Repetitive soccer heading has been implicated as a potential source of cumulative subconcussive brain injury, yet the magnitude and consistency of its cognitive effects remain incompletely defined. We conducted a systematic review and meta-analysis to quantify global and domain-specific cognitive outcomes associated with repetitive heading exposure. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, PubMed/MEDLINE, Scopus, and Web of Science were searched through December 2025. Of 2,846 identified records, 46 studies met the inclusion criteria, and 28 provided standardized cognitive data suitable for quantitative synthesis. Effect sizes (Hedges g, Fisher z) were transformed into log odds ratios and pooled using DerSimonian-Laird random-effects models. Heterogeneity was assessed using Q, I², and H² statistics, and publication bias was evaluated with funnel plots, Egger regression, and trim-and-fill procedures, alongside leave-one-out influence analyses. Across 28 independent author-level datasets, repetitive heading was associated with significantly increased odds of global cognitive underperformance (odds ratio 1.67; 95% confidence interval 1.61-1.72), with moderate heterogeneity (I² ≈ 34%). Trim-and-fill adjustment yielded a modestly attenuated but still significant estimate (odds ratio 1.49). Domain-level analyses demonstrated consistent impairments across visuospatial ability (odds ratio 1.49), verbal memory (odds ratio 1.62), attention (odds ratio 1.71), processing speed (odds ratio 1.64), executive function (odds ratio 1.86), and composite cognition (odds ratio 1.58). Confidence intervals were narrow, once, and the effect directionality was uniform across domains. These findings indicate that repetitive soccer heading is associated with robust, reproducible cognitive deficits across multiple cognitive systems, supporting cumulative subconcussive exposure as an independent risk factor for measurable cognitive decline.

The inferior frontal cortex (IFC), which includes Broca's area, is a frequent target in neurosurgical procedures, yet its sulcal landmarks remain under-characterized across populations. We evaluated 7 IFC sulci-the inferior precentral sulcus (prcs-i), inferior frontal sulcus (ifs), triangular sulcus (ts), diagonal sulcus (ds), pretriangular sulcus (prts), and the ascending (aaLF) and horizontal (haLF) anterior rami of the lateral fissure-using high-resolution magnetic resonance imaging (MRI) data from 40 Japanese and 40 North American White adults, supplemented by 9 cadaveric hemispheres. Sulci were manually labeled in FreeSurfer, quantified for surface area and depth, and analyzed for interhemispheric and inter-racial differences. Maximum probability maps (MPMs) were projected against meta-analytic functional MRI maps to evaluate structure-function relationships. The prcs-i and haLF were universally present, whereas the ds showed the lowest incidence (≈55%-60% left, ≈75% right), with variability across studies partly explained by misclassification with the aaLF. The prts was also infrequent and highly variable, whereas the ts, although structurally diverse, was nearly universal. Quantitative analyses confirmed the aaLF was significantly deeper than the ds (p < 0.0001), providing an objective criterion for differentiation. Functionally, high-frequency sulci (aaLF, haLF, ifs, prcs-i, ts) aligned with reliable activation patterns for verbal fluency, semantics, and syntax, whereas the ds frequently coincided with hotspots despite inconsistent presence. These findings can offer anatomical insights that may guide future clinical research on the frontal language area.

The asymmetry of the A1 segment of the anterior cerebral artery has been implicated in the development and rupture of anterior communicating artery aneurysms; however, its relationship with the severity of subarachnoid hemorrhage remains unclear. We retrospectively analyzed 114 patients with subarachnoid hemorrhage due to ruptured anterior communicating artery aneurysms (mean age, 64.2 ± 13.9 years; 56 males, 58 females) treated at 2 institutions between January 2014 and March 2024. Patients were categorized into Symmetric and Asymmetric A1 groups, with asymmetry defined as a diameter ratio of ≥2 between sides. Among the 114 patients, 72 (63.2%) and 42 (36.8%) had symmetric and asymmetric A1 segments, respectively. The Asymmetric A1 group demonstrated significantly larger aneurysm size, a higher incidence of World Federation of Neurosurgical Surgeons grade IV-V, and more frequent intracerebral hemorrhage. Surgical clipping was more frequently performed in the Asymmetric A1 group (p = 0.04), likely due to associated intracerebral hemorrhage. The A1 diameter ratio was negatively correlated with aneurysm angle (r = −0.27, p < 0.01) and positively correlated with aneurysm length (r = 0.28, p < 0.01). Multivariate analysis showed an association of A1 asymmetry with severe clinical presentation but not with functional outcome. The effect of A1 asymmetry on severity was attenuated after adjustment for intracerebral hemorrhage, the strongest predictor of both severity and outcome. These findings suggest that in ruptured anterior communicating artery aneurysms, A1 asymmetry is associated with larger aneurysms, more severe subarachnoid hemorrhage, and higher rates of intracerebral hemorrhage.

