Everything old is new again. revisiting hypophysectomy for the treatment of refractory cancer-related pain: a systematic review.

Cancer-related pain is a common and debilitating condition that can significantly affect the quality of life of patients. Opioids, NSAIDs, and antidepressants are among the first-line therapies, but their efficacy is limited or their use can be restricted due to serious side effects. Neuromodulation and lesioning techniques have also proven to be a valuable instrument for managing refractory pain. For patients who have exhausted all standard treatment options, hypophysectomy may be an effective alternative treatment. We conducted a comprehensive systematic review of the available literature on PubMed and Scielo databases on using hypophysectomy to treat refractory cancer-related pain. Data extraction from included studies included study design, treatment model, number of treated patients, sex, age, Karnofsky Performance Status (KPS) score, primary cancer site, lead time from diagnosis to treatment, alcohol injection volume, treatment data, and clinical outcomes. Statistical analysis was reported using counts (N, %) and means (range). The study included data from 735 patients from 24 papers treated with hypophysectomy for refractory cancer-related pain. 329 cancer-related pain patients were treated with NALP, 216 with TSS, 66 with RF, 55 with Y90 brachytherapy, 51 with Gamma Knife radiosurgery (GK), and 18 with cryoablation. The median age was 58.5 years. The average follow-up time was 8.97 months. Good pain relief was observed in 557 out of 735 patients, with complete pain relief in 108 out of 268 patients. Pain improvement onset was observed 24 h after TSS, a few days after NALP or cryoablation, and a few days to 4 weeks after GK. Complications varied among treatment modalities, with diabetes insipidus (DI) being the most common complication. Although mostly forgotten in modern neurosurgical practice, hypophysectomy is an attractive option for treating refractory cancer-related pain after failure of traditional therapies. Radiosurgery is a promising treatment modality due to its high success rate and reduced risk of complications.

Resting-State EEG Signature of Early Consciousness Recovery in Comatose Traumatic Brain Injury Patients.

Background Resting-state electroencephalogram (rsEEG) is usually obtained to assess seizures in comatose patients with traumatic brain injury (TBI) patients. We aim to investigate rsEEG measures and their prediction of early recovery of consciousness in comatose TBI patients. Methods This is a retrospective study of comatose TBI patients who were admitted to a level-1 trauma center (10/2013-1/2022). Demographics, basic clinical data, imaging characteristics, and EEG data were collected. We calculated using 10-minute rsEEGs: power spectral density (PSD), permutation entropy (PE - complexity measure), weighted symbolic-mutual-information (wSMI - global information sharing measure), Kolmogorov complexity (Kolcom - complexity measure), and heart-evoked potentials (HEP - the averaged EEG signal relative to the corresponding QRS complex on electrocardiogram). We evaluated the prediction of consciousness recovery before hospital discharge using clinical, imaging, rsEEG data via Support Vector Machine with a linear kernel (SVM). Results We studied 113 (out of 134, 84%) patients with rsEEGs. A total of 73 (65%) patients recovered consciousness before discharge. Patients who recovered consciousness were younger (40 vs. 50, p .01). Patients who recovered consciousness had higher Kolcom (U = 1688, p = 0.01,), increased beta power (U = 1652 p = 0.003), with higher variability across channels ( U = 1534, p = 0.034), and epochs (U = 1711, p = 0.004), lower delta power (U = 981, p = 0.04) and showed higher connectivity across time and channels as measured by wSMI in the theta band (U = 1636, p = .026, U = 1639, p = 0.024) than those who didn't recover. The ROC-AUC improved from 0.66 (using age, motor response, pupils' reactivity, and CT Marshall classification) to 0.69 (p < 0.001) when adding rsEEG measures. Conclusion We describe the rsEEG EEG signature in recovery of consciousness prior to discharge in comatose TBI patients. Resting-state EEG measures improved prediction beyond the clinical and imaging data.

Retrograde thoracic spinal cord stimulation paddle placement for complex persistent spinal pain syndrome type 2.

