Patient Satisfaction and Radiologic Assessability After Treatment of Complex Skull Defects With a Custom-Made Cranioplasty From a Thin Titanium Sheet.

OBJECTIVE: The cosmetically good coverage of skull defects is a challenge in neurosurgical clinics. In addition, the skull treated with implants and the underlying structures must remain radiologically assessable. In this examination, the postoperative courses of patients after implantation of CranioTop is described. Digital x-ray, computed tomography, and magnetic resonance images after implantation of CranioTop were evaluated with regard to their assessability. MATERIALS AND METHODS: Between 2018 and 2020, 23 titanium cranioplasties (CranioTop) were implanted to 21 patients. The intraoperative handling, the accuracy of fit, the healing process, the cosmetic result and the physical condition of the patients were examined. In addition, digital x-rays, magnetic resonance imaging, and computed tomography scans of the cranium supplied with CranioTop were examined. RESULTS: The evaluation showed good to very good results regarding patients' satisfaction. There were no severe complications; thirteen patients found the cosmetic result very good; 8 patients assessed the cosmetic result as good. Because of the low thickness and density of the CranioTop plastic there was only low formation of radial stripe artifacts (streaking) and susceptibility artifacts. The assessment of digital x-ray, computed tomography, and magnetic resonance imaging images is possible after implantation of CranioTop. CONCLUSION: The patients treated with CranioTop showed a high level of satisfaction with regard to the cosmetic result and their physical condition. Furthermore, the cranium supplied with CranioTop remains well assessable in radiologic imaging with only slight limitations in magnetic resonance imaging.

Rescuing Infected Deep Brain Stimulation Therapies in Severely Affected Patients.

(1) Background: Infections in deep brain stimulation (DBS) hardware, while an undesired complication of DBS surgeries, can be effectively addressed. Minor infections are typically treated with wound revision and IV antibiotics. However, when visible hardware infection occurs, most centers opt for complete removal, leaving the patient in a preoperative state and necessitating post-removal care. To avoid the need for such care, a novel technique was developed. (2) Methods: The electrodes are placed at the exact same spot and then led to the contralateral side. new extensions and a new generator contralateral to the infection as well. Subsequently, the infected system is removed. This case series includes six patients. (3) Results: The average duration of DBS system implantation before the second surgery was 272 days. Only one system had to be removed after 18 months due to reoccurring infection; the others remained unaffected. Laboratory alterations and pathogens were identified in only half of the patients. (4) Conclusions: The described surgical technique proves to be safe, well tolerated, and serves as a viable alternative to complete system removal. Importantly, it effectively prevents the need of post-removal care for patients.

Large language models: Are artificial intelligence-based chatbots a reliable source of patient information for spinal surgery?

PURPOSE: Large language models (LLM) have recently attracted attention because of their enormous performance. Based on artificial intelligence, LLM enable dialogic communication using quasi-natural language that approximates the quality of human communication. Thus, LLM could play an important role for patients to become informed. To evaluate the validity of an LLM in providing medical information, we used one of the first high-performance LLM (ChatGPT) on the clinical example of acute lumbar disc herniation (LDH). METHODS: Twenty-four spinal surgeons experienced in LDH surgery directed questions to ChatGPT about the clinical picture of LDH from a patient's perspective. They evaluated the quality of ChatGPT responses and its potential use in medical communication. The responses were compared with the information content of a standard informed consent form. RESULTS: ChatGPT provided good results in terms of comprehensibility, specificity, and satisfaction of responses and in terms of medical accuracy and completeness. ChatGPT was not able to provide all the information that was provided in the informed consent form, but did communicate information that was not listed there. In some cases, albeit minor, ChatGPT made medically inaccurate claims, such as listing kyphoplasty and vertebroplasty as surgical options for LDH. CONCLUSION: With the incipient use of artificial intelligence in communication, LLM will certainly become increasingly important to patients. Even if LLM are unlikely to play a role in clinical communication between physicians and patients at the moment, the opportunities-but also the risks-of this novel technology should be alertly monitored.

Clinical Results and Quality of Life After Transcortical Versus Transcallosal Resection of Adult Lateral and Third Ventricle Lesions: Long-Term Outcome.

