Neurosurgery

Background: Vertebroplasty and balloon kyphoplasty are used for symptomatic vertebral hemangiomas, although comparative evidence is limited. We summarized pain relief, cement leakage, and recurrence after vertebral augmentation and assessed whether direct comparison of the two techniques was feasible. Methods: Five databases were searched from inception to January 2, 2026, with an update on July 5, 2026. Because only one small cohort directly compared vertebroplasty with kyphoplasty, outcomes were pooled as single-arm proportions or, for early pain change, as a mean difference using random-effects models. Prespecified subgroup, sensitivity, small-study effect, and influence analyses were performed. Results: Forty-four studies were included: 33 case series, 10 cohort studies, and one randomized trial. Kyphoplasty-specific evidence comprised one dedicated series and one comparative cohort. Any cement leakage occurred in 10.5% of patients (14 studies; 95% CI 5.7-18.4%), while trim-and-fill gave an exploratory adjusted estimate of 20.4%. Early pain reduction averaged 5.13 points on a 0-10 scale (8 studies; 95% CI 4.48-5.77; I2=89.4%). Complete or near-complete pain relief occurred in 79.4% of patients (10 studies), and recurrence, progression, or retreatment occurred in 3.9% (13 studies). Symptomatic cement leakage was uncommon at 0.4%. Conclusion: The available literature, which is mainly retrospective and vertebroplasty-based, supports substantial pain relief with infrequent symptomatic complications. Kyphoplasty data remain insufficient for a reliable technique comparison. Prospective studies with standardized clinical and imaging outcomes are needed.

Background: The long-term benefit of deep brain stimulation (DBS) for neurological disorders depends on sustained post-implantation management, yet its geographic distribution remains poorly characterised. We aimed to describe regional variation, persistence, and longitudinal change in DBS management activity across Japan. Methods: We used claims from the National Database of Health Insurance Claims (NDB) Open Data during 2014-2024. Annual billings for DBS management were expressed per million population. Annual between-prefecture unevenness was summarised by the Gini coefficient of the prefecture DBS management billing rate. We evaluated longitudinal trajectories and trends in DBS management billing rates relative to the national rate, and related baseline billing rates to subsequent trends. Findings: From 2014 to 2024, national DBS management billings increased from 18,659 to 27,233, totalling 258,408. Between-prefecture unevenness remained high throughout (Gini coefficient, 0.54 to 0.40), and its narrowing decelerated over the study period. In 2024, the prefecture at the 90th percentile still billed at 9.1 times the rate of the prefecture at the 10th. Of the 23 low-baseline prefectures, nine showed a subsequent decline in relative billing rate; nonetheless, lower baseline DBS management billing rates were associated with a more positive relative rate of change overall. Interpretation: Ongoing post-implantation DBS management activity was markedly uneven and persistent across Japan. The observations suggest that universal health coverage and national-level growth do not by themselves ensure equitable long-term DBS treatment. This nationwide, longitudinal description could inform policies aimed at reducing geographic barriers to long-term specialist care across healthcare systems. Funding: None.

Background Endovascular treatment of unruptured intracranial aneurysms (UIAs) often requires dual antiplatelet therapy with aspirin and a P2Y12 inhibitor. Clopidogrel remains widely used, but variable bioactivation and high on-treatment platelet reactivity have prompted interest in alternatives such as prasugrel. We compared thromboembolic and hemorrhagic outcomes after clopidogrel versus prasugrel use in endovascular UIA treatment. Methods We queried the TriNetX Global Collaborative Network for adults with UIA who underwent endovascular treatment between 2016 and 2025 and received aspirin plus clopidogrel or prasugrel. Cohorts were matched 1:1 using propensity score matching based on demographics and comorbidities. Outcomes were assessed at 6 months and 1 year and reported as odds ratios (ORs) with 95% confidence intervals (CIs). Results Among 15,496 adults, 711 matched pairs were included. At 6 months, no significant differences were observed for in-stent thrombosis (OR 0.77, 95% CI 0.38?1.57; p=0.47), cerebral infarction (OR 1.04, 95% CI 0.75?1.46; p=0.80), cerebral hemorrhage (OR 1.07, 95% CI 0.80?1.44; p=0.65), or gastrointestinal hemorrhage (OR 0.84, 95% CI 0.43?1.64; p=0.61). Findings remained nonsignificant at 1 year. Conclusions In this propensity-matched TriNetX analysis, clopidogrel and prasugrel were not associated with significant differences in thromboembolic or hemorrhagic outcomes after endovascular UIA treatment. Prasugrel may be a reasonable alternative P2Y12 inhibitor in selected patients, including those with suspected or documented clopidogrel non-response.