BACKGROUND: Spinal cord stimulation (SCS) is a cost-effective option for treating refractory persistent spinal pain syndrome type-2 (PSPS-2). For patients with extensive spine instrumentation including the thoraco-lumbar junction, percutaneous placement of SCS leads is usually not an option being paddle leads typically implanted anterograde. Paddle lead placement will be particularly challenging in more complex cases when the instrumentation covers the targeted level. To overcome this barrier, we studied using a retrograde approach to reach the sweet spot, facilitate the placement, and reduce associated risks. OBJECTIVES: To study the use of retrograde SCS paddle as a placement method to optimize the spinal cord target and reduce the risks of conventional placement in complex cases. STUDY DESIGN: Case series and technical note. METHODS: We present three cases of thoracic retrograde SCS paddle lead placement cases, detailing patient selection, operative technique, and outcome. All the cases had extensive instrumentation to the thoraco-lumbar spine, and one had additional spinal canal stenosis. The surgical procedure entailed a retrograde midthoracic inter-laminar approach, flavectomy, and caudal placement of the paddle lead with intraoperative neurophysiologic monitoring (IONM) guidance for functional midline determination. RESULTS: All the cases had a successful lead placement over the sweet spot without complications. The same approach was used to decompress a focal spinal stenosis in one case. One case had significantly improved pain and hence underwent a pulse generator implant. The other cases had non-satisfactory pain control and were explanted. LIMITATIONS: These case description could guide technical procedural steps, however, a larger number of such cases would be needed to describe further technical nuances. CONCLUSIONS: We demonstrated that placing SCS paddle leads via retrograde midthoracic approach with IONM guidance is safe. This procedure should be an option for SCS paddle implants in patients with posterior spinal fusion encompassing the intended targeted spinal stimulation level.

Robotic-Assisted Stereoelectroencephalography: A Systematic Review and Meta-Analysis of Safety, Outcomes, and Precision in Refractory Epilepsy Patients.

Robotic assistance in stereoelectroencephalography (SEEG) holds promising potential for enhancing accuracy, efficiency, and safety during electrode placement and surgical procedures. This systematic review and meta-analysis, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and International Prospective Register of Systematic Reviews (PROSPERO) registration, delves into the latest advancements and implications of robotic systems in SEEG, while meticulously evaluating outcomes and safety measures. Among 855 patients suffering from medication-refractory epilepsy who underwent SEEG in 29 studies, averaging 24.6 years in age, the most prevalent robots employed were robotic surgical assistant (ROSA) (450 patients), Neuromate (207), Sinovation (140), and ISys1 (58). A total of 8,184 electrodes were successfully implanted, with an average operative time of 157.2 minutes per procedure and 15.1 minutes per electrode, resulting in an overall mean operative time of 157.7 minutes across all studies. Notably, the mean target point error (TPE) stood at 2.13 mm, the mean entry point error (EPE) at 1.48 mm, and postoperative complications occurred in 7.69% of robotically assisted (RA) SEEG cases (60), with 85% of these complications being asymptomatic. This comprehensive analysis underscores the safety and efficacy of RA-SEEG in patients with medication-refractory epilepsy, characterized by low complication rates, reduced operative time, and precise electrode placement, supporting its widespread adoption in clinical practice, with no discernible differences noted among the various robotic systems.

Deep Brain Stimulation for an Unusual Presentation of Myoclonus Dystonia Associated with Russell-Silver Syndrome.