It remains unclear whether frailty and white matter lesions are risk factors for surgical treatment of unruptured intracranial aneurysms in older adults. We conducted a prospective multicenter study of 397 patients aged ≥60 years with unruptured intracranial aneurysms enrolled from 20 hospitals in Japan. Unruptured intracranial aneurysms were treated by either microsurgical clipping or endovascular treatment according to institutional protocols. The primary endpoint was functional outcome at discharge assessed using the modified Rankin scale (mRS). Poor outcome was defined as a deterioration of 1 or more points in the mRS score at discharge compared with the preoperative baseline. Unruptured intracranial aneurysm size ranged from 2.1 to 26 mm (mean, 6.93 mm). Poor outcome occurred in 52 patients (13.1%). There was no significant association between poor outcome and age (p = 0.089) or treatment modality (clipping vs. coiling, p = 0.4739). In multivariate regression analysis, poor outcome was significantly associated with larger unruptured intracranial aneurysm size (p = 0.033), higher Clinical Frailty Scale score (p = 0.006), higher preoperative mRS score (p = 0.039), lower hemoglobin level (p = 0.016), absence of regular exercise (p = 0.046), slower walking speed (p = 0.002), severe white matter lesions (p = 0.001), and lower intraoperative blood pressure (p = 0.032). Severe white matter lesions were associated with a higher risk of postoperative ischemia (p ≤ 0.042) and intracranial hemorrhage (p = 0.0017). These findings indicate that preoperative frailty and severe white matter lesions are significant predictors of poor outcomes after unruptured intracranial aneurysm surgery in older adults.

Trial registration: umin.ac.jp/ctr Identifier: UMIN 000029977

Approximately 30% of patients still develop drug-resistant epilepsy despite the introduction of newer antiseizure medications. Brivaracetam, a high-affinity synaptic vesicle protein 2A ligand with a mechanism of action similar to that of levetiracetam, was only recently approved in Japan in June 2024 and became available at our institution in September 2024. Clinical data in real-world settings remain limited. To date, no real-world clinical data have been systematically reported in patients in Japan, and the present study aimed to characterize the initial real-world experience with Brivaracetam use shortly after its approval. We retrospectively analyzed 73 patients with focal epilepsy who initiated Brivaracetam at our center between September 2024 and August 2025, evaluating patient characteristics, seizure outcomes, treatment retention, and adverse events. Among 41 patients with at least 3 months of follow-up, seizure freedom was achieved in 5%, whereas 44% of patients were responders with ≥50% seizure reduction. Overall, 59 patients continued Brivaracetam, with a treatment retention rate of 76.5% and a mean treatment duration of 7.4 months. Adverse events were observed in 18 patients (24%), most frequently somnolence, followed by dizziness and irritability. Brivaracetam discontinuation occurred in 14 patients (19%), with psychiatric symptoms leading to discontinuation in only 3 patients (4%), a lower rate compared with prior reports of levetiracetam. These findings suggest that Brivaracetam is effective and generally well tolerated in patients in Japan with focal epilepsy. Future multicenter prospective studies with longer follow-up are warranted to further evaluate the role of Brivaracetam, including as monotherapy and in patients with multilobar epilepsy.