Artificial intelligence (AI) is increasingly embedded in U.S. emergency department workflows, but no medical specialty has defined what competent use of these tools requires of its physicians. Existing accreditation requirements are silent on AI, and parallel national efforts span the learning continuum but are intentionally specialty-agnostic. As one output of a working group of the 2026 Society for Academic Emergency Medicine (SAEM) Artificial Intelligence Consensus Conference, we developed an emergency medicine-specific framework for AI competency. We employed a multiphase consensus design: a Nominal Group Technique session generated themes from a curated set of clinical AI scenarios, and a two-round modified Delphi process (panel n = 13 across 12 academic medical centers), separated by a consolidation videoconference, evaluated and extended the framework. A priori consensus required [≥]70% of panelists rating [≥]4 on a 5-point Likert scale ([≥]75% for themes) with interquartile range [≤]1; we followed established Delphi reporting guidance. The framework comprises 5 themes (Communicating about AI, Understanding appropriate use cases, Interacting with AI, AI risk management, Cognitive impacts of AI), 5 derived competencies (one-to-one theme-to-competency mapping endorsed by 12 of 13 panelists), 19 subthemes, and 10 retained clinical scenarios. All themes, derived competencies, and rated subthemes met consensus thresholds; 9 of 10 scenarios reached consensus, with 1 retained as a future-state operational model. Two cross-cutting conceptual frames emerged: pre-emptive versus post-hoc AI integration, and tiered competencies as an articulated need rather than a pre-specified answer. This is, to our knowledge, the first specialty-specific AI competency framework for a United States medical specialty with quantitative content validity evidence from expert consensus. It provides a structural target for emergency medicine curriculum development, assessment design, and faculty development, with downstream priorities including stage-specific competency assignment, assessment instrument development, and periodic re-evaluation as AI deployment evolves.

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is frequently complicated by delayed cerebral ischaemia (DCI), for which current therapies incompletely target the underlying multifactorial pathophysiology. Transauricular vagus nerve stimulation (taVNS) modulates inflammatory, vasoactive and autonomic pathways and may attenuate secondary brain injury after aSAH. Methods: We conducted a prospective, single-centre, single-blind, randomised, sham-controlled pilot trial in adults within 5 days of aneurysm securing for non-traumatic aSAH. Participants were allocated 1:1 to active taVNS (left tragus) or sham (left earlobe) using a portable device delivered for 45 minutes twice daily over 5 days. Primary outcomes were safety (taVNS-related serious adverse events), acceptability, and compliance; secondary outcomes included inflammatory biomarkers, DCI, in-hospital complications, and functional outcomes to 1 month. Results: Thirty patients were randomised (16 taVNS, 14 sham), with numerically more severe aSAH at baseline in the taVNS arm. No taVNS-related serious adverse events occurred; side effects were generally mild and transient, and over 80% of planned sessions were completed. TaVNS produced greater reductions in serum tumour necrosis factor- and trends towards reductions in interleukin-1{beta} and interleukin-10, with numerically fewer DCI events (6.6% vs 35.7%) and neurological impairments (16.7% vs 53.8%), although functional outcomes were not statistically different at 1 month. Conclusions: Early taVNS after aSAH is safe, acceptable, and feasible in the neurocritical care setting and shows biologically plausible signals warranting evaluation in larger multi-centre trials.