Background: Myoclonus dystonia syndrome typically results from autosomal dominant mutations in the epsilon-sarcoglycan gene (SGCE) via the paternally expressed allele on chromosome 7q21. There is evidence that deep brain stimulation (DBS) is beneficial for this genotype, however, there are few prior case reports on DBS for myoclonus dystonia syndrome secondary to other confirmed genetic etiologies. Case Report: A 20-year-old female with concomitant Russell-Silver syndrome and myoclonus dystonia syndrome secondary to maternal uniparental disomy of chromosome 7 (mUPD7) presented for medically refractory symptoms. She underwent DBS surgery targeting the bilateral globus pallidus interna with positive effects that persisted 16 months post-procedure. Discussion: We present a patient with the mUPD7 genotype for myoclonus dystonia syndrome who exhibited a similar, if not superior, response to DBS when compared to patients with other genotypes. Highlights: This report outlines the first described case of successful deep brain stimulation treatment for a rare genetic variant of myoclonus dystonia syndrome caused by uniparental disomy at chromosome 7. These findings may expand treatment options for patients with similar conditions.

Navigated Dorsal Root Ganglion Stimulation (DRGS) for the Treatment of Chronic Refractory Coccygodynia: A Case Report.

Sacral stimulation is a well-established therapy for urologic neuromodulation. After the advent of dorsal root ganglion (DRG) stimulation, pain surgeons have started to reach this target mostly for pelvic and sacral pain. For those without good surgical experience, sacral foramen puncture, especially S3 and S4, can be a challenge, due to its entry angle and limited C-arm image resolution. In this report, we describe a new technique to utilize sacral navigation using the O-arm approach to guide DRG stimulation implants. We discuss a case of a 53-year-old male patient with refractory coccygodynia, who underwent sacral DRG implantation using neuronavigation. Punctures could be done without the need for multiple attempts to reach the foramen in this patient.

Safety Analysis of a New Portable Electrical Drill With a Smart Autostop Mechanism for Bedside Cranial Procedures.

BACKGROUND AND OBJECTIVES: Bedside procedures are often helpful for neurosurgical patients, especially in neurocritical care. Portable drills with technological advancements may bring more safety and efficiency to the bedside. In this study, we compared the safety and efficiency of a new cordless electric drill with smart autostop ("HD"-Hubly Cranial Drill, Hubly Surgical) with those of a well-established standard traditional electrical neurosurgical perforator ("ST"). METHODS: A cadaveric study was conducted using both drills to perform several burr holes in the fronto-temporo-parietal region of the skull. An evaluation was performed on the number of dura plunges, and complete burr hole success rates were compared. RESULTS: A total of 174 craniotomies using the HD and 36 burr holes using the ST perforator were performed. Despite significantly exceeding intended drill bit tolerance by multiple uses of a single-use disposable HD, autostop engaged in 100% of the 174 craniotomies and before violating dura in 99.4% of the 174 craniotomies, with the single dura penetration occurring on craniotomy no. 128 after the single-use drill bit had significantly dulled beyond its single-use tolerance. Autostop engaged before dura penetration for 100% of the 36 burr holes drilled with the ST perforator ( P = .610). All the perforations were complete using the HD after resuming drilling. An autostop mechanism in a cranial drill is not commonly available for portable bedside perforators. In the operating room, most use a mechanical method to stop the rotation after losing bone resistance. This new drill uses an electrical mechanism (smart autostop) to stop drilling, making it a single-use cranial drill with advanced features for safety and efficiency at the bedside. CONCLUSION: There was no difference in the safety and efficacy of the new cordless electric drill with smart autostop when performing craniotomies compared with a traditional well-established electric cranial perforator with mechanical autostop on a cadaveric model.

Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study.

BACKGROUND: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS: This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS: Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS: MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.

Chronic subdural hematoma drainage using anti-thrombotic catheter technique.

