Impact of selective dorsal rhizotomy to cerebral palsy children caregivers' burden.

PURPOSE: It is known that cerebral palsy (CP) children's caregivers suffer from burden, depression, and stress, impairing their quality of life (QoL). The more severe the CP, the more burden the caregiver has. Psychosocial support, education, therapies, and financial support are inversely related to the level of stress of the caregiver. Most parents of CP patients submitted to selective dorsal rhizotomy (SDR) report improvement not just on spasticity, but also in the functional role of the children, what can impact on caregiver's QoL. Our objective was to evaluate the burden of CP children's caregivers with and without previous SDR. METHODS: Spastic CP children caregivers were divided into two groups: those who take care of children without previous SDR (control group) and those that children were previously submitted to SDR (surgical group). The burden index was compared between groups using Burden Interview Questionnaire (BIQ). For statistical analysis, we used SPSS. RESULTS: The control group had enrolled 31 participants and the surgical group 36. The mean GMFCS level on the control and surgical groups was 3.94 ± 1.26 and 3.74 ± 1.12 (p = 0.61), respectively. The surgical group caregivers presented less burden related to the feeling that they should be doing more to their child (p = 0.003) and if they could do a better job in caring (p = 0.032), compared to controls. The total BIQ index was not significantly different between groups (surgical 32.14 ± 12.34 vs. control 36.77 ± 12.77; p = 0.87). Low economic status had a weak correlation to a higher BIQ index (R2 = 0.24). After age-matching, there was a significative higher BIQ index in the control group (p = 0.008). CONCLUSION: Caregivers of spastic CP children who were previously submitted to SDR presented less burden related to feeling of the amount of given care than those without previous surgery. The impression that they could do a better job with their kids was higher in the control group. The severity of CP and low economic status were related to more burden in both groups. After pairing groups by age, the control group had a significative higher BIQ index compared to the SDR group. CLINICAL TRIAL REGISTRATION: Trial registration number: CAAE 73407317.6.0000.0068 (Ethical and Research Committee of University of Sao Paulo, Sao Paulo, Brazil, approved on 08/06/2021). All the subjects were freely given an informed consent to participate in the study that was obtained from all participants. Non-consented ones were excluded from the study.

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.

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.

Review of spinal cord stimulation for disorders of consciousness.

PURPOSE OF REVIEW: High-cervical spinal cord stimulation can alter cortical activity and cerebral metabolism. These effects are potentially beneficial for disorders of consciousness. A better understanding of the effects of clinical application of stimulation is needed. We aimed to evaluate the existing literature to determine the state of available knowledge. We performed a literature review of clinical studies assessing cervical spinal cord epidural stimulation for disorders of consciousness. Only peer-reviewed articles reporting preoperative and postoperative clinical status were included. RECENT FINDINGS: Nineteen studies were included. A total of 532 cases were reported, and 255 patients were considered responsive (47.9%). Considering only studies published after the definition of minimally conscious state (MCS) as an entity, 402 individuals in unresponsive wakefulness syndrome (UWS) and 113 in MCS were reported. Responsiveness to SCS was reported in 170 UWS patients (42.3%) and in 78 MCS cases (69.0%), although the criteria for responsiveness and outcome measures varied among publications. SUMMARY: Cervical SCS yielded encouraging results in patients with disorders of consciousness and seems to be more effective in MCS. More extensive investigation is needed to understand its potential role in clinical practice.

Intracerebroventricular baclofen therapy improves function and quality of life in a child with severe cerebral palsy.

Limited therapies are available for severe cerebral palsy children (CP) with complex movement disorders, especially when both dystonia and spasticity are present. In this publication, we present the improvement of a child with severe CP after intracerebroventricular baclofen therapy. The treatment can impact not just the movement disorders but also on the quality of life of the child and caregivers. Global functional improvements can be observed on the 6-month follow-up.

Fitness-to-drive after adult civilian traumatic brain injury: protocol for a systematic review and meta-analysis.