BACKGROUND: Resection of intraventricular tumors can be achieved using 2 main operative approaches: transcallosal or transcortical. This study aims to describe preoperative and postoperative factors as well as quality of life (QoL) based on long-term results in these patients. METHODS: Patients underwent surgery of primary intraventricular lesions between 2007 and 2020 via a transcortical (group A) or transcallosal (group B) route. The main clinical parameters were completeness of resection, overall survival, surgical complications, postoperative neurologic deficits, and seizure rates. QoL was assessed using a modified questionnaire Short-Form 36 inventory. RESULTS: Forty patients (19 women and 21 men) met the inclusion criteria. Group A consisted of 26 patients (12 women and 14 men; median age 45.5 years ± 16.7 standard deviation) and had lower preoperative tumor volume (confounder) compared with group B (7 women and 7 men; age 50.0 ± 17.4 years). Gross total resection was achieved in 65% in group A and 71% in group B. Follow-up was 7.8 ± 3.9 years. New seizures/permanent neurologic deficits occurred in 27%/15% (group A) and 29%/29% (group B) and surgical complications in 23% of patients. Group B had a higher degree of memory impairment (21%) compared with group A (10%). QoL impairment was present in both groups mainly regarding physical role function and mental health index. CONCLUSIONS: Keeping in mind the limitations, transcallosal surgery was associated with a higher probability of neurologic deficits and memory impairment in our series. However, it had fewer surgical complications with similar gross total resection and seizure rates.

Cerebral Anatomy Detection and Surgical Planning in Patients with Anterior Skull Base Meningiomas Using a Virtual Reality Technique.

Anterior skull base meningiomas represent a wide cohort of tumors with different locations, extensions, configurations, and anatomical relationships. Diagnosis of these tumors and review of their therapies are inseparably connected with cranial imaging. We analyzed the influence of three-dimensional-virtual reality (3D-VR) reconstructions versus conventional computed tomography (CT) and magnetic resonance imaging (MRI) images (two-dimensional (2D) and screen 3D) on the identification of anatomical structures and on the surgical planning in patients with anterior skull base meningiomas. Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative 2D-CT and 2D-MRI scans were retrospectively reconstructed to 3D-VR images and visualized via VR software to detect the characteristics of tumors. A questionnaire of experienced neurosurgeons evaluated the influence of the VR visualization technique on identification of tumor morphology and relevant anatomy and on surgical strategy. Thirty patients were included and 600 answer sheets were evaluated. The 3D-VR modality significantly influenced the detection of tumor-related anatomical structures (p = 0.002), recommended head positioning (p = 0.005), and surgical approach (p = 0.03). Therefore, the reconstruction of conventional preoperative 2D scans into 3D images and the spatial and anatomical presentation in VR models enabled greater understanding of anatomy and pathology, and thus influenced operation planning and strategy.

Neurostimulator-induced ECG artefacts: A systematic analysis.

OBJECTIVES: Deep brain stimulation (DBS) is known to interfere with electrocardiographic (ECG) examinations. In emergency situations, such electrical interferences can not only thwart ECG diagnostics, but even induce an ECG pattern that causes the emergency medical service to initiate inadequate or even harmful therapy. Aim of this prospective study was to evaluate factors influencing ECG interpretation in DBS and to evaluate the susceptibility of ECG criteria 'frequency', 'rhythm', 'regularity', 'QRS-configuration', and 'ST-segment' on neurostimulation. PATIENTS AND METHODS: In 33 DBS patients (17 male, 16 female, mean age 64 years), limb-, 12 channel-, Nehb, and adhesive paddle-lead ECG were performed in activated (n = 33) and deactivated (n = 31) stimulation mode during outpatient follow-up examinations. The examinations were carried out using three different ECG devices (two portable emergency ECG-monitor/defibrillation/pacer-devices, one stationary hospital device), resulting in 4096 ECG leads. Statistics have been based on regression analyses and on a maximum likelihood estimation regression model. RESULTS: Monopolar settings were found to be a relevant factor interfering significantly more often with ECG recording than bipolar parameters (p < 0.0001). Due to recurring movement artefacts, deactivation of bipolar stimulation might even significantly worsen ECG quality (p < 0.0001). Interpretability of 'rhythm' (ß = -0.088, p = 0.03) and 'frequency' (ß = -0.110, p = 0.02) revealed significant negative correlation to the applied neurostimulation voltage. Nehb lead yielded in highest ECG interpretability. CONCLUSION: Bipolar neurostimulation mode barely affected the ECGs; furthermore, the suppression of motion artefacts by neurostimulation can improve ECG quality. If monopolar neurostimulation is required, at least, stimulation voltage should be as low as possible to obtain good stimulation results.

