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Abstract BACKGROUND The operative microscope and endoscope have significantly advanced modern neurosurgery. These devices are nonetheless limited by high costs and suboptimal optics, ergonomics, and maneuverability. A recently developed extracorporeal telescope (“exoscope”) operative system combines characteristics from both the operative microscope and endoscope and provides an affordable, portable, high-definition operative experience. Widespread use of exoscopes in neurosurgery has previously been limited by a lack of stereopsis with 2-dimensional(2-D) monitors. OBJECTIVE To assess the surgical potential of a novel, 3-D, high-definition (4K-HD) exoscope system. METHODS Assess dissection time and visualization of critical structures in a series of human cadaveric cranial neurosurgical approaches with the 3-D 4K-HD exoscope as compared to a standard operating microscope. RESULTS Dissection times and visualization of critical structures was comparable with the 3-D 4K-HD exoscope and a standard operating microscope. The low-profile exoscope nonetheless allowed for larger operative corridors, enhanced instrument maneuverability, and less obstruction in passing instrumentation. The large monitor also resulted in an immersive surgical experience, and gave multiple team members the same high-quality view as the primary operator. Finally, the exoscope possessed a more ergonomically favorable setup as compared to the traditional microscope, allowing the surgeon to be in a neutral position despite the operative angle. CONCLUSION The novel 3-D 4K-HD exoscope system possesses favorable optics, ergonomics, and maneuverability as compared to the traditional operating microscope, with the exoscope's shared surgical view possessing obvious educational and workflow advantages. Further clinical trials are justified to validate this initial cadaveric experience.

•The pros and cons of using a newly developed microscope, ORBEYE™, was evaluated.•The main benefits are its compact size and freedom from focusing through eye lens.•It appears to be disadvantageous for operating from a position of an assistant.•ORBEYE™ may facilitate microneurosurgery in the future. To evaluate the pros and cons of using a newly developed microscope, ORBEYE™, during microneurosurgery. ORBEYE™ use in 14 microneurosurgical procedures was retrospectively assessed by nine neurosurgeons after the procedure. A questionnaire comprising 20 questions was designed and used for evaluation. Compared with the current gold standard, the binocular microscope, ease of setting up the equipment was scored the highest, whereas ease of conducting surgery in a position of an assistant was scored the lowest. Among characteristics of ORBEYE™ itself, the space-saving feature was scored the highest and was followed by the ability to perform procedures in a comfortable position. The only characteristic that was rated below average was ease of operation in a position of an assistant. Neurosurgeons with greater experience (more than five procedures using ORBEYE™) provided significantly higher scores (p = 0.0196) for characteristics of ORBEYE™ itself compared with neurosurgeon with fewer ORBEYE™ experience. The main benefits of the ORBEYETM are its compact size and freedom from focusing through the eye lens of a conventional binocular microscope. However, it appears to be disadvantageous for operating in a position of an assistant because the surgical field has a rotated view on the monitor from a position of an assistant. Nonetheless, because of certain advantages, we believe the ORBEYE™ could be of additional help to use of conventional binocular microscope at the moment and will facilitate microneurosurgery in the future.

Background White matter microdissection represents a valuable method for studying the three-dimensional organization of the human brain. Building on Klingler’s classical technique, this approach has regained importance as both a research and educational tool in microneurosurgery. While the white matter dissection of the lateral aspect of the brain has been extensively described, the medial surface has received comparatively less attention. This article represents the second part of a three-paper series on white matter microdissection. It provides a structured, step-by-step demonstration of the dissection of the medial aspect of the brain, with a specific focus on the limbic lobe. As in the first paper, the core content is the supplementary video, which, through editing and annotation, has an enhanced didactic value. Methods The dissection was performed according to the Klingler technique and recorded during the 8th Sulci, Gyri, Ventricles and Fiber Dissection Hands-on Course (Taipei, 2025). The procedure was conducted under microscopic magnification and edited into a didactic video presentation. All identifiable participants provided informed consent for publication. Results The dissection proceeds through nine main stages, beginning with the identification of the medial sulci and gyri and continuing with the sequential removal of cortical layers and white matter bundles. This systematic approach exposes the cingulum, inferior longitudinal fasciculus, callosal fibers, hippocampal formation, tapetum, thalamic peduncles, and mammillothalamic tract, illustrating the organization of the limbic lobe and the relationships between major white matter tracts and the ventricular walls. Conclusion This work presents a comprehensive and didactic video demonstration of the medial hemispheric white matter dissection, highlighting the continuity and spatial relationships of limbic and periventricular structures. It contributes to a systematic and anatomically grounded understanding of cerebral white matter organization and supports the educational role of white matter microdissection in neurosurgical anatomy.

