Search Results (85)

Background: Hydatid disease, caused by Echinococcus granulosus, remains a significant public health concern in endemic regions. This study aimed to evaluate the role of ultrasound in the diagnosis, staging, and clinical management of liver hydatid cysts in the eastern city of Jalalabad, Afghanistan. Method: A cross-sectional study was conducted between February and November 2024 among 159 patients diagnosed with liver hydatid cysts. Demographic, clinical, laboratory, and imaging data were collected. Cysts were classified according to the WHO Informal Working Group on Echinococcosis (WHO-IWGE) and Gharbi systems. Ultrasound findings were compared with computed tomography (CT), and their association with treatment decisions was assessed. Result: A total of 159 patients with liver hydatid cysts were included in the study. Among them, 91 (57.2%) were female, 80 (50.3%) were aged 20–39 years, and 128 (80.5%) resided in rural areas. Most patients presented with a single cyst (144/159, 90.6%), while multiple cysts were observed in 15 (9.4%). The majority of cysts measured 5–9.9 cm in diameter (43.4%), followed by 1–4.9 cm (42.1%) and ≥10 cm (14.5%). According to the WHO-IWGE classification, CE1 (25.8%) and CE4 (24.5%) were the most common stages, followed by CE2 (17.6%), CE3a (13.8%), CE3b (11.3%), and CE5 (7.0%). Common exposure-related factors included dog ownership, poor hygiene practices, and consumption of raw vegetables. Ultrasound accurately identified cyst stages and demonstrated a significant association between WHO-IWGE staging and treatment modality (χ² = 63.56, p < 0.001). Almost perfect agreement was observed between ultrasound and CT for cyst classification (Cohen’s κ > 0.90), although CT provided additional anatomical information in selected complex cases. Conclusions: Ultrasound is an accessible, accurate, and reliable imaging modality for the diagnosis, staging, and management of liver hydatid cysts. In resource-limited settings, it serves as the primary imaging modality for guiding clinical decision-making, with CT reserved for complex or uncertain cases. Full article

Background/Objectives: Anthropometric measurements provide essential normative datasets that form the foundation for clinical practice and forensic identification. The human ear is a highly informative structure due to its complex morphology and individual specificity, making it a valuable tool for biometric systems. This study aimed to estimate biological sex based on auricular morphometric measurements, develop a logistic regression model for this purpose, and validate its performance using ROC analysis. Materials and Methods: This cross-sectional study included 120 adult participants (60 males, 60 females). Standardized digital photographs were analyzed in ImageJ to record 22 linear and 6 angular measurements using established anatomical landmarks. LASSO logistic regression was employed for variable selection and model shrinkage. The final model’s discriminative performance was assessed using the area under the receiver operating characteristic (ROC) curve (AUC), the Hosmer–Lemeshow test, and the Brier score. Results: A comparative analysis revealed that most linear and angular measurements showed significant sexual dimorphism. Almost all linear dimensions (A1–A22) were significantly larger in males (p < 0.001). Auricular width (A2) and width at the level of the tragus (A3) emerged as the most robust indicators, demonstrating “very large” effect sizes. Conversely, the angle between the preauricular line and the vertical plane (A28) was significantly greater in females, providing a unique inverse relationship for sex estimation. A parsimonious 5-predictor model (incorporating A2, A3, A5, A10, and A28) achieved exceptional discriminative performance with an AUC of 0.980. Conclusions: Auricular morphometry is a highly effective tool for sex estimation. The findings confirm significant sexual dimorphism in the external ear, particularly in linear dimensions. The developed model may serve as a preliminary morphometric reference for future automated biometric recognition studies, although no artificial intelligence-based classification model was developed in the present study. Full article

