Thai Journal of Neurological Surgery

Advancement in Diffuse Intrinsic Pontine Glioma (DIPG) treatment: Emerging strategies and innovations

Suvichan Phibalwong — 2026-07-21

Diffuse intrinsic pontine glioma (DIPG), currently classified within diffuse pediatric-type highgrade gliomas, is one of the most aggressive pediatric brain tumors and is associated with an extremely poor prognosis despite advances in neuro-oncology. This review summarizes current knowledge regarding the molecular pathogenesis, diagnosis, standard treatment, and emerging therapeutic strategies for DIPG. Recent molecular studies have identified H3K27 alterations, including H3.3K27M, H3.1K27M, and EZHIP, together with abnormalities in TP53, PDGFRA, and ACVR1, as key drivers of tumor development and treatment resistance. Magnetic resonance imaging remains the cornerstone of diagnosis, while stereotactic biopsy has become increasingly important for molecular characterization and treatment planning. Radiotherapy remains the standard treatment, providing temporary clinical improvement, whereas the survival benefit of temozolomide remains limited. Novel therapeutic approaches, including chimeric antigen receptor (CAR) T-cell therapy, oncolytic virotherapy, survivin peptide vaccination (SurVaxM), and immune checkpoint inhibitors, have demonstrated encouraging preliminary results in early-phase studies. Although these emerging therapies offer promising opportunities for improving outcomes, further translational research and well-designed clinical trials are required to establish their long-term efficacy and safety and to develop more effective personalized treatment strategies for patients with DIPG.

Cerebral hyperperfusion syndrome after STA-MCA bypass in moyamoya disease

Pakapon Yangsamit — 2026-05-28

Moyamoya disease (MMD) is a condition characterized by stenosis or occlusion of the internal carotid artery (ICA) at its bifurcation into the middle cerebral artery (MCA) and anterior cerebral artery (ACA). Patients may present with either cerebral ischemia or intracranial hemorrhage. The current standard treatment is cerebral revascularization surgery using direct bypass between the superficial temporal artery (STA) and the middle cerebral artery (MCA), often combined with indirect bypass procedures.One of the major complications of direct bypass surgery is cerebral hyperperfusion syndrome (CHS), which results from excessive cerebral blood flow following the operation. Clinical manifestations may occur immediately after surgery and include headache, seizures, neurological deficits, or altered consciousness. At present, there are still no clearly established guidelines for the diagnosis and management of CHS. Therefore, the authors reviewed the clinical manifestations, risk factors, diagnostic approaches, treatment, and prevention strategies of CHS in this article.

Characteristics of Blunt Cerebrovascular Injury in Khon Kaen Hospital: A Descriptive Study

Thiti Thitisaksakul — 2026-04-24

Background: Evidence on blunt cerebrovascular injury (BCVI) remains limited. This study aimed to describe the characteristics of BCVI in a tertiary care referral hospital and trauma center in northeastern Thailand. Methods: This retrospective descriptive study was conducted in the trauma ward and trauma intensive care unit (TICU) at Khon Kaen Hospital from 2020 to 2025. The eligible criteria were the patients sustained blunt trauma and were diagnosed BCVI by computed tomography of 4 vessels of the neck (CTA neck). Baseline data were recorded, including injury characteristics, clinical signs symptoms, and risk factors following standard screening criteria including Denver and Memphis group. Potential endpoints including mortality and in-hospital stroke were also collected. Results: A total of 14 patients were included in this study. Most were male 71.4%. The mean age was 47.9±17.5 years. The mean injury severity score (ISS) was 18.9±7.0. The potential parameters for BCVI were severe TBI with GCS < 6 (28.6%) and stroke as a primary presentation (28.6%). Relevant CT findings suggestive of BCVI were cervical spine fracture (42.9%) and complex skull fracture, respectively (28.6%). Most of the patients were presented with total occlusion (grade 4) BCVI with prevalence of 42.9%. The locations of BCVI were equal between common carotid and vertebral arteries. There were 3 (21.4%) patients with in-hospital stroke and 28.6% in-hospital mortality. Median hospital cost was 96,884.5 [45,090.5, 268,775.5] baht. Conclusion: BCVI was prevalent in tertiary care referral hospital and trauma center. Serious in-hospital complications especially stroke and death were not uncommon. The best way to prevent complications is early detection with high index of suspicious.

A Retrospective Review of the Clinical Outcomes of Stereotactic Radiation for Pituitary Adenoma In Ramathibodi Hospital

