle of resolution (logMAR) visual acuity (VA). METHODS: A retrospective review was performed on all patients at our institution who received first-line medical or surgical treatment for macro or giant prolactinomas between 2000 and 2022. Recurrent cases and those without a baseline neuro-ophthalmological examination were excluded. Vision status, RNFL thickness, and logMAR VA were collected at baseline and at 3 months. Linear mixed models were generated to investigate the interaction between initial treatment modality and change in RNFL thickness and logMAR over time. Pearson correlation and Wilcoxon rank sum tests were performed when appropriate. RESULTS: Forty-two patients were included, of whom 29 (69.0%) received first-line medical therapy and 13 (31%) received first-line surgery. Nineteen (65.5%) medical and 10 (76.9%) surgical patients had chiasmal compression at baseline. Change in RNFL thickness over time was independent of treatment modality (P = .990). Treatment modality did not influence change in logMAR VA over time (P = .891). When incorporating chiasmal compression into the linear mixed model, change in RNFL thickness and logMAR VA over time remained independent of treatment. CONCLUSION: In this patient cohort, available data showed that visual outcomes did not differ significantly by treatment modality. Further studies with larger sample sizes may be able to elucidate additional insights but treatment selection must continue to reflect individual patient characteristics at presentation.
Optimal MGMT promoter methylation cut-off to predict better survival in glioblastoma patients undergoing gross-total resection Claudia FANIZZI, Petra BINTINTAN-SOCACIU, Elena PIROLA, Giorgio FIORE, Ilaria CARNICELLI, Leonardo TARICIOTTI, Andrea PARLANGELI, Elena SCAGLIOTTI, Silvia M. TABANO, Gianluca LOPEZ, Stefano FERRERO, Stefania NAVONE, Laura GUARNACCIA, Giovanni MARFIA, Manuela CAROLI, Marco LOCATELLI Journal of Neurosurgical Sciences, 2026 BACKGROUND: O6-Methylguanine-DNA methyltransferase (MGMT) promoter percentage of methylation in gliomas has been proved to be the most important predictive factor in temozolomide (TMZ) response. Nevertheless, an agreement about the cut-off to discriminate between a "methylated" and "unmethylated" status has not been reached yet. Many reports have analyzed the correlation between methylated status cut-off and survival, but they lacked sample homogeneity. Our aim was to calculate a clinical significant cut-off considering a homogenous group of patients. METHODS: We retrospectively analyzed 96 patients who underwent a complete removal of glioblastoma in our Institution. All the patients underwent to radiation therapy plus concomitant TMZ and twelve cycles of adjuvant TMZ as described by Stupp. Receiver operating characteristic (ROC) curve analysis was performed and 21% was determined as the optimal cut-off. RESULTS: The median OS was significantly higher in methylated patients compared to unmethylated ones (median 48 months vs. 22 months respectively 95% CI 30-42 vs. 15-19, P<0.001). No difference was observed for PFS. The multivariate analysis with Cox regression model identified MGMT methylation status as an independent predictive factor for OS (P<0.001). CONCLUSIONS: We confirmed the prognostic role of MGMT methylation status even in a highly selective group of patients with the best outcome. We calculated a cut-off of 21% to be highly predictable of survival.