Background: Burr hole evacuation is a well-established treatment for symptomatic cases with chronic subdural hematoma (cSDH). Routinely postoperative catheter is left in the subdural space to drain the residual blood. Drainage obstruction is commonly seen, and it can be related to suboptimal treatment. Methods: Two groups of patients submitted to cSDH surgery were evaluated in a retrospective non-randomized trial, one group that had conventional subdural drainage (CD group, n â€‹= â€‹20) and another group that used an anti-thrombotic catheter (AT group, n â€‹= â€‹14). We compared the obstruction rate, amount of drainage and complications. Statistical analyses were done using SPSS (v.28.0). Results: For AT and CD groups respectively (median â€‹± â€‹IQR), the age was 68.23 â€‹± â€‹26.0 and 70.94 â€‹± â€‹21.5 (p â€‹> â€‹0.05); preoperative hematoma width was 18.3 â€‹± â€‹11.0 â€‹mm and 20.7 â€‹± â€‹11.7 â€‹mm and midline shift was 13.0 â€‹± â€‹9.2 and 5.2 â€‹± â€‹8.0 â€‹mm (p â€‹= â€‹0.49). Postoperative hematoma width was 12.7 â€‹± â€‹9.2 â€‹mm and 10.8 â€‹± â€‹9.0 â€‹mm (p â€‹< â€‹0.001 intra-groups compared to preoperative) and MLS was 5.2 â€‹± â€‹8.0 â€‹mm and 1.5 â€‹± â€‹4.3 â€‹mm (p â€‹< â€‹0.05 intra-groups). There were no complications related to the procedure including infection, bleed worsening and edema. No proximal obstruction was observed on the AT, but 8/20 (40%) presented proximal obstruction on the CD group (p â€‹= â€‹0.006). Daily drainage rates and length of drainage were higher in AT compared to CD: 4.0 â€‹± â€‹1.25 days vs. 3.0 â€‹± â€‹1.0 days (p â€‹< â€‹0.001) and 69.86 â€‹± â€‹106.54 vs. 35.00 â€‹± â€‹59.67 â€‹mL/day (p â€‹= â€‹0.074). Symptomatic recurrence demanding surgery occurred in two patients of CD group (10%) and none in AT group (p â€‹= â€‹0.230), after adjusting for MMA embolization, there was still no difference between groups (p â€‹= â€‹0.121). Conclusion: The anti-thrombotic catheter for cSDH drainage presented significant less proximal obstruction than the conventional one and higher daily drainage rates. Both methods demonstrated to safe and effective for draining cSDH.

Covert Tracking to Visual Stimuli in Comatose Patients With Traumatic Brain Injury.

OBJECTIVES: This study investigated video eye tracking (VET) in comatose patients with traumatic brain injury (TBI). METHODS: We recruited healthy participants and unresponsive patients with TBI. We surveyed the patients' clinicians on whether the patient was tracking and performed the Coma Recovery Scale-Revised (CRS-R). We recorded eye movements in response to motion of a finger, a face, a mirror, and an optokinetic stimulus using VET glasses. Patients were classified as covert tracking (tracking on VET alone) and overt tracking (VET and clinical examination). The ability to obey commands was evaluated at 6-month follow-up. RESULTS: We recruited 20 healthy participants and 10 patients with TBI. The use of VET was feasible in all participants and patients. Two patients demonstrated covert tracking (CRS-R of 6 and 8), 2 demonstrated overt tracking (CRS-R of 22 and 11), and 6 patients had no tracking (CRS-R of 8, 6, 5, 7, 6, and 7). Five of 56 (9%) tracking assessments were missed on clinical examination. All patients with tracking recovered consciousness at follow-up, whereas only 2 of 6 patients without tracking recovered at follow-up. DISCUSSION: VET is a feasible method to measure covert tracking. Future studies are needed to confirm the prognostic value of covert tracking.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Related to Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is a connective tissue disease with vascular abnormalities involving multiple organs. The prevalence of ADPKD associated with a spontaneous subdural hematoma (SDH) is very low, with less than 10 cases reported in the literature to date. Symptomatic chronic SDH is classically treated with a twist drill, burr holes, or craniotomy. Recently, middle meningeal artery (MMA) embolization has emerged as an ancillary modality. We present the first case in the literature of a bilateral SDH in a young ADPKD patient successfully managed with MMA embolization. Moreover, we discuss the role of different treatment modalities on this subset of patients.

The Cost of Gunshot Wounds to the Head: An Unevenly Distributed Burden.