Purpose: To develop a fully automated 2D nnU-Net pipeline for multi-class skeletal muscle segmentation (psoas, paraspinal, and abdominal wall) at the third lumbar (L3) vertebral level, and to quantitatively evaluate its diagnostic performance and reliability compared to manual segmentation. Materials and Methods: A 2D nnU-Net was trained on 164 axial L3 CT slices from the multi-institutional AMOS22 dataset, spanning diverse abdominal pathologies and multivendor imaging. To assess generalizability under severe anatomical distortion, independent external validation was performed in 50 consecutive patients with advanced liver disease from a single institution (January–December 2025; mean age, 63 ± 15 years; 32 women, 18 men), of whom 88% had moderate-to-severe ascites. Model stability was examined by comparing a five-fold ensemble with the best-performing single-fold model. Intra-observer reliability of the manual reference standard was evaluated in a random subset of 30 cases. Inter-observer agreement was additionally assessed using an independent second reader. Performance metrics included the Dice Similarity Coefficient (DSC), Pearson correlation coefficient (r), and Bland–Altman analysis for cross-sectional areas and mean attenuation. The inference workflow was deployed via a custom Streamlit-based graphical user interface (GUI). Results: In this anatomically complex external validation cohort, the 5-fold ensemble 2D nnU-Net achieved an overall mean DSC of 0.937 ± 0.043 (95% CI, 0.925–0.950), with 80% of cases achieving a mean DSC ≥ 0.90. While the mean DSC was statistically comparable to the best single-fold model (0.937, [95% CI, 0.921–0.952], p = 0.736), the ensemble strategy increased the minimum observed DSC (worst-case performance) from 0.720 to 0.822. Class-specific external validation performance for the 5-fold ensemble was highest for the paraspinal muscles (DSC: 0.960; 95% CI, 0.952–0.967), followed by the psoas muscles (DSC: 0.941; 95% CI, 0.927–0.956), and lowest for the anatomically complex abdominal wall muscles (DSC: 0.911; 95% CI, 0.893–0.929). Comparison between the ensemble model and manual segmentation yielded a Pearson correlation of r = 0.955 (p < 0.001) for total skeletal muscle area, with a mean bias of +7.17 cm². Intra- and inter-observer agreements for the manual reference standard demonstrated correlation coefficients of r = 0.995 and 0.090 for total areas, respectively. The automated pipeline required 3–5 s per case for inference and quantitative reporting, compared to 3–5 min for manual segmentation. Conclusions: In patients with advanced liver disease and substantial anatomical distortion from ascites, an ensemble-based 2D nnU-Net provides high quantitative agreement with manual L3 skeletal muscle segmentation, while mitigating lower-bound (worst-case) errors relative to single-fold models. Integration with a dedicated GUI enables substantial time savings and supports scalable quantitative body composition measurement. Full article

Objectives: This study aimed to evaluate the diagnostic performance of peripapillary retinal nerve fiber layer (RNFL) thickness measurements corrected by artificial intelligence (AI) compared to original uncorrected values for glaucoma detection in highly myopic patients. Methods: This cross-sectional diagnostic accuracy study included 57 eyes from highly myopic patients (31 with glaucoma, 26 without glaucoma). Peripapillary RNFL parameters were obtained using Spectralis optical coherence tomography (OCT). A deep learning algorithm (MGU-Net) was employed to automatically segment retinal layers and compensate for scan tilt in elongated eyes, producing AI-corrected measurements. RNFL thickness values were extracted for six sectoral parameters (ST, SN, N, IN, T, IT) and global. Diagnostic performance was assessed using area under the ROC curve (AUC) and compared between corrected and uncorrected values. Multivariable logistic regression models were also developed using stepwise selection. Results: AI-corrected values were significantly lower than original measurements in all sectors (p < 0.001), with mean differences ranging from 15 to 35 µm. In glaucomatous eyes, significant thinning was observed in the global (p = 0.049) and inferior nasal (IN) sector (p = 0.037) among corrected values. The highest AUCs were found in IN (0.69), IT (0.67), and global (0.66) for corrected values, and in IT (0.63), T (0.59), and global (0.63) for uncorrected data. A model combining ST, T, and IT AI-corrected values achieved an AUC of 0.79. Conclusions: AI-corrected RNFL thickness measurements improve consistency and enhance diagnostic performance in highly myopic glaucoma patients. Correction algorithms may reduce false positives and help reveal glaucomatous damage otherwise obscured by myopic anatomical changes. Full article