Integrative transcriptomics and network analysis reveals core genes driving meningioma pathogenesis and clinical outcomes Youssef M Zohdy, Ali M Alawieh, Arman Jahangiri, Benjamin Siciliano, Leonardo Tariciotti, Alejandra Rodas, Justin Maldonado, Kimberly Hoang, Edjah Nduom, Brian M Howard, Daniel L Barrow, Aliaksandr Aksionau, Stewart G Neill, Zhexing Wen, Gustavo Pradilla, Tomas Garzon-Muvdi Scientific Reports, 2025 Meningiomas are the most common primary CNS tumors, often managed conservatively due to their benign histology. Molecular phenotyping is considered the current frontier in meningioma classification to predict progression and guide clinical management of adjuvant therapies. While several biomarkers have been studied, a definitive molecular prognostic panel has yet to be established-a gap this study seeks to address. Using patient-resected meningioma tumor tissues paired with normal meninges, transcriptomic analysis identified a subset of significantly differentially-expressed-genes(DEG) linked to cellular proliferation and immune suppression in the tumor microenvironment. Graph-theory analysis revealed a rich-club organization in the gene networks, with highly connected core nodes. Core gene expression levels significantly correlated with tumor WHO grading, achieving an ROC-AUC of 0.8 for distinguishing low-grade(grade-1) from high-grade(grades-2&3) tumors(P < 0.001). For clinical outcomes, core gene expression achieved an AUC of 0.96 for predicting tumor recurrence(P < 0.001) and 0.74 for patient survival(P = 0.018). This study employs an analytical pipeline integrating transcriptomic analysis of meningiomas with a graph-theory approach to identify core regulators within pathological tumor networks. This refined method facilitated the discovery of phenotype-encoding biomarkers, which accurately predicted histological grade and clinical outcomes. The identified core markers provide insights into meningioma-specific pathophysiological pathways and offer potential targets for therapeutic intervention.
Combined Petrosal Approach With Transcochlear Extension for Fisch D Jugular Paraganglioma: A Technical Case Report Eduardo J. Medina, Biren Khimji Patel, Erion Jr De Andrade, Youssef M. Zohdy, Juan M. Revuelta Barbero, Edoardo Porto, Alejandra Rodas, Leonardo Tariciotti, Rodrigo Uribe-Pacheco, Esther X. Vivas, Tomas Garzon-Muvdi, C. Arturo Solares, Gustavo Pradilla Operative Neurosurgery, 2025 BACKGROUND AND IMPORTANCE: Surgery for jugular paragangliomas (JPs) is known to be a formidable challenge because of the tumor's intimate involvement of neurovascular structures. Although radiosurgery is commonly the first-line treatment, recent advances in neuroimaging, surgical techniques, and intraoperative monitoring have positioned surgery as a feasible alternative for aggressive tumors with substantial intradural extension not amenable to upfront radiosurgery, provided the surgeon has an in-depth knowledge of lateral skull-base anatomy and access to safe and effective preoperative embolization. CLINICAL PRESENTATION: A patient with a Fisch Type D JP with extensive intradural tumor and brainstem compression underwent a combined petrosal approach with transcochlear extension at our institution. The transcochlear extension allowed additional anteromedial access to the petrous apex and internal carotid artery, whereas the combined craniotomy granted access to the supratentorial space for the tumor with transtentorial extension. The surgery's critical steps, along with key neurovascular structures, were documented and reviewed in a surgical video. CONCLUSION: The combined petrosal approach with transcochlear extension is a complex but effective surgical approach for large JPs invading the petrous apex and involving the internal carotid artery not amenable to upfront radiosurgical treatment. This procedure relies on a thorough understanding of temporal bone anatomy and should be reserved for experienced multidisciplinary teams in specialized centers.
NIR Indocyanine–White Light Overlay Visualization for Neuro-Oto-Vascular Preservation During Anterior Transpetrosal Approaches: A Technical Note Leonardo Tariciotti, Alejandra Rodas, Erion De Andrade, Juan Manuel Revuelta Barbero, Youssef M. Zohdy, Roberto Soriano, Jackson R. Vuncannon, Justin Maldonado, Samir Lohana, Francesco DiMeco, Tomas Garzon-Muvdi, Camilo Reyes, C. Arturo Solares, Gustavo Pradilla Journal of Clinical Medicine, 2025 Objectives: Anterior petrosectomy is a challenging neurosurgical procedure requiring precise identification and preservation of multiple critical structures. This technical note explores the feasibility of using real-time near-infrared indocyanine green (NIR-ICG) fluorescence with white light overlay to enhance visualization of the petrous internal carotid artery (ICA) during transpetrosal drilling. We aimed to assess its utility for planning and performing modified Dolenc–Kawase drilling. Methods: We integrated NIR-ICG and white light overlay using a robotic microscope with simultaneous visualization capabilities. This technique was applied to improve neurovascular preservation and skull base landmark identification. Intraoperative video frames and images were captured during an anterior transpetrosal approach for a petroclival meningioma, with technical details, surgical time, and feedback documented. Results: Real-time NIR-ICG with white light overlay successfully identified the posterior genu, horizontal petrosal segment, anterior genu, and superior petrosal sinus. It facilitated precise localization of cochlear landmarks, enabling tailored drilling of the Dolenc–Kawase rhomboid according to patient anatomy and accommodating potential anatomical variants. Conclusions: This approach could enhance intraoperative safety and improve exposure, possibly reducing neurovascular risks without extending operative time. It may serve as a valuable adjunct for complex skull base surgeries.