Background Passive advancement--antegrade movement of the aspiration catheter upon inner delivery device withdrawal without active operator force--is a physical phenomenon observed during mechanical thrombectomy, with anecdotal reports of favorable recanalization outcomes. This study characterizes its prevalence and associations with recanalization. Methods Consecutive thrombectomy cases at two high-volume stroke centers (January 2019-December 2025) were retrospectively reviewed. Stored fluoroscopy and angiograms were assessed for passive advancement and final catheter tip position at arterial branch points. Per-pass and per-vessel mixed-effects multivariable regression identified independent associations with eTICI score, first-pass effect (FPE, eTICI [&ge;]2c-3), modified FPE (mFPE, eTICI [&ge;]2b-3), secondary occlusion, and complications. Results Of 1,824 passes in 995 consecutive patients (1,027 occlusions), 733 had imaging adequate for passive advancement assessment. Passive advancement occurred in 525/733 passes (71.6%), including to an arterial branch in 306/733 (41.7%). On per-pass analysis, passive advancement was associated with higher eTICI [&ge;]2b-3 (71.0% vs 19.7%) and eTICI [&ge;]2c-3 (57.5% vs 10.1%); advancement to a branch amplified these associations (90.5% vs 32.1% and 79.4% vs 18.7%; all p<0.001). Among 429 first passes, mFPE was 74.1% vs 10.8% and FPE 63.4% vs 7.5% with vs without passive advancement; rates reached 95.0% and 87.2%, respectively, at a branch point (all p<0.001). Passive advancement to a branch was inversely associated with secondary occlusion (13.3% vs 31.3%; p<0.001). On multivariable analysis, passive advancement independently predicted eTICI score, eTICI [&ge;]2b-3, and eTICI [&ge;]2c-3 (all p<0.001); final catheter position at a branch was the dominant independent predictor of FPE, mFPE, secondary occlusion, any complication, and intracranial complication on per-vessel analysis (all p[&le;]0.046). Conclusions Passive advancement is a prevalent physical phenomenon and an independent predictor of successful recanalization. When advancing to an arterial branch point, it is associated with mFPE >87%. Passive advancement should be a technical objective of aspiration thrombectomy.

Background: Unruptured intracranial aneurysms (UIAs) are increasingly identified incidentally, and management balances rupture risk against treatment risk. UIA diagnosis has been linked to psychological distress, but psychotropic medication initiation after UIA discovery has not been compared across the full UIA management spectrum. Methods: We conducted a retrospective cohort study using IBM MarketScan claims (CCAE, MDCD, and MDCR; 2009-2023) among adults with a UIA diagnosis, continuous enrollment for 365 days before and after the index date, and no SAH/rupture on or before the index date. We compared the prevalence of 6 mental-health diagnoses before versus after UIA discovery and used adjusted logistic regression to examine psychotropic medication initiation within 365 days by management strategy (untreated observation as the reference). Results: Among 54,945 patients (untreated, 78.5%; endovascular, 11.3%; clipping, 3.0%; other/uncertain, 7.2%), prevalence of every mental-health diagnosis was higher after UIA discovery, most for depression (+4.6 percentage points) and anxiety (+4.5 points). Medication initiation was most common for benzodiazepines (8.7%). Endovascular treatment was associated with higher adjusted odds of benzodiazepine (aOR, 1.21), SSRI (aOR, 1.20), and sedative-hypnotic (aOR, 1.25) initiation.Surgical clipping demonstrated the broadest association, with higher odds across 5 of 6 classes, including benzodiazepines (aOR, 1.71) and sedative-hypnotics (aOR, 1.86). Benzodiazepines had the lowest 1-year persistence (10.5%) despite being the most commonly initiated class. Findings were consistent across sensitivity analyses, with the exception of the increase in panic disorder, which was no longer observed after applying a 30-day post-index lag. Conclusions: Mental-health diagnoses and psychotropic medication initiation increased after UIA discovery, and medication initiation was most pronounced among patients treated with surgical clipping. These findings support psychological assessment as part of aneurysm management regardless of strategy.

Cervical spondylotic myelopathy (CSM) is the most common cause of nontraumatic spinal cord dysfunction in adults and is an increasingly important source of disability as populations age. Gabapentin is widely prescribed for neuropathic pain and may therefore be used for symptoms related to known or undiagnosed CSM. However, there is sparse evidence related specifically to gabapentin's use for CSM-related pain. We investigate gabapentin use and trends over time in patients with CSM compared to matched controls. We observed that gabapentin prescriptions were higher in CSM patients compared to controls across two multi-hospital datasets. These results highlight the need for further research into pharmacologic treatment for chronic pain in CSM.