Background/Objectives: Recent studies have increasingly focused on the morphological characteristics of surrounding arteries as rupture predictors, particularly because these vessel configurations remain stable before and after aneurysm rupture, providing a reliable anatomical substrate for risk assessment. This study aimed to identify independent predictors of rupture by evaluating both aneurysmal and internal carotid artery (ICA) morphological characteristics. Methods: We retrospectively analyzed imaging data from 64 patients with posterior communicating artery (PcomA) aneurysms who underwent treatment at a single tertiary center between 2018 and 2022, including 25 ruptured aneurysms (39.1%). Only treated aneurysms were included to ensure the availability of high-quality pre-treatment digital subtraction angiography (DSA) suitable for three-dimensional (3D) reconstruction and centerline-based analysis. Seventeen aneurysm morphological parameters and thirteen ICA-related parameters were measured. Because time-to-event data were not available, logistic regression analysis was performed with rupture status as the outcome variable. Receiver operating characteristic (ROC) curve analyses were conducted to evaluate discriminative performance. Results: Multivariate logistic regression revealed that three ICA-associated factors—the tortuosity of the communicating ICA segment (Tcco), the ICA cross-sectional area at the PcomA origin (Pcs), and the angle between the ICA and PcomA (θ2)—were independently associated with rupture. Among aneurysm-related factors, Maximum 3D Diameter remained significantly related to rupture risk. ROC analyses demonstrated that Maximum 3D Diameter had the highest discriminative value (AUC 0.779; cut-off 7.805 mm), followed by Pcs, Tcco, and θ2. Conclusions: Both aneurysm morphology and the anatomical configuration of surrounding arteries significantly contribute to rupture risk in PcomA aneurysms. Incorporating parent-vessel morphological features into rupture-risk assessment may enhance patient-specific decision-making. Full article

Background/Objectives: Several methods have been proposed to assess lower limb-length discrepancies; however, none have demonstrated sufficient reliability and validity for diagnosing anatomical discrepancies (DA). Objectives: This study primarily aims to evaluate the accuracy of two traditional tests—the Modified Iliac Crests Palpation and Pelvimeter with Blocks test (ICPBL) and plantar pressure analysis—by comparing them with the gold standard telemetry (TE) method for diagnosing DA. The secondary objective is to assess the intra-rater reliability of these two tests and determine their potential applicability in clinical settings. Methods: Thirty subjects between the ages of 20 and 80 were enrolled in the present prospective, cross-sectional diagnostic accuracy pilot study; thirteen with a positive TE for DA of more than 3 mm were classified into the group with the condition DA, and 17 were classified into the group without the condition DA. Pelvic tilting and plantar pressures were evaluated. Results: The TE revealed a difference of 8.09 ± 3.24 mm between the short and long limbs, while subjects without DA had only a 0.41 mm difference (p < 0.001). Similarly, the Modified ICPBL test showed a 4.38 ± 2.10 mm difference in subjects with DA, compared to 0.51 ± 0.53 mm in those without DA (p < 0.001). Additionally, plantar pressure measurements supported these findings, with a difference of 5.17 ± 3.28 kg/cm² between the short and long limbs in subjects with DA, versus 2.28 ± 1.77 kg/cm² in subjects without DA (p < 0.05). The area under the receiver operating characteristic (ROC) curve was 0.783 (95% CI: 0.456–0.877) for plantar pressures and 1.000 (95% CI: 0.742–0.942) for the Modified ICPBL test. Conclusions: The Modified ICPBL and plantar pressure tests demonstrated high diagnostic accuracy within the sample studied, suggesting they are useful tools for supporting the diagnosis of DA. In this pilot study, the Modified ICPBL showed very high discriminative ability, while plantar pressure testing demonstrated moderate sensitivity. Both methods may serve as preliminary practical alternatives to telemetry TE, potentially reducing X-ray exposure; however, these results should be interpreted with caution due to the limited sample size and the specific clinical setting of this study. Full article