Vitchapon Pitaksinpanit — 2026-05-22

Background: Stereotactic radiation, including conventional stereotactic radiotherapy (CSRT), hypofractionated stereotactic radiotherapy (HFSRT), and stereotactic radiosurgery (SRS), plays a crucial role in the management of nonfunctioning pituitary adenomas (NFPAs) and functioning. However, the optimal selection of treatment modality to maximize long-term control while minimizing late toxicities, particularly delayed hypopituitarism, remains a subject of ongoing clinical debate. Objective: To evaluate the long-term efficacy and safety of a tailored, risk-adapted stereotactic radiation strategy for the management of pituitary adenomas. Material and method: We retrospectively reviewed 127 patients with pituitary adenomas treated with conventional stereotactic radiotherapy (CSRT) (n=86), hypofractionated stereotactic radiotherapy (HFSRT) (n=29), or stereotactic radiosurgery (SRS) (n=12). The primary outcomes were radiographic tumor local control and biochemical control in functioning adenomas. Secondary outcomes included late toxicities and the evaluation of predictors for new-onset hypopituitarism, which was specifically analyzed using Cox proportional hazards regression in a subgroup of preoperatively hormonally intact patients (n=73). Results: The overall radiographic tumor control rate was 96.6%, with no significant difference in progression-free survival (PFS) across the three modalities (p = 0.823). Among functioning adenomas, the overall biochemical control rate was 87.9%, with 69.7% achieving remission off medication. Regarding secondary outcomes, the treatment demonstrated a highly favorable safety profile; zero instances of Grade 3-4 severe toxicities, radiation necrosis, or cerebrovascular events were observed. New-onset hypopituitarism occurred in 12.6% of the cohort (all Grade 1-2). In the preoperatively hormonally intact subgroup, multivariate analysis revealed that the specific radiation modality was not an independent predictor of new endocrine deficits. Conclusion: A tailored, risk-adapted stereotactic radiation strategy provides excellent and comparable long-term local control and biochemical control for pituitary adenomas. The choice of radiation modality does not independently predict delayed hypopituitarism. Instead, the risk of endocrine decline is likely multifactorial, emphasizing the importance of baseline tumor complexity and the preexisting functional reserve of the gland when counseling patients.

Risk factors associated with secondary delayed contralateral expanding hematoma in patient with bilateral acute traumatic intracranial hematomas

Kriangsak Champawong — 2026-06-27

Background: Secondary delayed contralateral expanding hematoma (SDCEH) may occur after unilateral surgery in patients with bilateral acute traumatic intracranial hematomas and can lead to neurological deterioration. Identifying patients at risk may help guide early postoperative imaging and timely intervention.
Methods: We performed a retrospective cohort study of adult patients with bilateral acute traumatic intracranial hematomas who underwent unilateral surgical evacuation at a Level I trauma center between January 2021 and February 2024. Postoperative CT was obtained within 24 hours based on predefined clinical criteria. SDCEH was defined as a postoperative increase in contralateral hematoma volume or thickness by >30% requiring contralateral surgical intervention. Patients were categorized into progression (SDCEH) and non-progression groups. Variables associated with SDCEH were assessed using univariate analysis and multivariable logistic regression.
Results: Sixty-one patients were included; 29 (47.5%) developed SDCEH. On univariate analysis, midline shift, contralateral skull fracture, and postoperative coagulopathy were associated with SDCEH. In multivariable analysis, contralateral skull fracture (p=0.048) and postoperative coagulopathy (p=0.011) remained independent predictors, whereas midline shift was not significant after adjustment.
Conclusions: SDCEH occurred in nearly half of patients with bilateral acute traumatic intracranial hematomas treated with unilateral surgery. Contralateral skull fracture and postoperative coagulopathy independently predicted SDCEH. Patients with these features may benefit from intensive postoperative surveillance and early serial CT imaging to facilitate prompt detection and management.

The Anatomical Relationship Between the Transverse-Sigmoid Complex and Skull Landmarks in a 3D CTV Imaging Study

Siriwut Pokanan — 2026-10-01

Background: The retrosigmoid craniotomy is one of the most common approaches in neurosurgery. The bony landmarks related to the transverse-sigmoid sinus are important for performing surgery safely and effectively. This study investigated the relationship between the transverse-sigmoid sinus complex and external skull landmarks, focusing on the asterion–digastric point line as a reference for the vertical sigmoid sinus and related anatomy. Method: Radiographic study was conducted using 51 three-dimensional computed tomography venography scans obtained from patients older than 15 years at Ramathibodi Hospital between 2021 and 2023. Volume-rendering techniques were applied to identify the asterion, the digastric point, the transverse-sigmoid sinus junction, and the vertical segment of the sigmoid sinus. Measurements were taken at the proximal, mid, and distal portions relative to the asterion-digastric point line, with the angles in the x (coronal), y (sagittal), and z (rotational) axes set at 12°, 15°, and 120°, respectively. Results: The line connecting the asterion and the digastric point serves as the most reliable landmark (100%) for locating the vertical segment of the sigmoid sinus on both sides. The mean distances from this line to the medial border of the vertical part of the sigmoid sinus were 4.16±2.45 mm, 7.90±2.33 mm, and 3.24±1.64 mm from proximal to distal, respectively. The mastoid emissary foramen is more commonly found on the right side than on the left and is mostly located medial to this line. The occipitomastoid suture was found to be medial to the asterion- digastric point line in all cases. The mean distance from the digastric point to the occipitomastoid suture is 9.36 ± 1.30 mm on the right side and 9.48 ± 1.22 mm on the left side. Additionally, the right sigmoid sinus was significantly larger (7.50 ± 1.22 mm, P < 0.001) than the left in most cases. Conclusion: Recognizing the asterion-digastric point line and the occipitomastoid suture as the most reliable landmark for the vertical part of sigmoid sinus helps surgeons avoid inadvertent injury to the transversesigmoid venous sinus during routine craniotomy in this area.