The Low-Profile Visualized Intraluminal Support EVO stent enables full fluoroscopic visualization and provides higher metal coverage than conventional devices used to assist coil embolization of wide-neck unruptured intracranial aneurysms. We conducted a prospective multicenter clinical trial to assess its efficacy and safety in stent-assisted coil embolization. A total of 41 patients were enrolled across 6 centers. The primary endpoint of clinical success was achieved in 39 of 40 implanted cases (97.5%; 95% confidence interval, 86.8%-99.9%). These findings demonstrate the efficacy and safety of Low-Profile Visualized Intraluminal Support EVO as an assist stent for wide-neck aneurysms. Given that concerns remain regarding thrombotic risk with small-diameter devices (2.5-3.0 mm), a subgroup analysis comparing the results of small-diameter Low-Profile Visualized Intraluminal Support EVO (2.5-3.0 mm) versus those of larger Low-Profile Visualized Intraluminal Support EVO (3.5-4.0 mm) was conducted. Fifteen cases were included in the small-diameter group, and 25 were included in the comparative group. Ischemic events occurred in 1 of 15 (6.7%) patients in the small-diameter group and in 2 of 25 (8.0%) patients in the larger-diameter group, with no statistically significant difference between the 2 groups, and all events were transient or asymptomatic. At 6 months, 13 of 14 (92.9%) patients in the small-diameter group achieved complete occlusion (Raymond-Roy Class I, core laboratory adjudicated). Overall, small-diameter Low-Profile Visualized Intraluminal Support EVO did not confer a significantly higher risk of ischemic complications compared with larger-diameter devices and demonstrated favorable therapeutic potential for the treatment of wide-neck aneurysms. Trial registration: jRCT2042230075.

Microsurgical clipping is an established treatment for unruptured intracranial aneurysms; however, long-term cerebrovascular outcomes beyond aneurysm obliteration remain incompletely characterized in surgically treated patients, particularly regarding non-hemorrhagic cerebrovascular events. We retrospectively analyzed 930 patients (990 procedures; 655 females, 275 males; mean age, 62.8 years) with asymptomatic anterior circulation unruptured intracranial aneurysms treated between 2003 and 2025, with a total follow-up of 7,638 patient-years (median, 8.3 years). The primary endpoint was postoperative subarachnoid hemorrhage, and secondary endpoints included all-stroke events and all-cause mortality. Incidence rates with 95% confidence intervals were calculated, and rate ratios versus natural-history cohorts (Unruptured Cerebral Aneurysm Study and Small Unruptured Intracranial Aneurysm Verification Study) and standardized incidence ratios versus the general population were computed using Poisson methods. Ten subarachnoid hemorrhage events occurred (1.31 per 1,000 patient-years; 95% confidence interval, 0.63-2.41), with most arising from untreated or de novo aneurysms; only 1 case originated from a previously clipped site, demonstrating durable protection at treated sites. Subarachnoid hemorrhage incidence was substantially lower than that reported in natural-history cohorts of conservatively managed unruptured intracranial aneurysms. In contrast, age-adjusted all-stroke incidence remained approximately 2-fold higher than in the general population (standardized incidence ratio 2.11; 95% confidence interval, 1.50-2.90; p < 0.001), driven predominantly by ischemic events. These findings indicate that microsurgical clipping effectively reduces the risk of subarachnoid hemorrhage from treated aneurysms, whereas overall cerebrovascular risk remains elevated, reflecting persistent systemic vascular vulnerability rather than failure of local treatment. Long-term follow-up incorporating appropriate imaging surveillance and intensive management of modifiable vascular risk factors is therefore essential to optimize outcomes in this patient population.

Non-ipsilateral ischemic lesions after carotid artery stenting are considered to arise from emboli originating in the aortic arch, but the quantitative contribution of aortic arch calcification to post-carotid artery stenting ischemic lesions remains unclear. This study aimed to investigate the association between volumetric aortic arch calcification and non-ipsilateral diffusion-weighted imaging hyperintense lesions after transfemoral carotid artery stenting.