Cataract diagnosis requires a comprehensive dilated examination by an ophthalmologist using a slit lamp; there is currently no effective means to objectively screen for cataracts in the community using portable devices without dilation. We hypothesized that it would be possible to predict cataract severity using deep learning on images taken using a portable smartphone-based slit lamp prototype, with and without dilation. In this prospective cross-sectional pilot study, slit lamp images were captured from eligible patients with cataracts in a tertiary clinic using a portable slit lamp prototype attached to a smartphone. The Pentacam nuclear staging score (PNS, Pentacam^®, Oculus, Inc., Arlington, WA, USA) was taken from the dilated pupils and served as ground truth. A transformer prototypical network with the Swin transformer on the images was trained to assign the class label corresponding to the highest predicted probability. Heat maps were generated based on attribution masks to identify the anatomical areas of concern. A total of 1900 images from 198 eyes of 99 patients were captured. The average age was 65.3 ± 10.4 years (range, 41.0 to 88.0 years) and the average PNS score was 1.57 ± 0.81 (range, 0 to 4). The model achieved an average accuracy of 81.25% and 74.38% for undilated and dilated eyes, respectively. Heat map visualization using the integrated gradient method successfully identified the anatomical area of interest in certain images. This study suggests the possibility of estimating cataract density using a portable smartphone slit lamp device without dilation. Further work is under way to validate this technique in a larger and more diverse group of eyes with cataracts. Full article

Background/Objectives: Tendon injuries are a common cause of emergency department presentation and impose a substantial socioeconomic burden. Despite advances in surgical techniques, rupture rates after primary repair remain at 3.1–11.7%. Contemporary repairs typically combine at least four core strands with epitenon sutures to achieve sufficient tensile strength while limiting bulk. Increasing the number of core strands improves strength but may impair gliding and healing. Looped core sutures increase the effective strand number without additional knots or passes, potentially allowing omission of the epitenon suture and thus limiting repair complexity and bulk. The objective was to determine whether six- or eight-strand looped core suture techniques provide sufficient tensile strength to allow omission of an epitenon suture without excessive repair bulk, compared with a conventional four-strand Adelaide repair. Methods: One hundred and twenty human flexor digitorum profundus tendons were harvested from fresh-frozen anatomical specimens and allocated to six groups: Adelaide (four-strand) ± epitenon suture, six-strand ± epitenon suture, and eight-strand ± epitenon suture. Repairs were performed in zone II. The cross-sectional area (CSA) was measured before and after repair to quantify bulkiness. Tendons were tested to failure using axial tensile loading, and the failure mode was recorded. Results: The Adelaide with epitenon suture, six-strand with epitenon suture, and eight-strand with epitenon suture demonstrated significantly higher load to failure than the Adelaide without epitenon suture. The eight-strand without epitenon suture achieved a load to failure comparable to the Adelaide with epitenon suture, while also resulting in a smaller increase in CSA. The Adelaide with epitenon suture showed the greatest increase in CSA, while the six-strand without epitenon suture showed the smallest increase in CSA. Suture breakage was the predominant failure mode. Conclusions: An eight-strand looped core suture without epitenon suture provides comparable tensile strength to the conventional Adelaide repair with epitenon suture while minimizing repair bulk. The six-strand with epitenon suture demonstrated similar tensile strength to higher-strand techniques and may represent a mechanically adequate alternative with less tissue manipulation. These findings support a more individualized approach to flexor tendon repair, in which the choice of repair construct can be tailored to biomechanical demands and clinical context rather than applying a single uniform technique. Full article