Background: Pain relief is the principal patient-centered goal of surgery for symptomatic lumbar synovial facet cysts, yet comparative reviews have often emphasized cyst recurrence. Whether adding fusion improves postoperative pain or reduces later surgery remains uncertain. Objective: To compare decompression alone with decompression plus fusion, with postoperative back- and leg-pain outcomes as the primary domain. Methods: PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to 2 June 2026. Comparative cohorts and case series with at least five patients were eligible. Twenty-two studies were re-extracted for VAS/NRS scores, change scores, and persistent or recurrent pain. Random-effects restricted maximum likelihood models with Hartung-Knapp inference were used; clinically distinct pain outcomes were analyzed separately. Results: Twenty-two studies (16 cohorts, 6 case series; 51,899 participants) were included. Two studies provided compatible final VAS data. Fusion did not improve postoperative back pain (MD -0.04, 95% CI -0.17 to 0.10; I2=0%) or leg pain (MD -0.03, 95% CI -0.28 to 0.21; I2=0%). Postoperative back pain (RR 0.58, 95% CI 0.14-2.30) and leg/radicular symptoms (RR 0.75, 95% CI 0.42-1.32) were also not significantly reduced. Fusion decreased confirmed cyst recurrence (RR 0.29, 95% CI 0.15-0.57) but not reoperation or subsequent lumbar surgery (RR 0.80, 95% CI 0.42-1.50). Conclusion: Current comparative evidence does not demonstrate superior postoperative pain control with routine fusion. Fusion reduces cyst recurrence without clearly reducing reoperation, supporting selective use when instability is present or anticipated.

Severe peripheral nerve injuries result in incomplete recovery despite neurorrhaphy. Microsurgical suturing is technically demanding, time-intensive, and may produce variable fascicular alignment. Nerve Tape is an FDA-approved sutureless device enabling rapid, reproducible nerve coaptation. This study compared Nerve Tape with epineurial microsuturing following common peroneal nerve transection in Yucatan minipigs. Over 12 months, both groups demonstrated reinnervation of the tibialis anterior and extensor digitorum brevis, representing proximal and distal muscle targets, respectively. Tibialis anterior recovery was comparable between groups. In contrast, Nerve Tape produced greater distal motor recovery in the extensor digitorum brevis, with approximately 1.8-fold higher compound muscle action potential amplitude and 74.3% versus 46.0% recovery compared with microsutures. Compound nerve action potential amplitudes recorded from the motor branch of the deep peroneal nerve were also greater with Nerve Tape, whereas conduction velocities were comparable. Histological analysis demonstrated preserved fascicular architecture distal to the repair in both groups, with no significant differences in axon count, mean myelinated axon diameter, or g-ratio in the terminal common peroneal nerve or its distal motor branch. Clinical use was demonstrated in a representative case with progressive recovery. Nerve Tape supported durable structural and functional recovery and improved distal motor reinnervation compared with microsuturing.

Objectives: Aneurysmal subarachnoid haemorrhage is a life-threatening emergency that commonly presents with a sudden, severe headache. The diagnosis is usually confirmed on CT imaging, however a small subset of patients demonstrate normal imaging, particularly if presentation is delayed - in which case spectrophotometric analysis of cerebrospinal fluid (CSF) is undertaken. Nevertheless, thunderclap headache is a common presentation and the vast majority of investigated patients do not have aneurysmal subarachnoid haemorrhage. This ten-year service evaluation at a tertiary neurosurgery centre aims to estimate the utility of lumbar puncture in the diagnostic work-up of these patients. Methods: All instances of CSF spectrophotometry between 01/01/2011 and 31/12/2020 were evaluated. Clinical records of patients with positive spectrophotometry were analysed. A second method identified all coded diagnoses of non-traumatic subarachnoid haemorrhage over the same time period, with review of clinical records in cases of negative imaging. Results: Of 2158 instances of CSF spectrophotometry performed at the tertiary neurosurgery centre, four aneurysms were identified and treated by coiling or clipping, resulting in a number needed to treat of 540 patients to diagnose one case of aneurysmal subarachnoid haemorrhage. Of 648 patients with a coded diagnosis of non-traumatic subarachnoid haemorrhage (including local patients and transfers from satellite hospitals), 27 patients displayed initial negative imaging, of which 9 were found to have aneurysms and underwent neuro-intervention. Lumbar puncture was instrumental in the diagnosis and led to intervention in three patients identified by this method. Conclusion: CSF analysis resulted in diagnosis and intervention for missed (CT-negative) aneurysmal subarachnoid haemorrhage in approximately 1/540 tested patients. The estimated yield in a real-world setting may be useful for clinicians or provide a basis for discussion when counselling patients on benefit and risk.