Exploring the relationship between dystonia and STN-DBS in Parkinson’s disease: insights from a single-centre cohort Luigi G. Remore, Delia Gagliardi, Linda Borellini, Alfonso Fasano, Valeria Lo Faso, Filippo Cogiamanian, Enrico Mailand, Gloria Valcamonica, Elena Pirola, Luigi Schisano, Antonella M. Ampollini, Giulio A. Bertani, Giorgio Fiore, Antonio D’Ammando, Leonardo Tariciotti, Giovanni Marfia, Stefania Elena Navone, Sergio Barbieri, Marco Locatelli Neurological Sciences, 2025 Introduction Motor side effects may emerge after deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson’s disease (PD) patients. Out of 60 PD patients, we observed 16 patients displaying de novo dystonic symptoms after the implantation and 11 dystonic PD patients without benefit from the stimulation. We hypothesized that a common neural pathway may cause dystonia in both conditions. Our study aims to investigate the clinical and connectivity substrates of dystonia after STN-DBS. Methods We divided our cohort into four groups: 16 patients displaying dystonia after STN-DBS, 11 patients with previously known dystonia not improving after surgery, 14 patients with dystonic symptoms relieved by the stimulation and 19 controls who never experienced dystonia. MANOVA was used to compare clinical data and the distance of the active contact center from the STN border among the four groups. Finally, we reconstructed the “sour” spots for dystonic symptoms and the associated structural and functional connectivity using a Parkinsonian normative connectome. Results De novo dystonic and not-improved dystonic patients had a statistically significant longer PD duration before surgery (p = 0.001) and a greater active contact-STN distance (p < 0.001). Moreover, the “sour” spots were similar in both groups and structural and functional connectivity profiles were associated with brain areas correlated with dystonia pathophysiology (cerebellum, midbrain, parietal and temporal cortices). Conclusions We formulated a two-hit model for dystonia after STN-DBS: a clinical feature of Parkinsonian patients causes predisposing altered plasticity contributing to dystonic symptoms development when coupled with the stimulation of dystonia-related subcortical and cortical structures.
Deep Brain Stimulation in Parkinson Disease: A Switch for On/Off Dystonia Valeria Lo Faso, Luigi Schisano, Luigi Gianmaria Remore, Leonardo Tariciotti, Giorgio Fiore, Gloria Valcamonica, Linda Borellini, Filippo Cogiamanian, Antonio D'Ammando, Elena Pirola, Antonella Ampollini, Giovanni Marfia, Marco Locatelli World Neurosurgery, 2025
Superior orbital fissure narrowing and tumor-associated pain in spheno-orbital meningiomas Youssef M. Zohdy, Arman Jahangiri, Ali Alawieh, Matthew Agam, Megan Cosgrove, Fadi Jacob, Edoardo Porto, Samson A. Argaw, Alejandra Rodas, Justin Maldonado, Katherine E. Chandler, J. Manuel Revuelta Barbero, Erion De Andrade, Biren Patel, Leonardo Tariciotti, Silivia Vergara, Gustavo Pradilla, Tomas Garzon-Muvdi Acta Neurochirurgica, 2024