BACKGROUND: Despite the significant clinical consequences and socioeconomic costs of gunshot wounds to the head (GSWH), studies examining prehospital risk factors, geospatial patterns, and economic cost are lacking. METHODS: A retrospective analysis was performed for patients with GSWH (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami-Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. In addition, ME data were queried from the previous decade (2008-2017) to analyze longitudinal trends. RESULTS: A total of 402 consecutive patients met the inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly affecting males, whites, and individuals who committed suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be black males from low socioeconomic status (SES) regions involved in assault. Older white males were overrepresented in patients attempting and completing suicide and thus comprised a higher percentage of ME cases. Geospatial analysis of hospital patient injury zip codes shows that GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total health care costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498, respectively. CONCLUSIONS: In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings show prehospital risk factors and the unequal distribution of the significant economic costs of GSWH.

Neurologic Outcomes for Octogenarians Undergoing Emergent Surgery for Traumatic Acute Subdural Hematoma.

BACKGROUND: Determining the appropriate surgical indications for obtunded octogenarians with traumatic acute subdural hematoma (aSDH) has been challenging. We sought to determine which easily available data would be useful adjuncts to assist in early and quick decision-making. METHODS: We performed a single-center, retrospective review of patients aged ≥80 years with confirmed traumatic aSDH who had undergone emergent surgery. The clinical measurements included the Karnofsky performance scale score, Charlson comorbidity index, Glasgow coma scale (GCS), and abbreviated injury score. The radiographic measurements included the Rotterdam computed tomography score, aSDH thickness, midline shift, and optic nerve sheath diameter (ONSD). The neurologic outcomes were defined using the extended Glasgow outcome scale-extended (GOS-E) at hospital discharge and 3-month follow-up. The Pearson correlation coefficient was used to compare the ONSD with all clinical, radiographic, and outcome variables. Multivariate logistic regression was used to assess the relationship between the discharge and 3-month GOS-E scores between all clinical and radiographic variables. RESULTS: A total of 17 patients met the inclusion criteria. The mean age was 82.5 ± 1.6 years (range, 80-85 years), and the mean GCS score was 11.2 ± 4.1 (range, 4-15). The mean discharge and 3-month GOS-E scores were 3.4 ± 2.6 (range, 1-8) and 2.3 ± 2.1 (range, 1-7), respectively. We found significant negative correlations between the ONSD and the GCS score (r = -0.62; P < 0.01) and the ONSD and discharge GOS-E score (r = -0.49; P = 0.05). Multivariate analysis revealed a significant association between the abbreviated injury score and the discharge GOS-E score (P = 0.05). CONCLUSIONS: Octogenarians sustaining aSDH and requiring emergent surgery have poor outcomes. More data are needed to determine whether the ONSD can be a useful adjunct tool to predict the efficacy of emergent surgery.

Simple wound closure compared with surgery for civilian cranial gunshot wounds.