Background: The mechanisms driving cervical dystonia remain unclear, limiting effective, non-invasive treatment development. Lesion network mapping previously localized a brain network derived from lesions causing cervical dystonia, with a network hub in the somatosensory cortex, a viable target for non-invasive brain stimulation. Objectives: We conducted a randomized, sham-controlled, crossover trial administering continuous theta-burst stimulation (cTBS) to the S1 lesion network hub, testing whether modulating this network reduces CD symptoms. Methods: Thirteen idiopathic cervical dystonia patients (57.85 {+/-} 10.85 years) received two 10-session blocks of bilateral somatosensory cortex cTBS (active or sham; counterbalanced). The primary outcome was change in cervical dystonia symptoms, measured by the Toronto Western Spasmodic Torticollis Scale (TWSTRS). A wearable motion sensor objectively measured change in head and neck movement patterns. Motor evoked potentials and resting-state fMRI assessed cTBS-induced changes in corticospinal excitability and functional connectivity, respectively. Results: Active cTBS did not significantly reduce cervical dystonia symptoms compared to sham (condition x timepoint interaction: p = .149). Range of motion significantly increased with active, versus sham, cTBS (p = .015). Corticospinal excitability decreased following sham (p = .042), but not active, cTBS. No significant connectivity changes were seen from the somatosensory cortex stimulation site after active cTBS; however, significant changes emerged from the globus pallidus interna. Conclusion: This study prospectively tested the effects of neuromodulation on a lesion network mapping-derived target. Active cTBS did not significantly improve TWSTRS scores relative to sham. The intervention was well tolerated by all patients, and future studies could consider higher-dose or alternative protocols to this target.

Introduction Mechanical thrombectomy has been well-established as the standard of care treatment for patients with moderate to severe acute ischaemic stroke secondary to large vessel occlusion. However, the clinical value of endovascular treatment (EVT) in patients presenting with minor stroke and low baseline National Institutes of Health Stroke Scale scores remains incompletely defined, with limited high-quality clinical evidence. This protocol outlines the methodology of a randomized trial designed to evaluate whether EVT combined with best medical therapy (BMT) achieves superior functional outcomes relative to BMT alone among patients with minor stroke. Methods and analysis Eligible patients with acute minor anterior circulation ischaemic stroke and confirmed large vessel occlusion (n=264) will be randomized via a computer generated block randomization sequence to receive either EVT plus BMT (intervention arm) or BMT alone (control arm). The primary efficacy outcome is the proportion of participants achieving excellent functional recovery, defined as a modified Rankin Scale score of 0 or 1 at 90 days. Primary safety outcomes comprise symptomatic intracranial haemorrhage within 48 hours after randomization (classified according to Heidelberg criteria) and all cause mortality at 90 days. Participants will be considered eligible if they satisfy all of the following inclusion criteria: (1) enrolment within 24 hours of stroke symptom onset or time last known well; (2) baseline NIHSS score of 2 - 5 accompanied by at least one focal neurological deficit (including altered consciousness, facial palsy, limb weakness, aphasia or hemispatial neglect); (3) angiographically confirmed acute occlusion of the intracranial internal carotid artery, the M1 segment of the middle cerebral artery, or a dominant M2 branch; (4) a hypoperfusion volume (Tmax >6s) [&ge;] 50mL on computed tomography or magnetic resonance perfusion imaging. Both intention to treat and per protocol analyses will be undertaken, and potential sources of heterogeneity in treatment effect magnitude will be explored. Ethics and Dissemination This study was approved by the ethnic committee from the First Affiliated Hospital of Wannan Medical University (2023-IRB90). The findings of this study will be disseminated through publication in peer-reviewed journals. Registration URL:https://www.clinicaltrial.gov; Unique identifier: NCT06143488.

Objective: To evaluate decision concordance between commercially available multimodal large language models (LLMs), resident doctors, and senior-surgeon ground truth for surgical indication and spinal level in degenerative lumbar spine disease. Methods: We retrospectively analyzed 147 consecutive patients. Each case included clinical documentation and MRI presented as two composite PNG images. Two resident doctors and three multimodal LLMs (GPT 5.5, Claude Sonnet 4.6, Gemini 3.1 Pro) independently assessed operative versus conservative management and, if operative, the surgical level. Analyses used Cochran's Q, McNemar tests with Holm correction, and Bayesian methods. Results: LLMs achieved higher therapy-decision accuracy (66.0%-68.0%; 97-100/147) than residents (54.4%; 80/147) but over-recommended surgery. Conditional level accuracy when surgery was correctly indicated was 71.4% (20/28) for residents versus 33.3%-41.1% for LLMs. Conclusion: Off-the-shelf multimodal LLMs approximate human performance for binary surgical indication but remain inferior for precise level localization. These results establish a practice-relevant baseline of spatial reasoning limitations for tools already used by patients and junior doctors.

Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) has been demonstrated to be a safe and effective minimally invasive therapy for essential tremor (ET). However, it is not clear whether older adults ([&ge;]70 years old) or individuals with comorbidities exhibit similar safety and efficacy. This IRB approved project collected EPIC EMR data on patients that underwent MRgHIFU at Parkview Regional Medical Center from January 2023 to November 2025. 68 patients were assessed for tremor severity using Clinical Rating Scale for Tremor (CRST), quality of life using Quality of life in ET Questionnaire (QUEST), and safety profile via reported post-procedure side effects. CRST and QUEST scores improved up to 1 year from baseline in our patient cohort and efficacies in older ([&ge;]70 years of age) and younger (<70 years of age) patients up to 3 months post MRgHIFU were not statistically different. Effects of comorbidities on CRST or QUEST scores improvements were all transient or did not affect endpoints. Older patients showed fewer total side effects at 3 months (1.17 (95% CI: 0.47-1.87) vs 0.21 (95% CI: -0.09-0.51), p=0.017) as did patients with pulmonary disease at 1 month (1.9 (95% CI: 1.6-2.2) vs 1.1 (95% CI: 0.9-1.3), p=0.036) while patients with family history of tremor showed more side effects at day 1 (1.5 (95% CI: 0.8-2.2) vs 2.5 (95% CI: 2.1-2.9), p=0.025). Age and comorbidities were not detected to adversely affect safety or efficacy following MRgHIFU in ET patients.

INTRODUCTION Large language models (LLMs) have demonstrated substantial performance on medical licensing and board examinations, but their application to anesthesiology remains less well studied. Prior evaluations have not compared current-generation models from different developers or assessed performance on figure-dependent questions that earlier models lacked the capability to interpret. This study evaluates the performance of two current-generation LLMs on a comprehensive anesthesiology in-training examination (ITE) review question bank, including figure-dependent items. METHODS A total of 1,001 single-best-answer questions from an anesthesiology ITE review text, spanning 11 content chapters, were administered to Claude Opus 5 and GPT-5.6. No questions were excluded. Each item was presented once in a fresh, stateless context with no tool access, retrieval, answer key, or explanation provided in the prompt. Performance was analyzed by question format, and all 27 figure-dependent items were administered with their published figures supplied. Accuracy between models was compared using McNemar's test. RESULTS Claude Opus 5 answered 947/1,001 items correctly (94.6%; 95% CI, 93.0-95.8), and GPT-5.6 answered 946/1,001 correctly (94.5%; 95% CI, 92.9-95.8); the difference was not significant (McNemar p=1.00). Accuracy was similar across most question formats. On standard questions, accuracy was 94.3% and 94.6% for Claude Opus 5 and GPT-5.6, respectively; on the 18 figure-based questions with figures supplied, accuracy was 94.4% and 83.3%, respectively; and both models achieved 100% accuracy on image-option items. Withholding figures from the same 18 figure-based questions reduced pooled accuracy from 88.9% to 52.8% (exact McNemar p=0.03 and p=0.04 for Claude Opus 5 and GPT-5.6, respectively). The models agreed on 957/1,001 items (95.6%). Of the 33 items both models answered incorrectly, they selected the same incorrect option on 32 (97%). DISCUSSION Current-generation LLMs achieved approximately 95% accuracy, substantially improving on our prior results with earlier-generation models and placing both models within the highest band of the ITE normative framework, corresponding approximately to the 99th percentile across training levels. By comparison, our prior work with previous models placed ChatGPT-3.5 at the 52nd, 3rd, and 1st percentiles and ChatGPT-4.0 at the 99th, 95th, and 84th percentiles across increasing levels of training. Multimodal capability now permits successful interpretation of many figure-dependent questions, although performance declines markedly when required visual information is unavailable, and highly concordant errors remain. These findings support an increasingly promising role for LLMs as accessible, on-demand educational adjuncts for anesthesiology trainees, provided complete source material is supplied and outputs are critically reviewed.