Verbal learning in frontal patients: area 9 is critical for employing semantic strategies Alessandro Cocuzza, Giulio Bertani, Giorgio Conte, Edoardo Nicolò Aiello, Barbara Zarino, Teresa Difonzo, Stefano Zago, Leonardo Tariciotti, Claudia Gendarini, Elena Baratelli, Federico Verde, Barbara Poletti, Nicola Ticozzi, Mauro Pluderi, Marco Locatelli, Giacomo Pietro Comi, Maria Cristina Saetti Neurological Sciences, 2024
Towards a common language in neurosurgical outcome evaluation: the NEON (NEurosurgical Outcome Network) proposal Paolo FERROLI, Silvia SCHIAVOLIN, Arianna MARINIELLO, Francesco ACERBI, Francesco RESTELLI, Marco SCHIARITI, Emanuele LA CORTE, Jacopo FALCO, Vincenzo LEVI, Francesco DIMECO, Roberto ASSIETTI, Daniele BONGETTA, Elena V. COLOMBO, Silvio BELLOCCHI, Simone SANGIORGI, Simona BISTAZZONI, Maria POLOSA, Maria I. ORRU, Giannantonio SPENA, Claudio BERNUCCI, Angelo M. SICIGNANO, Andrea FANTI, Carlo BREMBILLA, Bruno RESMINI, Emanuele COSTI, Marco CENZATO, Giuseppe TALAMONTI, Gabriella BOTTINI, Pina SCARPA, Alessandra BOLLANI, Matteo QUERZOLA, Giulio PALMAS, Federico DE GONDA, Lorenzo BOSIO, Marcello EGIDI, Valentina TARDIVO, Antonio FIORAVANTI, Sara SUBACCHI, Marco FONTANELLA, Antonio BIROLI, Claudio CEREDA, Pier Paolo PANCIANI, Riccardo BERGOMI, Marta PERTICHETTI, Flavio TANCIONI, Alberto BONA, Fulvio A. TARTARA, Maurizio FORNARI, Federico PESSINA, Giovanni LASIO, Andrea CARDIA, Franco SERVADEI, Marco RIVA, Alessandra CASAROTTI, Carlo GIUSSANI, Leonardo FIORI, Fabio MAZZOLENI, Simona VAIANI, Giorgio CARRABBA, Andrea DI CRISTOFORI, Erik P. SGANZERLA, Alberto VIMERCATI, Valeria ISELLA, Ilaria MAURI, Michele INCERTI, Giovanni SICURI, Valentina MIRAMONTI, Roberto STEFINI, Diego SPAGNOLI, Maurizio PIPARO, Gianluca GRIMOD, Rossana REGAZZONI, Daniela VISMARA, Lucio MAZZEO, Emanuele MONTI, Alberto FRANZIN, Oscar VIVALDI, Alessandra MAIETTI, Elisa PINI, Domenico SERVELLO, Edvin ZEKAJ, Sara DE MICHELE, Marco LOCATELLI, Stefano BORSA, Nadia GRIMOLDI, Manuela CAROLI, Leonardo TARICIOTTI, Giorgia ABETE-FORNARA, Mario VITALE, Matilde LEONARDI, Morgan BROGGI Journal of Neurosurgical Sciences, 2023
Predicting tumor consistency and extent of resection in non-functioning pituitary tumors Giorgio Fiore, Giulio Andrea Bertani, Giorgio Conte, Emanuele Ferrante, Leonardo Tariciotti, Elisabetta Kuhn, Letterio Runza, Mauro Pluderi, Stefano Borsa, Manuela Caroli, Elisa Sala, Giulia Platania, Karin Kremenova, Stefano Ferrero, Fabio Maria Triulzi, Giovanna Mantovani, Marco Locatelli Pituitary, 2023
Computer-Based Cognitive Training in Children with Primary Brain Tumours: A Systematic Review Francesco Sciancalepore, Leonardo Tariciotti, Giulia Remoli, Danilo Menegatti, Andrea Carai, Giuseppe Petruzzellis, Kiersten P. Miller, Francesco Delli Priscoli, Alessandro Giuseppi, Roberto Premuselli, Alberto E. Tozzi, Angela Mastronuzzi, Nicola Vanacore, Eleonora Lacorte, Allena-Mente Study Group Cancers, 2022