Objective: We examined vastus lateralis (VL), gastrocnemius medialis (GM), gastrocnemius lateralis (GL), and biceps femoris (BF) muscle architecture and force–time parameters recorded during a countermovement jump (CMJ). Methods: Eighty-nine 9 year-old girls (43 rhythmic gymnasts and 46 recreationally active controls) were assessed in: (a) muscle architecture (fascicle length—FL; angle; muscle thickness; and anatomical cross-sectional area—CSA) using ultrasonography, (b) CMJ performance (maximum force—Fmax; rate of force development—RFD; jump height; and peak power) using force–time data, and (c) anthropometrics and body composition. Results: Rhythmic gymnasts exhibited greater BF fascicle length and muscle thickness than controls (7.84 ± 0.73 vs. 7.26 ± 0.75 cm and 1.76 ± 0.19 vs. 1.61 ± 0.22 cm, respectively, p < 0.001), while VL muscle CSA was larger in controls (p = 0.001). When normalized to the respective segment length (thigh or shank), the FL was longer in gymnasts across all muscles (p ≤ 0.017). Gymnasts also demonstrated greater CMJ height (13.1%, p = 0.005), power scaled to body mass, and RFD (p < 0.005), while controls produced a greater Fmax (16.9%, p = 0.002). Body mass was the strongest predictor of Fmax in both groups (p < 0.001). CMJ power was best predicted by gastrocnemius CSA in gymnasts and by VL CSA combined with maturity offset in controls (all p < 0.001). Maturity offset and gastrocnemius CSA also predicted allometrically scaled power in controls. Conclusions: Rhythmic gymnasts are characterized by muscle-specific adaptations, specifically in the BF muscle FL and muscle thickness, which favor superior CMJ performance. In developing athletes, body mass is primarily related to maximal force, whereas muscle CSA is more closely associated with power output. Full article

Background/Objectives: The human larynx exhibits marked sexual dimorphism and undergoes age-related structural remodeling, both of which influence voice characteristics and have important implications for diagnostic assessment. While sex-related differences in laryngeal size are well recognized, the extent to which aging contributes to dimensional versus qualitative structural changes remains incompletely defined. This study aimed to analyze sex- and age-related morphometric and histological characteristics of the human larynx, with a focus on features relevant to voice evaluation and diagnostic interpretation. Methods: A cross-sectional anatomical study was conducted on 80 cadaveric human larynges preserved in 10% buffered formalin. Specimens were stratified by sex and age (<30, 30–60, and ≥60 years). Direct morphometric measurements included anteroposterior laryngeal length, thyroid cartilage height, thyroid angle, and relative glottic area. Epiglottic morphology and the presence of laryngeal cartilage calcification/ossification (binary classification: present vs. absent) were recorded. Histological analysis of vocal fold tissue was performed on a stratified subset of specimens. Statistical analysis included t-tests, chi-square tests, two-way ANOVA, effect size estimation, and logistic regression. Results: Male specimens showed significantly greater anteroposterior length, thyroid cartilage height, and relative glottic area, along with a narrower thyroid angle, compared with females (all p < 0.001), with large effect sizes. Age did not significantly influence overall laryngeal dimensions. In contrast, cartilage calcification/ossification increased markedly after the age of 60. Logistic regression identified age ≥ 60 years as the only independent predictor of calcification (OR = 4.37, p = 0.039), while sex was not significant. Epiglottic morphology demonstrated a sex-dependent distribution. Histology revealed age-related muscle atrophy and reduced collagen and elastin density. Conclusions: Sex defines the baseline morphometric framework of the adult larynx, whereas aging, particularly beyond 60 years, drives qualitative structural degeneration. These findings provide a reproducible anatomical reference for distinguishing sex-related variation from age-related changes in diagnostic assessment. Full article