Background: Exosome- and extracellular vesicle-based therapies have emerged as promising cell-free approaches for spinal cord injury repair, with reported effects on inflammation, apoptosis, myelination, axonal regeneration, angiogenesis, blood-spinal cord barrier integrity, and neurogenesis. However, the preclinical evidence is heterogeneous, and the extent to which the available data permit quantitative synthesis remains unclear. Methods: This systematic review was conducted in accordance with PRISMA 2020 and registered in PROSPERO as a preclinical animal intervention review (CRD420261446664). PubMed/MEDLINE, Scopus, Web of Science, and Embase were searched from inception to 1 June 2026 without language or publication-date restrictions. Eligible studies evaluated an exosome- or extracellular vesicle-based intervention for spinal cord injury and reported functional, histological, molecular, electrophysiological, vascular, regenerative, or safety-related outcomes. Risk of bias was assessed using an adapted version of SYRCLE's tool for animal studies, while the first-in-human phase I study was appraised separately using the JBI Critical Appraisal Checklist for Quasi-Experimental Studies. Study characteristics, intervention strategies, outcome domains, and risk-of-bias patterns were synthesized descriptively. Where complete group-level means, standard deviations, and sample sizes were available, exploratory quantitative synthesis was performed using standardized mean differences calculated as Hedges' g. Results: The search identified 1,329 records. After removal of 481 duplicates, 848 records were screened, 108 full-text reports were assessed for eligibility, and 24 studies were included, comprising 23 animal/preclinical studies and one human phase I study. Exosome sources, injury models, administration routes, dosing strategies, and follow-up durations varied substantially. Reported outcomes included locomotor recovery, lesion and tissue preservation, myelination, axonal and neural regeneration, inflammation, apoptosis, angiogenesis, blood-spinal cord barrier repair, neurogenesis, and safety. Among the 23 animal studies, none was judged to be at overall low risk of bias; 20 were classified as unclear risk and three as high risk. The human phase I study was appraised separately and judged to be at high risk of bias for causal efficacy inference. Two studies contributed complete data to the exploratory meta-analysis of Basso, Beattie, and Bresnahan locomotor recovery. Both study-level estimates favored exosome treatment, while the random-effects pooled estimate was imprecise and crossed the null (Hedges' g 3.74; 95% CI -0.53 to 8.00). Conclusions: Exosome- and extracellular vesicle-based therapies demonstrated promising signals across functional and biological domains of spinal cord injury repair. However, the evidence was limited by methodological heterogeneity, unclear risk of bias, inconsistent reporting of vesicle characterization and dosing, and insufficient complete numerical data for robust quantitative synthesis. Preregistered, adequately powered, and transparently reported studies using standardized intervention and outcome-reporting methods are required to clarify therapeutic efficacy and translational potential.

Background: Large language models have been proposed to improve patient comprehension of radiology reports. However, whether they improve objective understanding remains unproven. Purpose: To evaluate the effect of appending an LLM-generated lay summary to brain MRI reports on objective and subjective patient comprehension in a randomized controlled trial. Materials and Methods: In this randomized controlled trial, 2,727 adult participants from the ComPaRe e-cohort were randomly assigned to interpret six standardized brain MRI reports for headache, presented either in their native format (control; n = 1,401) or appended with a lay summary generated by an open-weights LLM (Mistral Small 3.2) (intervention; n = 1,326). The primary outcome was objective comprehension, defined as the rate of correct classification of whether the report provided a probable explanation for the headache, with ground truth established by four-radiologist consensus. Secondary outcomes included satisfaction, subjective comprehension, anxiety, and willingness to contact a healthcare professional. Generalized estimating equations accounted for repeated within-participant observations. Results: A total of 2,727 participants (mean age, 52 years +/- 15; 75.2% women) were evaluated. Objective comprehension did not differ between arms (58.3% vs 59.4%; odds ratio (OR) 0.97; 95% CI: 0.90-1.06; P = .54). The intervention significantly improved overall satisfaction (64.9% vs 36.7%; OR 3.26; 95% CI: 2.93-3.64; P < .001) and subjective comprehension (50.3% vs 24.0%; OR 3.17; 95% CI: 2.82-3.56; P < .001). High anxiety was modestly reduced (25.1% vs 26.6%; OR 0.92; P = .037). The effect on objective comprehension varied by report type (P for interaction < .001): summaries improved comprehension of symptom-explaining reports (42.4% vs 37.4%; P < .001) but reduced it for normal reports (72.5% vs 76.6%; P = .001). Conclusion: LLM-generated lay summaries appended to brain MRI reports improved patient satisfaction and subjective comprehension but did not improve objective comprehension, indicating a gap between perceived and actual understanding that should be addressed before clinical integration.