Traumatic brain injury (TBI) poses significant challenges for assessing fitness-to-drive (FTD) and determining the appropriate timing for return-to-driving (RTD) in civilian adults. This systematic review and meta-analysis protocol is designed to offer a comprehensive assessment of RTD timelines post-TBI, examining the effects of injury severity as well as demographic and clinical factors that influence driving capabilities. In response to gaps identified in previous literature-namely, the absence of recent systematic search strategies and thorough quality assessments-this study employs rigorous methodologies for literature search, data extraction, and evaluation of study quality. Our approach aims to provide reliable estimates and detailed analyses of subgroups within the TBI population. The findings aim to support clinical decision-making, inform RTD readiness, and potentially impact policy and driving assessment protocols. Ultimately, this review seeks to contribute to public safety measures, reduce traffic-related harm, and improve life outcomes for individuals recovering from TBI, thereby filling a vital research niche in neurotrauma rehabilitation.

Motor cortex stimulation for chronic neuropathic pain: results of a double-blind randomized study.

Motor cortex stimulation via surgically implanted electrodes has been used as an off-label treatment for chronic neuropathic pain, but its efficacy has not been fully established. We aimed to objectively study the efficacy of motor cortex stimulation and characterize potential predictors of response. In this randomized, double-blind, sham-controlled, single centre trial, we recruited 18 patients with chronic neuropathic pain who did not adequately respond to conventional treatment and had a numerical pain rating scale (NRS) score ≥6. Patients were initially assigned to receive 3 months of active ('on') or sham ('off') stimulation in a double-blind cross-over phase. This was followed by a 3-month single-blind phase, and 6 months of open-label follow-up. A meaningful response in our trial was defined as a ≥30% or 2-point reduction in NRS scores during active stimulation. Using Bayesian statistics, we found a 41.4% probability of response towards on versus off motor cortex stimulation. The probability of improvement during active stimulation (double-blind, single-blind and open-label phases) compared to baseline was 47.2-68.5%. Thirty nine per cent of the patients were considered long-term responders, 71.4% of whom had facial pain, phantom limb pain or complex regional pain syndrome. In contrast, 72.7% of non-responders had either post-stroke pain or pain associated with brachial plexus avulsion. Thirty-nine per cent of patients had a substantial postoperative analgesic effect after electrode insertion in the absence of stimulation. Individuals with diagnoses associated with a good postoperative outcome or those who developed an insertional effect had a near 100% probability of response to motor cortex stimulation. In summary, we found that ∼40% of patients responded to motor cortex stimulation, particularly those who developed an insertional effect or had specific clinical conditions that seemed to predict an appropriate postoperative response.

Computer-assisted craniometric evaluation for diagnosis and follow-up of craniofacial asymmetries: SymMetric v. 1.0.

PURPOSE: The current assessment of patients with craniofacial asymmetries is accomplished by physical examination, anamnesis and radiological imaging. We propose a semi-automated, computer-assisted craniofacial evaluation (SymMetric v 1.0) based on orthogonal photography of the patient's head in 3 positions. The system is simple, low-cost, no-radiation or special resources needed. Although it does not substitute CT in cases of doubt between craniosynostosis and positional plagiocephaly, multiple numeric evaluations indicate regional deformities and severity of the asymmetry, which can help in the clinical decision of indicating or not the orthosis in positional deformities, determining treatment duration or evaluating surgical outcomes after correction. METHODS: A Matlab-based tool was developed for digital processing of photographs taken in 3 positions (anterior, superior and lateral). The software guides the user to select visible and reproducible landmarks in each photograph acquisition and calculates multiple indexes and metrics, generating a set of comprehensive plots to offer the user an overview of head and facial symmetry across the orthogonal views. For purposes of demonstration, we evaluated 2 patients (one control and one with non-sinostotic deformity). RESULTS: The results show a clear differentiation of the control and plagiocephalic patient metrics mainly in the superior view, showing potential for diagnosis of the condition, and also detected the clinical improvement during helmet treatment in the follow-up, 3 and 5 months after orthosis' use. CONCLUSION: We presented a proof-of-concept for a low cost, no radiation evaluation system for craniofacial asymmetries, that can be useful in a clinical context for diagnosis and follow-up of patients.

Pediatric intrinsic brainstem lesions: clinical, imaging, histological characterization, and predictors of survival.