Digital technologies have improved the visualization of anatomical structures for veterinary education and clinical practice. In this study, a detailed three-dimensional anatomical model of the equine palmar metacarpal region was generated using E12-based epoxy sheet plastination combined with digital reconstruction in Amira^® V5.6 software. Serial cross-sections of the metacarpal region provided high-resolution visualization of bones, tendons, ligaments, nerves, vessels, fasciae, and synovial structures, with minimal shrinkage or deformation, ensuring improved anatomical accuracy. These sections were digitized, aligned, and manually segmented to accurately delineate anatomical boundaries, particularly in areas of low contrast. The resulting three-dimensional model represents the topographical relationships of key structures, including palmar nerves and vessels, the palmar fascia with the metacarpal flexor retinaculum (MFR), and the common synovial sheath (Vag. synovialis communis mm. flexorum, CSS). The model allows rotation and selective visualization of individual structures, facilitating examination from multiple perspectives. This combined plastination–digital approach provides an accurate anatomical reference with value for veterinary anatomy education, clinical training, surgical planning, and research on equine musculoskeletal disorders. Full article

Objectives: Compression neuropathies such as Anterior Tarsal Tunnel Syndrome are usually associated with focal thickening at the compression site. This study aimed to determine the frequency and location of thickenings of dorsal foot nerves in asymptomatic, healthy volunteers. We hypothesized that focal nerve thickening of dorsal foot nerves is a frequent finding in asymptomatic individuals and occurs at anatomically plausible locations, potentially limiting the specificity of ultrasound in the diagnosis of anterior tarsal tunnel syndrome. Materials and Methods: In this prospective study, the nerves at the dorsal foot were examined with ultrasound in 60 volunteers without clinical signs of neuropathy. Cross-sectional area (CSA) changes along the nerve course were assessed, their anatomical location recorded, and demographic data collected. Results: Focal deep peroneal nerve (DPN) thickening was observed in 45% of participants, with a median CSA of 2.14 mm² (range: 0.84–5.16) and median length of 3.98 mm (range: 1.46–9.95). The most frequent site was the first tarsometatarsal joint (41%). Thickening occurred across all age groups. Superficial peroneal nerve (SPN) thickening was found in 13.3% of participants, primarily affecting the intermediate branch, with a median CSA of 1.82 mm² and length of 3.02 mm. No thickening was observed in the sural nerve (SN). A strong correlation was found between CSA and length of DPN thickening (r = 0.67, p < 0.001). Conclusions: Asymptomatic, focal thickening of dorsal foot nerves, particularly the DPN, is a frequent sonographic finding in healthy volunteers. These findings highlight the potential for false-positive ultrasound results and the necessity of correlating imaging findings with clinical examination when evaluating for anterior tarsal tunnel syndrome and similar neuropathies. Full article

Obstructive sleep apnea (OSA) is characterized by recurrent partial or complete upper airway collapse during sleep. Accurate assessment of airway anatomy is crucial for risk stratification, diagnosis, and treatment planning. While polysomnography (PSG) is considered the gold standard for OSA diagnosis, it provides limited anatomical insights. Cone-beam computed tomography (CBCT) has emerged as a valuable tool with lower radiation dose for three-dimensional (3D) assessment of the upper airway space and craniofacial structures. CBCT enables precise measurement of critical airway parameters including total airway volume and length, minimum cross-sectional area, linear dimensions of anteroposterior and lateral diameters, as well as soft tissue structures such as tongue, tonsils, and adenoids. This review aims to explore and comprehensively review the role of CBCT, primarily in upper airway assessment for OSA, with an emphasis on airway measurement parameters, anatomical reference landmarks, and the variabilities, in addition to its clinical applications in treatment planning and simulation and post-treatment efficacy evaluation. This review also highlights the technical considerations such image acquisition protocols, machine specifications and software algorithm, and patient positioning, which may affect measurement reliability and diagnostic accuracy. CBCT serves as a powerful adjunct in OSA diagnosis and management, enabling comprehensive assessment of the airway space and hard and soft tissue structures. It complements PSG by guiding personalized interventions such as maxillomandibular advancement or CPAP optimization. Standardized imaging protocols and consideration of patient positioning can further improve its clinical utility. Full article