Background Endovascular thrombectomy (EVT) is used selectively for vertebrobasilar artery occlusion (VBAO), but its net value in mild deficits remains uncertain. We performed a hierarchical win-ratio analysis of EVT versus best medical management (BMM) in patients with acute VBAO and admission National Institutes of Health Stroke Scale (NIHSS) scores of 10 or less. Methods We performed a secondary analysis of a multicenter retrospective registry of acute VBAO with admission NIHSS scores of 10 or less. EVT plus BMM was compared with BMM alone in the overall cohort and in admission NIHSS strata of 0-5 and 6-10. The primary hierarchy ranked death status through common follow-up, 90-day modified Rankin Scale score, and symptomatic intracranial hemorrhage (sICH). All EVT-BMM pairs were compared sequentially and classified as an EVT win, BMM win, or tie. The adjusted analysis used stabilized inverse probability of treatment weighting (IPTW), with weights truncated at the 1st and 99th percentiles in a sensitivity analysis. Results The analysis included 1,232 patients: 428 underwent EVT and 804 received BMM. In the unweighted overall analysis, EVT had 146,674 wins, BMM had 149,958 wins, and 47,480 ties, yielding a WR of 0.98 (95% CI, 0.84-1.15; P = 0.749). After stabilized IPTW, the WR was 0.96 (95% CI, 0.80-1.14; P = 0.618). Sensitivity analyses did not show a robust overall association favoring EVT. In exploratory NIHSS-stratified analyses, the WR was 0.80 (95% CI, 0.61-1.05; P = 0.101) for NIHSS scores of 0-5 and 1.36 (95% CI, 1.10-1.68; P = 0.004) for scores of 6-10. Conclusions EVT was not associated with an overall net advantage over BMM in this hierarchical analysis. The exploratory signal among patients with admission NIHSS scores of 6-10 suggests that EVT may be feasible in selected patients and warrants confirmation in randomized trials; for patients with NIHSS scores of 0-5, EVT use should remain cautious and individualized.

[Abstract] Objective: Intraventricular haemorrhage (IVH) carries high mortality and morbidity; accurate early prediction of 6-month functional outcome is essential for guiding treatment decisions and optimising prognosis. We developed and externally validated a prognostic model that integrates a novel neuroimaging marker, the Brainstem Dorsal Line (BSDL), with the TabICLv2 algorithm to predict 6-month functional outcomes after IVH. Methods: In this multicentre retrospective study, patients with IVH were enrolled from nine tertiary centres in China between Dec 1, 2020, and Dec 31, 2024; seven centres constituted the derivation cohort (8:2 training-validation split) , and two centres formed the external validation cohort. Feature selection followed a three-step pipeline comprising univariable testing, Spearman correlation analysis, and LASSO regression; eight machine-learning models were trained with five-fold cross-validated hyperparameter tuning. Performance was assessed by the area under the receiver operating characteristic curve (AUC), the area under the precision-recall curve (AUPRC), calibration curves, and decision curve analysis (DCA). Interpretability was evaluated using SHapley Additive exPlanations (SHAP). Results: In total, 728 eligible patients were enrolled 610 in the derivation cohort (unfavourable outcome, 27.9%) and 118 in the external validation cohort (26.3%). Feature selection identified nine optimal predictors, of which BSDL grade 2 ranked highest in feature importance. TabICLv2 showed the best performance in external validation (AUC 0.9014 [95% CI 0.825-0.985], AUPRC 0.8192 [0.688-0.916], F1 score 0.7742 [0.651-0.877]); calibration was excellent (Hosmer-Lemeshow test, P>0.05) and DCA showed clinical net benefit across threshold probabilities of 0.05-0.97. SHAP confirmed BSDL grade 2 as the strongest predictor of unfavourable outcome. Conclusions: Integrating BSDL with TabICLv2 yielded a robust, interpretable prognostic model for 6-month outcomes after IVH, providing a practical tool for early risk stratification and individualised treatment planning.