We retrospectively analyzed 99 consecutive transfemoral carotid artery stenting procedures performed between January 2018 and December 2023. Aortic arch calcification volume was quantified using preoperative computed tomography angiography using threshold-based segmentation. Postprocedural diffusion-weighted imaging performed within 48 h was assessed for hyperintense lesions in the contralateral hemisphere or cerebellum. Variables were evaluated using univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis was used to determine the optimal cut-off value for predicting non-ipsilateral lesions.

Non-ipsilateral high-intensity diffusion-weighted imaging lesions occurred in 14 patients (14.1%), who showed significantly higher aortic arch calcification volumes than did those without lesions (median 2.2 vs. 1.0 mL, p = 0.005). Receiver operating characteristic analysis identified an optimal cutoff of 1.3 mL (sensitivity 78.6%, specificity 62.3%, area under the curve 0.73). Both age (odds ratio 1.1 per year, p = 0.039) and aortic arch calcification volume (odds ratio 1.3 per mL, p = 0.040) were independently associated with non-ipsilateral lesions. Aortic arch type and guiding catheter size showed no significant associations. Quantitative aortic arch calcification on preoperative computed tomography angiography was independently associated with non-ipsilateral ischemic lesions after transfemoral carotid artery stenting. Incorporating calcification volume into preprocedural assessments may assist in selecting alternative access routes or protective strategies for patients at high risk.

Exoscopic surgery provides superior ergonomics compared with conventional microscopic surgery. This retrospective study aimed to compare the clinical outcomes between exoscopic and conventional microscopic carotid endarterectomy for asymptomatic carotid stenosis. We retrospectively analyzed 23 consecutive microscopic carotid endarterectomy cases between March 2012 and November 2018 and 21 consecutive exoscopic carotid endarterectomy cases between December 2018 and August 2024. Patient demographics, lesion characteristics, operative parameters, and postoperative outcomes were compared between the groups. There were no significant differences in baseline characteristics between the microscopic and exoscopic carotid endarterectomy groups. The mean indocyanine green volume was significantly lower in the exoscopic (2 ± 1 mL) vs. microscopic carotid endarterectomy groups (6 ± 2 mL) (p < 0.0001). Similarly, the mean skin incision length was shorter in the exoscopic vs. microscopic group (74 ± 10 mm vs. 90 ± 18 cm, respectively; p = 0.0016). The microsurgical time was significantly shorter in the exoscopic vs. microscopic groups (157 ± 63 min vs. 219 ± 97 min, respectively; p = 0.04). There were no significant differences in safety or clinical outcomes between the 2 groups. Exoscopic carotid endarterectomy demonstrated safety and clinical outcomes comparable to those of microscopic carotid endarterectomy while offering certain benefits associated with advances in equipment and surgical technology.

We assessed the technical utility and preliminary outcomes of endoscopic hematoma evacuation via the high parietal approach for thalamic hemorrhage with intraventricular extension (intraventricular hemorrhage) by retrospectively reviewing 270 patients treated between April 1, 2006, and July 31, 2024. Prior to 2017, the primary treatment was external ventricular drainage, and in selected patients with thick intraventricular hematoma, an anterior endoscopic approach was used primarily for intraventricular hemorrhage removal. Since April 2017, the high parietal approach technique has been used for the simultaneous removal of both thalamic hematoma and intraventricular hemorrhage in 21 patients. The high parietal approach group showed a median hematoma evacuation rate of 92.2% and, compared with the external ventricular drainage-only group, a significantly shorter duration of ventricular drainage and a lower incidence of tracheostomy. No cases of surgical site infection or meningitis occurred in the high parietal approach group. Complications included 1 death due to postoperative rebleeding and another due to worsening pneumonia and heart failure. Secondary hydrocephalus requiring shunt placement was observed only in the external ventricular drainage group. Although not statistically significant, the high parietal approach group showed a higher rate of early resumption of oral intake. These findings suggest that endoscopic evacuation via the high parietal approach is a minimally invasive technique that achieves high hematoma removal rates, facilitates early postoperative recovery, and may reduce complications such as prolonged drainage, tracheostomy, and hydrocephalus in selected patients with large thalamic hemorrhage and intraventricular hemorrhage.