OBJECTIVE: A carefully selected subset of civilian cranial gunshot wound (CGSW) patients may be treated with simple wound closure (SWC) as a proactive therapy, but the appropriate clinical scenario for using this strategy is unknown. The aim of this study was to compare SWC and surgery patients in terms of their neurological outcomes and complications, including infections, seizures, and reoperations. METHODS: This was a single-center, retrospective review of the prospectively maintained institutional traumatic brain injury and trauma registries. Included were adults who sustained an acute CGSW defined as suspected or confirmed dural penetration. Excluded were nonfirearm penetrating injuries, patients with an initial Glasgow Coma Scale (GCS) score of 3, patients with an initial GCS score of 4 and nonreactive pupils, and patients who died within 48 hours of presentation. RESULTS: A total of 67 patients were included; 17 (25.4%) were treated with SWC and 50 (74.6%) were treated with surgery. The SWC group had a lower incidence of radiographic mass effect (3/17 [17.6%] SWC vs 31/50 [62%] surgery; absolute difference 44.4, 95% CI -71.9 to 16.8; p = 0.002) and lower incidence of involvement of the frontal sinus (0/17 [0%] SWC vs 14/50 [28%] surgery; absolute difference 28, 95% CI -50.4 to 5.6; p = 0.01). There were no differences in the frequency of Glasgow Outcome Scale-Extended scores ≥ 5 between the SWC and surgery groups at 30 days (4/11 [36.4%] SWC vs 12/35 [34.3%] surgery; OR 1.1, 95% CI 0.3-4.5; p > 0.99), 60 days (2/7 [28.6%] SWC vs 8/26 [30.8%] surgery; OR 0.9, 95% CI 0.3-3.4; p > 0.99), and 90 days (3/8 [37.5%] SWC vs 12/26 [46.2%] surgery; OR 0.7, 95% CI 0.1-3.6; p > 0.99). There were no differences in the incidence of infections (1/17 [5.9%] SWC vs 6/50 [12%] surgery; OR 0.5, 95% CI 0.1-4.1; p = 0.67), CSF fistulas (2/11 [11.6%] SWC vs 3/50 [6%] surgery; OR 2.1, 95% CI 0.3-13.7; p = 0.60), seizures (3/17 [17.6%] SWC vs 9/50 [18%] surgery; OR 1, 95% CI 0.2-4.1; p > 0.99), and reoperations (3/17 [17.6%] SWC vs 4/50 [8%] surgery; OR 2.5, 95% CI 0.5-12.4; p = 0.36) between the SWC and surgery groups. CONCLUSIONS: There were important clinically relevant differences between the SWC and surgery groups. SWC can be considered a safe and efficacious proactive therapy in a carefully selected subset of civilian CGSW patients.

Source-sink connectivity: a novel interictal EEG marker for seizure localization.

Over 15 million epilepsy patients worldwide have drug-resistant epilepsy. Successful surgery is a standard of care treatment but can only be achieved through complete resection or disconnection of the epileptogenic zone, the brain region(s) where seizures originate. Surgical success rates vary between 20% and 80%, because no clinically validated biological markers of the epileptogenic zone exist. Localizing the epileptogenic zone is a costly and time-consuming process, which often requires days to weeks of intracranial EEG (iEEG) monitoring. Clinicians visually inspect iEEG data to identify abnormal activity on individual channels occurring immediately before seizures or spikes that occur interictally (i.e. between seizures). In the end, the clinical standard mainly relies on a small proportion of the iEEG data captured to assist in epileptogenic zone localization (minutes of seizure data versus days of recordings), missing opportunities to leverage these largely ignored interictal data to better diagnose and treat patients. IEEG offers a unique opportunity to observe epileptic cortical network dynamics but waiting for seizures increases patient risks associated with invasive monitoring. In this study, we aimed to leverage interictal iEEG data by developing a new network-based interictal iEEG marker of the epileptogenic zone. We hypothesized that when a patient is not clinically seizing, it is because the epileptogenic zone is inhibited by other regions. We developed an algorithm that identifies two groups of nodes from the interictal iEEG network: those that are continuously inhibiting a set of neighbouring nodes ('sources') and the inhibited nodes themselves ('sinks'). Specifically, patient-specific dynamical network models were estimated from minutes of iEEG and their connectivity properties revealed top sources and sinks in the network, with each node being quantified by source-sink metrics. We validated the algorithm in a retrospective analysis of 65 patients. The source-sink metrics identified epileptogenic regions with 73% accuracy and clinicians agreed with the algorithm in 93% of seizure-free patients. The algorithm was further validated by using the metrics of the annotated epileptogenic zone to predict surgical outcomes. The source-sink metrics predicted outcomes with an accuracy of 79% compared to an accuracy of 43% for clinicians' predictions (surgical success rate of this dataset). In failed outcomes, we identified brain regions with high metrics that were untreated. When compared with high frequency oscillations, the most commonly proposed interictal iEEG feature for epileptogenic zone localization, source-sink metrics outperformed in predictive power (by a factor of 1.2), suggesting they may be an interictal iEEG fingerprint of the epileptogenic zone.