Background/Objectives: Functional impairment of the complex motility system in the upper gastrointestinal tract is high in patients suffering from obesity and even higher after metabolic bariatric surgery (MBS). Sleeve gastrectomy (SG) and gastric bypass (GB) represent the most common MBS procedures worldwide. Despite procedural standardization, no diagnostic method is able to depict the functional consequences resulting from intraoperative anatomical changes during MBS. This pilot study was conducted to reveal immediate intraoperative functional effects of MBS on the anti-reflux barrier in SG and GB. Methods: A prospective analysis was performed on consecutive patients with informed consent for MBS. A standard protocol for each procedure was established prior to study onset to analyze functional parameters at the lower esophageal sphincter (LES). Measurements were conducted intraoperatively during minimally invasive SG and GB. Distensibility index (DI), intra-balloon pressure, diameter (Dmin), and minimal cross-sectional area (CSA) at the LES served as points of interest for analyzation. Results: Intraoperative evaluation was performed successfully in 40 patients and no directly related adverse events were reported. DI and Dmin intraoperatively significantly increased immediately in SG (2.1 mm²/mmHg (±0.5) vs. 2.9 mm²/mmHg (±1.3), 95% CI: −1.6 to −0.14, p = 0.023 and 12.0 mm (±1.2) vs. 13.9 mmH (±2.8), 95% CI: −3.6 to −0.2, p = 0.028, respectively) whereas GB did not affect functional measurements. Conclusions: Sleeve gastrectomy immediately and significantly influences the LES and increases the opening area whereas gastric bypass surgery appears not to influence LES distensibility or opening diameters. Intraoperative standardized EndoFLIP^TM measurements are feasible and safe and add additional real-time information during MBS. Full article

Background/Objectives: Managing large midline olfactory groove meningiomas is especially difficult in elderly patients who have limited physiological reserves. Here we describe a unique and dangerous geriatric case where we used new quantifiable anatomical measurements and developed a structured multidisciplinary preoperative and postoperative protocol to assist in all aspects of surgery. Case Presentation: A 68-year-old male with fronto-lobe syndrome and disability (astasia-abasia; Tinetti Balance Score of 4/16 and Gait Score of 0/12) as well as cognitive dysfunction (MoCA score of 12/30) and blindness bilaterally. Imaging prior to surgery demonstrated a very large olfactory groove meningioma which severely compressed both optic pathways at the level of the optic canals (up to 71% reduction in cross-sectional area of the optic nerves) and had complex vascular relationships with the anterior cerebral artery complex (210° contact surface). Due to significant cardiovascular disease and liver disease, his care followed a coordinated optimization protocol for the perioperative period. He underwent bifrontal craniotomy, initial early devascularization and then staged ultrasonic internal decompression (approximately 70% reduction in tumor volume) and finally microsurgical dissection of the tumor under multi-modal monitoring of neurophysiology. Discussion: We analyzed his imaging data prior to surgery using a standardized measurement protocol to provide quantitative measures of the degree of compression of the optic pathways (traction-stretch index = 1.93; optic angulation = 47.3°). These quantitative measures allowed us to make a risk-based evaluation of the anatomy and to guide our choices of corridors through which to dissect and remove the tumor. Following surgery, imaging studies demonstrated complete removal of the tumor with significant relief of the frontal lobe and optic apparatus from compression. His pathology showed that he had a WHO Grade I meningioma with an AKT1(E17K) mutation identified on molecular profiling. Conclusions: This case is intended to demonstrate the feasibility of integrating quantitative anatomical measurements into a multidisciplinary, protocol-based perioperative pathway to maximize the safety and effectiveness of the surgical removal of a complex and high-risk skull-base tumor. While the proposed quantitative indices are experimental and require additional validation, the use of a systematic approach such as this may serve as a useful paradigm for other complex skull-base cases. Full article