PURPOSE: Brainstem lesions comprise 10-20% of all pediatric brain tumors. Over the past years, the benefits of stereotactic biopsy versus the use alone of MRI features to guide treatment have been controversial. METHODS: Retrospective study with pediatric patients submitted to stereotactic brainstem biopsies between 2008 and 2018. Demographic, clinical, imaging, and surgical characteristics were recorded, as well as the histological diagnosis, complications, and survival. Predictors of survival were evaluated through Cox regression models after multivariate adjustment. RESULTS: Twenty-six patients (mean age of 8.8 ± 4.3 years and 14 female). Diagnosis was reached on 84.6% (95% CI 65.1-95.6%) of the patients. Glioma was diagnosed on 20 cases (11 high-grade and 9 low-grade lesions). There was no association between age and gender and the dichotomized histological diagnosis. Contrast enhancement, diffuse distribution, invasion of adjacent structures, and remote injury were present on 62.5%, 75.0%, 62.5%, and 25.0% of the cases. Hydrocephalus at admission was present on almost half of the patients (46.2%). Only radiological invasion of adjacent structures had a possible association with high-grade lesions (p = 0.057). Surgical trajectory was trans-cerebellar in most of the cases (79.9%). There were no major complications and only two minor/transitory complications. Poorer survival was independently associated with high-grade lesions (HR 32.14, 95% CI 1.40-735.98, p = 0.030) and contrast enhancement at MRI (HR 36.54, 95% CI 1.40-952.26, p = 0.031). CONCLUSIONS: Stereotactic biopsy was safe and allows successful tissue sampling for a definite diagnosis. Poorer survival was independently associated with high-grade and contrast-enhancing lesions.

Ultrasound-Guided DREZotomy: Technical Note.

Dorsal root entry zone (DREZ) lesioning is still used as a choice of treatment for some painful conditions as well as spasticity in selected patients. The most commonly used techniques to perform DREZotomy are the microsurgical one and DREZ radiofrequency (RF) coagulation. The technical difficulties using punctures to perform RF lesions include complications such as occurrence of lesions in the dorsal columns or in the corticospinal tract. This paper describes a new technical improvement in RF lesions at DREZ using intraoperative ultrasound (US) to optimize the lesions and to minimize the risk of complications. Using intraoperative US after laminotomy allows the surgeon to differentiate between the gray matter of the spinal cord and white matter, showing the correct entry zone, the angle to introduce the RF electrode, and the depth. Using intraoperative US to guide DREZ lesions provides real-time optimization of DREZotomy.

Intrathecal morphine therapy in the management of status dystonicus in neurodegeneration brain iron accumulation type 1.

Neurodegeneration with brain iron accumulation type 1 (NBIA-1) is a rare disorder characterized by progressive extrapyramidal dysfunction and dementia. NBIA-1 encompasses typical iron brain accumulation, mostly in the globus pallidus with secondary dementia, spasticity, rigidity, dystonia, and choreoathetosis. Treatment remains mostly symptomatic and is challenging. We present the case of a 14-year-old boy diagnosed with NBIA-1, presenting intractable progressive generalized dystonia leading to unresponsive status dystonicus (SD). The patient received a SynchroMed II (model 8637) programmable system pump (Medtronic®, Inc.) implant with an Ascenda intrathecal catheter for intrathecal morphine therapy (IMT). The initial dose of morphine was 1.0 mg/day. Overall, we observed no complications with IMT treatment and important improvement of the patient's motor function with stabilization of his incapacitating dystonia and his quality of life. On the Global Dystonia Severity Rating Scale, he presented 52% improvement, 30% improvement on the Unified Dystonia Rating Scale, and 38% improvement on the Fahn-Marsden Rating Scale after 10 months, when the dose was 1.7 mg/day. IMT should be considered as a potential palliative treatment in the management of intractable dystonia and SD secondary to NBIA-1.

Synergistic neuromodulation therapy for persistent spinal pain: a proof-of-concept trial on the use of spinal cord and dorsal root ganglion stimulation.