Robotic-assisted stereotactic percutaneous balloon compression for trigeminal neuralgia treatment.

Trigeminal neuralgia (TN) is a facial pain disorder that can be a source of significant disability. Percutaneous balloon compression (PBC) has low cost, high efficacy, and minimal invasiveness. Complications can occur due to the balloon inflation or the needle placement itself. In this paper, we describe for the first time the clinical use of robotic-assistance to perform a PBC for TN, presenting our experience in two patients. The stereotactic planning targeted the foramen ovale (FO) establishing a safe and seamless needle trajectory. This yielded a streamlined, single pass needle placement and eliminated the need to "search" for the FO. There were no immediate complications and post-operatively both patients improved their symptoms. Robotic assistance is potentially a useful tool to reduce needle placement related complications, radiation exposure and PBC learning curve.

Simple Wound Closure for Civilian Cranial Gunshot Wounds: A Systematic Literature Review.

Civilian cranial gunshot wounds are common injuries associated with significant morbidity and mortality. Simple wound closure has been previously proposed as an alternative treatment option for a small subset of patients, but the exact outcomes of this strategy are not well-defined. The objective of this paper was to describe the scientific literature reporting simple wound closure of civilian cranial gunshot wounds, its effect on short-term and long-term neurologic outcomes, and rates of seizures and infections. A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The strength of evidence was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria. Seventeen studies were found that met inclusion criteria. There was very low strength of evidence that patients treated with simple wound closure can achieve good short and long-term neurologic outcomes. There was very low strength of evidence that simple wound closure has a higher incidence of mortality compared to operative intervention, especially in patients with initial low Glasgow Coma Scale (GCS) scores. There was very low strength of evidence that patients treated with simple wound closure have a small risk of subsequently developing infections or seizures. In conclusion, under most circumstances, neurosurgical operative intervention should be viewed as the optimal treatment for salvageable civilian cranial gunshot wound patients. However, our literature review showed that simple wound closure is safe and viable. More data are needed to determine the appropriate clinical scenario for using this alternative option.

Design-development of an at-home modular brain-computer interface (BCI) platform in a case study of cervical spinal cord injury.

OBJECTIVE: The objective of this study was to develop a portable and modular brain-computer interface (BCI) software platform independent of input and output devices. We implemented this platform in a case study of a subject with cervical spinal cord injury (C5 ASIA A). BACKGROUND: BCIs can restore independence for individuals with paralysis by using brain signals to control prosthetics or trigger functional electrical stimulation. Though several studies have successfully implemented this technology in the laboratory and the home, portability, device configuration, and caregiver setup remain challenges that limit deployment to the home environment. Portability is essential for transitioning BCI from the laboratory to the home. METHODS: The BCI platform implementation consisted of an Activa PC + S generator with two subdural four-contact electrodes implanted over the dominant left hand-arm region of the sensorimotor cortex, a minicomputer fixed to the back of the subject's wheelchair, a custom mobile phone application, and a mechanical glove as the end effector. To quantify the performance for this at-home implementation of the BCI, we quantified system setup time at home, chronic (14-month) decoding accuracy, hardware and software profiling, and Bluetooth communication latency between the App and the minicomputer. We created a dataset of motor-imagery labeled signals to train a binary motor imagery classifier on a remote computer for online, at-home use. RESULTS: Average bluetooth data transmission delay between the minicomputer and mobile App was 23 ± 0.014 ms. The average setup time for the subject's caregiver was 5.6 ± 0.83 min. The average times to acquire and decode neural signals and to send those decoded signals to the end-effector were respectively 404.1 ms and 1.02 ms. The 14-month median accuracy of the trained motor imagery classifier was 87.5 ± 4.71% without retraining. CONCLUSIONS: The study presents the feasibility of an at-home BCI system that subjects can seamlessly operate using a friendly mobile user interface, which does not require daily calibration nor the presence of a technical person for at-home setup. The study also describes the portability of the BCI system and the ability to plug-and-play multiple end effectors, providing the end-user the flexibility to choose the end effector to accomplish specific motor tasks for daily needs. Trial registration ClinicalTrials.gov: NCT02564419. First posted on 9/30/2015.