Background Skull base neurosurgery (SBNS) emerged as a specialized branch of microneurosurgery as it addressed the challenges posed by intricate skull base anatomy. Initially developed through close collaboration with otolaryngologists, SBNS expanded in the 1990s and has undergone substantial advancements over the following decades. In this review, we analyze whether SBNS evolved as an organic development within neurosurgery or an external innovation, and we review key historical literature to support of either hypothesis. Methods This is a synthetic, narrative historical review. An initial Pubmed review was performed with combination of keywords of “skull base neurosurgery”, “skull base surgery”, “neuroanatomy”, “microsurgical anatomy” and” neurosurgery complications”. Resulting database was restructured based on peer to peer, semi-structured interviews of two senior skull base neurosurgeons, with over 25 skull base neurosurgeons that were active 1970s–1990s. Emerging themes formed the framework for the analysis. Results The evolution of SBNS was organic. It could be categorized into four distinct phases: Initially, Early attempts preceding the systematic application of SBNS techniques, subsequently the birth phase coincided with the widespread adoption of microneurosurgery and the establishment of dedicated societies and international meetings. During the popularization phase, advances in microneuroanatomy and novel approaches enhanced outcomes. Finally, the Maturation phase brought refined surgical approaches, the reevaluation of surgical indications, and the integration of stereotactic radiosurgery and endoscopic skull base surgery as well as international collaboration and teaching activities. Discussion SBNS emerged within neurosurgery as a means to address challenging skull base pathologies and to enable surgical access through the skull-base. Its development was driven by collaboration with otolaryngology, alongside technological innovations such as the operating microscope, power drills, endoscopy, and stereotactic radiosurgery. These innovations facilitated the creation of novel surgical approaches, which were later refined through advances in neuroanatomical knowledge and improved understanding of pathology. Over time, SBNS were integrated into general neurosurgical practice and training curricula, allowing wide implementation and continued evolution in many directions.

Background The white matter dissection technique owes its modern recognition to Josef Klingler, whose fixation protocol enabled detailed fiber bundle visualization and led to an outstanding and still relevant atlas of white matter anatomy. After a period of decline in the late twentieth century, the technique was reintroduced into neurosurgical training with the aid of the surgical microscope, emphasizing the importance of fiber dissection and its practical applications in clinical neuroanatomy. This article provides a structured, step-by-step demonstration of white matter microdissection, progressing from superficial anatomy to deeper fiber layers. Its main contribution is the supplementary video, which offers a detailed, structured demonstration of the dissection steps and white matter layers, replicating the format and clarity of hands-on dissection courses . Careful editing and post-processing were applied to optimize educational impact. Methods The dissection was recorded during the 7th Sulci, Gyri, Ventricles and Fiber Dissection Hands-on Course (Taipei, November 2024). Identifiable participants gave informed consent for publication. Results The video illustrates a systematic lateral-to-medial dissection, beginning with sulcal and gyral identification. Grey matter is removed to expose U-fibers, followed by progressive visualization of the superior longitudinal fasciculus, insular cortex, extreme and external capsules, claustrum, basal ganglia, and anterior commissure. Each step is accompanied by commentary and technical tips to guide the dissection and preserve anatomical integrity. Conclusion By mastering the topography of white matter, neurosurgeons can enhance their understanding of pathological anatomy, allowing for precise mental rehearsal and strategic planning before surgery. This approach underscores the enduring importance of anatomical studies in improving surgical outcomes and advancing neurosurgical practice.

Background and objective The posterior interhemispheric approach provides optimal access to lesions located in a number of areas. A major advantage of this approach is that the parieto-occipital vein is typically the only venous structure encountered, which minimizes venous interference during exposure. In a surgical series of 12 patients, we identified a previously undescribed venous variant extending from the cuneus to the falx cerebri. Here, we characterize this venous structure and propose a microsurgical strategy to preserve it. Methods A total of 303 posterior interhemispheric approaches were performed from September 2005 to August 2025. We retrospectively reviewed clinical and radiological data collected from patients’ electronic medical records and searched the operative database to locate surgical videos. Results In 12 patients undergoing the posterior interhemispheric approach (12/303, 4%), we identified a previously unreported venous variation in which a cortical vein extended from the cuneus to the falx cerebri. We have termed this structure the cuneus vein . Among these 12, 2 were observed during a right-sided approach (2/157, 1.3%) and 10 during a left-sided approach (10/146, 6.8%). The vein-releasing technique was used in 7 patients, while the falx-cutting technique was done in 4. In all but one patient, the cuneus vein was successfully preserved. In one patient with hydrocephalus, excessive brain relaxation after CSF drainage limited mobilization and caused vein injury, without hemorrhagic or ischemic morbidity during follow-up. Conclusions The cuneus vein, a cortical vein extending from the cuneus to the falx cerebri, is an anatomical variation that has not been described previously but requires careful consideration during the posterior interhemispheric approach. The cuneus vein drains the visual cortex; thus, its sacrifice may lead to postoperative complications, including visual deficits secondary to venous infarction. In this study, we identified and characterized this venous variation and demonstrated its preservation using the vein-releasing technique and the falx-cutting technique.

