Mini Temporal Craniotomy Using Anatomical Surface Landmarks for Temporal Lobe Epilepsy: Technical Note and Clinical Outcomes.

Background: Patients with temporal lobe epilepsy are subjected to standard temporal lobectomy wherever indicated. This is performed using a reverse question mark flap and a standard frontotemporal craniotomy. We describe the technique of minitemporal craniotomy (3 × 3cms) for temporal lobe epilepsy (TLE) and analyze the clinical outcomes of patients operated using this approach. Objectives: To describe the technique of minitemporal craniotomy for TLE without navigation guidance and to analyze the clinical outcomes of patients operated using this approach. Materials and Method: This was a retrospective analysis of all consecutive TLE cases operated at our institute from 2014 to 2019, via minitemporal craniotomy, using surface landmarks only without navigation guidance. The surgical technique, indications for surgery, and their clinical outcomes were analyzed. Results: A total number of 48 patients underwent surgery for TLE. There were no complications except three patients who had transient hemiparesis. The average duration of hospital stay was 4 days following surgery. Out of 28 patients with mesial temporal sclerosis, 22 (82%) had international league against epilepsy, Class I seizure outcome, 4 (12.5%) had Class II outcome and 2 (5.5%) had Class III outcome. 9 patients with dysembryoplastic neurectodermal tumor (DNET), 4 gangliogliomas, 2 neurocystecercosis (NCC), all had Class I outcome. Out of the five patients with MTS and associated anterior temporal focal cortical dysplasia (FCD), four (80%) had a Class I outcome, whereas one (20%) had Class II outcome. Conclusion: Utilizing surface anatomical landmarks, minitemporal craniotomy can be performed in even peripheral centers without neuronavigation, with good cosmesis, seizure outcomes.

Case report on ear numbness following deep brain stimulation implantation.

INTRODUCTION AND IMPORTANCE: Deep brain stimulation (DBS) implantation is a neurosurgical procedure in which electrodes are implanted in the brain. Complications that may occur include wound infection, issues with the DBS hardware, and others. This case report presents a patient who suffered ear numbness following DBS implantation. CASE PRESENTATION: A 50-year-old man presented with resting tremors in both hands. He reported that his handwriting had worsened and his movements had slowed. Physical examination revealed rigidity and postural instability. The patient was diagnosed with Parkinson's disease and a bilateral subthalamic nucleus DBS implantation was scheduled combined with the patient's medication all this time. Patient's symptoms showed improvement after the procedure. However, the patient complained of ear numbness and occasional pain in the area around his ear. We observed the patient over the next 3 months and the symptoms eventually resolved without any medication and intervention. CLINICAL DISCUSSION: Ear numbness is a rare complication that occasionally occurs after DBS implantation. This complication occurs because the tunneling track's proximity to the great auricular nerve and the lesser occipital nerve can result in accidental damage to either one or both of these nerves during subcutaneous tunneling. CONCLUSION: We suggest a simple procedure to avoid neural injury while maintaining the course of the tunneling in which the tunnel is created below the periosteum rather than at the subcutaneous level.

Chronic subdural hematoma-induced parkinsonism: A systematic review.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical cases, especially in elderly individuals. Secondary parkinsonism due to CSDH is a rare entity. The mechanism of parkinsonism symptoms in chronic subdural hematoma has been suggested to include direct mechanical compression of the basal ganglia due to hematoma or indirectly through brain structure changes due to space lesions and vascular disorders. Surgery on the subdural hematoma provides a favorable outcome for parkinsonism symptoms. OBJECTIVES: To systematically review the literature on CSDH-induced parkinsonism. SEARCH METHODS: This is a systematic review on case reports. Literature search was performed using the predefined keywords on PubMed, ProQuest, and Google Scholar. We also provided our own case report and compared it with published studies. RESULT: Sixteen cases from 13 case reports/series were identified, predominantly consisting of male patients with the mean age of 66.5 ± 9.73 years. The most common symptoms were rigidity, gait disturbance, and bradykinesia, observed in 12 (75%) cases each. The second and third most common symptoms were tremor (11; 68.75%) and facial masking (8; 50%), respectively. Other reported symptoms were dysphasia (3; 18.75%), dysarthria (3; 18.75%), and urinary incontinence (2; 12. 5%). Time gap between the symptom onset and CSDH diagnosis and unilateral location seemed to influence the outcome. CONCLUSION: Only 16 CSDH-induced parkinsonism were identified since the 1960s. This condition is thought to occur due to basal ganglia compression. Surgery on the subdural hematoma provides a favorable outcome for parkinsonism symptoms. Timely CSDH diagnosis might yield better outcome. However, further research on CSDH-induced parkinsonism is needed, especially in the mechanisms and treatment outcomes.

Robotic-Guided Stereoelectroencephalography for Refractory Epilepsy: Technique and Nuances.

BACKGROUND: Stereoelectroencephalography (SEEG) has become an integral part of epilepsy surgery, often used in the localization of the epileptogenic zone. It is an essential modality not only in the evaluation of nonlesional but also lesional drug refractory epilepsy, especially in the presence of anatomo-electro-clinical discordance. OBJECTIVE: To describe our technique and the operative nuances involved in the performance of robotic SEEG placement. METHODS: A 28-year lady with seizure onset at the age of 15 years presented with two types of seizures: one was associated with an aura of chest discomfort, palpitations along with oral and bilateral automatisms. There was associated speech and behavioral arrest along with ictal urinary incontinence. The other type has head turning to the right with secondary generalization lasting up to 1 min. RESULTS: Multimodality investigations showed bilateral temporal origin of seizures. SEEG evaluation revealed left amygdala and anterior temporal neocortical (ATL) origin of seizures. The patient underwent left ATL and amygdalectomy. Histopathology revealed focal cortical dysplasia (FCD type Ib). The patient became seizure free (ILAE Class 1) at 1-year follow up. CONCLUSION: Robotic-guided SEEG is a safe and accurate method of evaluating complex MRI negative epilepsy.