Traumatic brain injury and subsequent brain tumor development: a systematic review of the literature.

The role of prior head trauma in stimulating brain tumor development has been previously described in the literature but continues to be debated. The goal of this study was to conduct a systematic review interrogating the contemporary literature to delineate any possible relationship between traumatic brain injury and brain tumor development. A systematic review exploring development of post-TBI brain tumor was conducted by searching electronic databases. Abstracts from articles were read and selected for full-text review according to criteria previously established in the scientific literature. Relevant full-text articles were divided into case reports and single-arm studies and epidemiological studies. Of 1070 resultant articles, 18 case reports and single-arm studies (level of evidence of IV and V) with 45 patients were included. The most common cause of TBI was traffic accidents. The average period between TBI and subsequent tumor diagnosis was 12.8 years. Meningiomas represented the largest share of tumors, followed by gliomas. Most post-TBI brain tumors developed in the frontal and temporal lobes. Fifteen epidemiological studies were also interrogated from a variety of countries (level of evidence of III). Case-control studies were more common than cohort studies. There were 9 of 15 studies proposed a possible relationship between history of head trauma and development of brain tumor. The relationship between head trauma and neoplastic growth continues to be heavily debated. There are certainly case reports and epidemiological studies in the literature that suggest a correlational relationship between the two. However, there is no concrete evidence of a causal relationship between TBI and brain tumors. More research is needed to definitively delineate the extent of any such relationship.

Clinical complications of surviving gunshot wounds to the head in children and adolescents: the Miami experience.

BACKGROUND: Gunshot wounds (GSWs) to the head in the pediatric population are both rare and devastating, with the clinical course of pediatric survivors poorly understood. Correspondingly, the aim of this study was to summarize the clinical complications clinicians can expect of survivors of GSW to the head in children and adolescents in hospital and after discharge. METHODS: A retrospective review of our Level 1 trauma center database between 2011 and 2021 was performed. Clinical data was extracted for those patients aged ≤ 18 years old who survived initial hospitalization with at least one documented follow-up. Categorical data were then compared using Chi-squared test. RESULTS: A total of 19 pediatric survivors of GSW to the head satisfied all selection criteria with an average age was 15.3 years. The majority of cases were isolated head injuries (63%), with an average Glasgow Coma Score (GCS) of 11.9. Bullet trajectory was intraparenchymal in 11 (58%) cases and extraparenchymal in 8 (42%) cases, with 15 (79%) patients treated by surgical intervention. A total of 13 (68%) patients experienced a complication during their hospitalization, with the most common being sympathetic hypertension and endocrinologic salt wasting, each occurring in 5 (26%) patients. With respect to complication categories, the intraparenchymal patients experienced statistically more complications than extraparenchymal patients that were infectious (54% vs 0%, P = 0.01) and sympathetic (45% vs 0%, P = 0.03) in nature. However, with respect to overall neurologic (P = 0.24), endocrinologic (P = 0.24), and traumatic (P = 0.24) complications, their incidences were statistically comparable. All patients were successfully discharged on average post-injury day 22 with an average GCS of 14.0. Mean follow-up for the cohort was 42.6 months, with an average GCS of 14.3. A total of 6 (32%) patients experienced a complication relatable to their initial GSW injury after discharge. The most common individual complication was new-onset seizures in 3 (16%) patients. CONCLUSIONS: Survivors of pediatric GSW to the head can experience multi-systemic complications during both initial hospitalization and afterwards, and bullet trajectory involving the parenchyma may be associated with specific complications more than others. Dedicated inpatient management and outpatient follow-up involving surveillance for complications across all systems, not just neurological, are recommended to ensure patients receive the best care possible.