Background Tentorial dural arteriovenous fistulas (dAVFs) are categorized based on venous drainage and location. Although their angioarchitecture may initially appear intimidating, once “decodified,” treatment is straightforward. Posteromedial tentorial dAVFs have an arterialized draining vein that emanates from the inferior tentorium along the posterior third of the straight sinus, just slightly off the midline. Method With the aid of anatomical dissections, intraoperative photos, and operative videos, we outline the key steps for surgical treatment of posteromedial tentorial dAVFs. Conclusion Posteromedial tentorial dAVFs constitute a precise and well-defined subtype of tentorial dAVF for which surgical ligation has an important role.

Background Microsurgical resection of thalamic tumors requires precise anatomical knowledge and meticulous preoperative planning. Given the complexity of thalamic surgery, selecting an optimal surgical approach demands an accurate three-dimensional understanding of relevant structures. Advanced imaging post-processing, including three-dimensional (3D) model construction, can aid surgical planning and mental rehearsal of the procedure. The integration of Mixed Reality (MxR) with interactive holograms may further enhance anatomical clarity, improve risk assessment, and facilitate safer and more extensive tumor resection. Methods This retrospective study analyzed patients who underwent thalamic tumor resection with holographic surgical planning between 2022 and 2024. Key anatomical structures, particularly those delimiting the four “free thalamic surfaces”, in contact with cerebrospinal fluid spaces, were segmented using post-processing software (Lumi and 3D Slicer) based on volumetric MRI sequences. The resulting patient-specific holograms were utilized preoperatively to simulate and select the optimal surgical approach and intraoperatively to verify its suitability. Demographic, clinical, radiological, and perioperative data were collected. Results Ten surgical procedures were performed in nine patients, including seven neuroepithelial tumors and two metastases. All critical structures were successfully segmented, allowing effective surgical simulation and approach selection (8 Anterior Interhemispheric Transcallosal, 2 Perimedian Supracerebellar Transtentorial approaches). The additional planning time for segmentation averaged 45 min. The mean extent of resection achieved was 94.88% (range: 78.6%–100%). At 3-months postoperative follow-up one out of nine patients experienced a permanent new neurological deficit due to surgery. Conclusion Integrating MxR into the preoperative workflow for microsurgical removal of complex thalamic tumors proved to be a valuable tool for surgical planning, risk assessment, and intraoperative guidance. The additional preparation time required for holographic simulation appears justified given the anatomical complexity of thalamic lesions.

Background Anterior communicating artery (ACOM) aneurysms are among the most common aneurysms associated with aneurysmal subarachnoid hemorrhage (International Study of Unruptured Intracranial Aneurysms I (N Engl J Med 339:1725-1733, 1998), Wiebers (Lancet 362:103-110, 2003)). Surgical clipping of posterior-superiorly projecting ACOM aneurysms can be challenging, as the ipsilateral A2 can interfere with clip trajectory and ACOM perforating vessels obstructed from view. Intraluminal coils can further increase the difficulty of the procedure. Method The relevant surgical anatomy with illustration is presented. A video detailing our technique on an illustrative case is provided. Conclusion Surgical clipping of posterior-superiorly projecting ACOM aneurysms can require complex clip configurations. We describe the key steps of posterior-superiorly projecting ACOM aneurysm clipping through a lateral supraorbital craniotomy and fenestrated tandem clipping.

Transcranial neurosurgery assisted by endoscopy and intraoperative ultrasound (IOUS) has become an effective approach for real-time visualization and guidance during tumor resection. This study explores the application of these techniques in falcine meningioma (FM) resection, assessing their feasibility and safety. Eleven FM patients underwent transcranial endoscopic resection with IOUS assistance. Preoperative neuroimaging, including magnetic resonance (MR) imaging, computed tomography, MR angiography, and MR venography, guided surgical planning. IOUS provided real-time tumor localization, boundary visualization, adjacent structure assessment, and guidance throughout the resection. Tumors were located in the anterior, middle, and posterior falx in 4, 5, and 2 patients, respectively. Of the 11 cases, 8 involved unilateral falx tumors and 3 involved bilateral falx tumors. Simpson grade 1 resection was achieved in 12 patients; one case involved a deeply located tumor closely associated with the deep venous plexus. Pathologically, 10 patients had World Health Organization (WHO) grade 1 meningiomas, and 1 had a WHO grade 3 anaplastic meningioma. Postoperative complications included temporary contralateral hemiplegia in one patient and pulmonary infection in another. The average follow-up period was 19.3 months, with all patients achieving Karnofsky Performance Status scores of > 90. In conclusion, endoscopic resection with IOUS assistance is both feasible and safe for FM patients.