PURPOSE: Persistent Spinal Pain Syndrome type 2 (PSPS-T2) poses a significant clinical challenge, demanding innovative therapeutic interventions. The integration of Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion Stimulation (DRG-S) is emerging as a potent synergistic strategy for comprehensive pain management. This single patient-blind proof of concept (POC) trial explores the efficacy and synergistic potential of combined SCS and DRG-S in a patient with refractory PSPS-T2. METHODS: A 45-year-old male with intractable PSPS-T2 underwent a unique, methodically structured study, involving three treatment phases: Phase A with SCS alone, Phase B with DRG-S alone, and Phase C The patient, blinded to the treatment modalities, provided pain assessments using the Visual Analogue Scale (VAS) and Douleur Neuropathique 4 Questions (DN4) conducted by clinical investigators at each phase. Baseline pain scores were ten and nine, respectively. RESULTS: Distinct responses were noted across the phases. Phase A demonstrated moderate pain relief, while Phase B offered further pain intensity reduction. However, Phase C, combining both strategies, yielded the most significant improvement, remarkably enhancing the patient's quality of life and functional capacity. CONCLUSION: This POC trial underscores the synergistic potential of SCS and DRG-S in managing complex cases of PSPS-T2, suggesting a paradigm shift towards integrated neuromodulation strategies for enhanced pain control. The development of dual intent implantable pulse generators (IPGs) capable of offering combination therapy simultaneously might be effective for pain management in select cases. The significant pain reduction and functional improvement observed advocate for further research in dual neuromodulation therapies. TRIAL REGISTRATION NUMBER: IRB 20190536.

Traumatic Brain Injury in the Setting of Fahr Syndrome.

Fahr syndrome, or bilateral striatopallidodentate calcinosis, is a rare syndrome that can confound interpretation of traumatic brain injury seen on computed tomography of the head (CTH). Understanding that this syndrome presents with diffuse calcified lesions will assist clinicians unfamiliar with Fahr syndrome when evaluating diffuse hyperdensities seen on CTH in the setting of trauma between traumatic acute blood versus calcification. We present a unique image that demonstrates how a traumatic brain injury patient can present with traumatic acute hemorrhage and Fahr syndrome. We highlight 2 methods within the CTH images that can be used to assist in these diagnoses, which will better inform neurosurgeons and other clinicians when encountering this unique and rare presentation for the first time.

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.

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.

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.

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.

Unusual Intraventricular Bullet Migration During Operation: A Case Report on Treatment Strategies.

Gunshot head injuries are increasingly prevalent in the urban setting and carry complex technical and clinical decision-making challenges to practicing neurosurgeons. Here, we present a unique case of a patient who suffered a gunshot injury and presented to the emergency department with an intraventricular bullet lodgment without significant neurological deficits. The patient was rushed to the operating room to remove the bullet after neuroimaging demonstrated its migration inside the ventricular system. The patient showed a favorable outcome postoperatively. This case report highlights the importance of prompt diagnosis and tailored management strategies in cases of intraventricular bullet lodgment.

Burr Hole Hematoma Evacuation of Large Subdural Component Using Recombinant Tissue-Type Plasminogen Activator and a Novel Catheter: Case Report.

The large acute component in a chronic subdural hematoma (cSDH) typically requires a craniotomy. Open surgery can be associated with increased morbidity and is not always possible due to systemic conditions. We present the case of a 58-year-old patient who presented with a Glasgow Coma Scale (GCS) of three fixed pupils, but remaining brainstem reflexes were present. Brain CT showed a large mixed subdural left chronic hematoma, with a predominant acute component, with a 26mm midline shift. The patient was hemodynamically unstable and coagulopathic; thus, emergency bedside burr hole evacuation was done. An "anti-thrombotic catheter" was left in the subdural space as a postoperative drain. Postoperatively, GCS improved, and CT presented a residual 12.7mm midline shift due to the acute bleeding component. Recombinant tissue-type plasminogen activator (r-tPA) solution was repeatedly administered using the catheter for two days, and it continued to drain for 10 more days with no additional dose. The patient presented clinical and radiological improvement with the dissolution of the acute component. This case is the first description of local subdural use of r-tPA to treat the acute component of cSDH with success associated with an anti-thrombotic catheter.