Stereotactic aspiration of spontaneous intracerebral hematoma: Case series.

INTRODUCTION: Minimally invasive techniques such as stereotactic aspiration of spontaneous intracerebral hematoma (SICH) evacuation can minimize brain tissue damage due to surgery. We share our experience of adopting stereotactic aspiration of SICH in our center without compromising safety. PRESENTATION OF CASES: Three stereotactic aspiration procedures for SICH immediately after 24 h of onset are reported. All cases showed good results. Level of consciousness of all the patient returned to normal. Two patients could carry out routine activities independently. One patient has left hemiparesis. DISCUSSION: Stereotactic aspiration of SICH has been newly implemented at our center with acceptable results achieved. Patient selection has an important role in determining the choice of technique. The procedures were done without anticoagulant agent. Stereotactic aspiration of SICH is associated with limited brain tissue damage, shorter duration of surgery, reduced length of stay, faster postoperative healing, and better functional improvement. CONCLUSION: Stereotactic aspiration of SICH is a minimally invasive defined strategy for hematoma evacuation without compromising safety.

Vim line technique thalamotomy for Parkinson tremor: Case series.

INTRODUCTION: The ventral intermediate (Vim) nucleus of the thalamus is difficult to identify even with 3 T magnetic resonance imaging. Stereotactic Vim thalamotomy is a usual procedure to control Parkinson tremor. Successful relieving of the tremor depends on the accuracy of defining the Vim location. PRESENTATION OF CASES: Three patients with Parkinson tremor were subjected to stereotactic thalamotomy using the Vim line technique (VLT) so as to precisely determine the Vim location. All patients showed good results, with improved tremors, as indicated by the UPDRS score, without any complications. DISCUSSION: The precise targeting of the Vim nucleus is crucial importance for the successful Vim thalamotomy. Various method has been developed to determine Vim location. Atlas based and Guiot's technique routinely used by neurosurgeon. VLT is a new technique that has been developed to determine the Vim location on MRI. CONCLUSION: VLT is useful for the determination of the Vim location. However, further research is warranted to prove its effectiveness.

Complete resolution of recurrent piriformis syndrome after piriformis resection with 3 years' follow up: A case report.

INTRODUCTION: Piriformis syndrome (PS) is an uncommon neuromuscular condition characterized by buttock pain radiating to the leg. Although the goal of PS treatment is symptom relief, it is difficult in some patients using conservative treatment alone. PRESENTATION OF CASE: A 72-year-old male underwent piriformis resection after failed sequential steroid injection of the piriformis. The patient ultimately underwent surgery for resection of the piriformis muscle and experienced satisfactory pain relief (pain reduction > 75% according to visual analog scale for at least 12 months) following surgery and in the 3-year follow-up period. DISCUSSION: Conservative treatment is first-choice treatment for managing PS. Surgery was indicated when the patient did not achieve satisfactory pain relief with conservative treatment. Surgical resection of the piriformis muscle has been shown to be effective and feasible. CONCLUSION: Piriformis resection is effective and can be a feasible option for the treatment of PS following failure of appropriate conservative treatment(s).

Endoscope-assisted (with robotic guidance and using a hybrid technique) interhemispheric transcallosal hemispherotomy: a comparative study with open hemispherotomy to evaluate efficacy, complications, and outcome.

OBJECTIVEEndoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.METHODSThis was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.RESULTSOf 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen's syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.CONCLUSIONSEH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.

Stereotactic Radiofrequency Thermocoagulation of Hypothalamic Hamartoma Using Robotic Guidance (ROSA) Coregistered with O-arm Guidance-Preliminary Technical Note.

INTRODUCTION: Treatment options for hypothalamic hamartoma (HH) include microvascular surgery, stereotactic radiofrequency thermocoagulation (SRT), laser interstitial thermal therapy, or Gamma Knife surgery. During SRT, thermographic monitoring cannot be performed and therefore highly accurate placement of electrode and confirmation of its position are required. We have used robotic guidance (ROSA) and coregistered it with O-arm for performing ablation of hamartoma. METHODS: Five patients with HH and gelastic seizures underwent SRT. Robotic guidance (ROSA) was used for placement of electrodes. An O-arm was used for coregistering and confirming the robotic trajectory with real-time intraoperative imaging. Intraoperative computed tomography was merged with preoperative magnetic resonance imaging to confirm the exact position and trajectory of the electrode. Ablation was performed using a radiofrequency generator (70°C for 60 seconds). Multiple target sites were ablated to achieve proper ablation and disconnection. RESULTS: Most patients (4/5) had International League Against Epilepsy class I outcome. One patient 2 sittings of lesioning. All but 1 electrode could be placed in the planned trajectories. One electrode was detected to have a medial deviation, and it had to be revised. No permanent complication was observed. CONCLUSIONS: SRT is a cost-effective method of treating HH when compared with laser interstitial thermal therapy. With the use of a robotic arm we have demonstrated accurate placement of electrodes. Intraoperative computed tomography acquired using an O-arm can be merged with preoperative magnetic resonance imaging. This confirms electrode location and trajectory on a real-time basis by performing intraoperative imaging. This method is safe and can be used for radiofrequency ablation of HH.