Virtual reality-based evaluation of neurovascular conflict for the surgical planning of microvascular decompression in trigeminal neuralgia patients.

OBJECTIVE: Trigeminal neuralgia (TN) is a lightning bolt of violent, electrifying, and stinging pain, often secondary to the neurovascular conflict (NVC). The vessels involved in NVC are mostly arteries and rarely veins. Evaluation of NVC in the deep infratentorial region is inseparably connected with cranial imaging. We retrospectively analyzed the potential influence of three-dimensional (3D) virtual reality (VR) reconstructions compared to conventional magnetic resonance imaging (MRI) scans on the evaluation of NVC for the surgical planning of microvascular decompression in patients with TN. METHODS: Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative MRI scans were retrospectively visualized via VR software to detect the characteristics of NVC. A questionnaire of experienced neurosurgeons evaluated the influence of VR visualization technique on identification of anatomical structures involved in NVC and on surgical strategy. RESULTS: Twenty-four patients were included and 480 answer sheets were evaluated. Compared to conventional MRI, image presentation using 3D-VR modality significantly influenced the identification of the affected trigeminal nerve (p = 0.004), the vascular structure involved in the NVC (p = 0.0002), and the affected side of the trigeminal nerve (p = 0.005). CONCLUSIONS: In patients with TN caused by NVC, the reconstruction of conventional preoperative MRI scans and the spatial and anatomical presentation in 3D-VR models offers the possibility of increased understanding of the anatomy and even more the underlying pathology, and thus influences operation planning and strategy.

Retrospective Comparison of Minimally Invasive and Open Monosegmental Lumbar Fusion, and Impact of Virtual Reality on Surgical Planning and Strategy.

BACKGROUND AND STUDY AIMS: Spinal fusion for symptomatic lumbar spondylolisthesis can be accomplished using an open or minimally invasive surgical (MIS) technique. Evaluation of segmental spondylolisthesis and instabilities and review of their therapies are inseparably connected with lumbar tomographic imaging. We analyzed a cohort of patients who underwent MIS or open monosegmental dorsal fusion and compared surgical outcomes along with complication rates. We furthermore evaluated the influence of virtual reality (VR) visualization on surgical planning in lumbar fusion. MATERIAL AND METHODS: Patient files were retrospectively analyzed regarding patient- and disease-related data, operative performance, surgical outcomes, and perioperative surgical complications. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans were retrospectively visualized via VR software. A questionnaire evaluated the influence of three-dimensional (3D) VR images versus two-dimensional CT and MRI scans on therapy planning, fusion method, and surgical technique and procedure. RESULTS: Overall, 171 patients were included (MIS/open: 90/81). MIS was associated with less blood loss, shorter surgery time and hospital stay, lower complication rates, equivalent long-term patient-reported outcomes, but lower fusion rates and higher late reoperation rates than open surgery. Image presentation using VR significantly influenced the recommended surgical therapies (decompression only/decompression and fusion; p = 0.02), had no significant influence on the recommended fusion method (rigid/dynamic/stand-alone; p = 0.77), and, in cases of rigid fusion, a significant influence on the recommended technique (MIS/open; p = 0.03) and fusion procedure (p = 0.02). CONCLUSION: In patients with monosegmental degenerative or isthmic spondylolisthesis, MIS fusion was advantageous concerning perioperative complication rates and perioperative surgical outcomes, but disadvantageous regarding fusion and reoperation rates compared to open fusion. 3D-VR-based analysis of sectional images significantly influenced the recommended surgical planning.

Impact of Virtual Reality in Arterial Anatomy Detection and Surgical Planning in Patients with Unruptured Anterior Communicating Artery Aneurysms.

Anterior-communicating artery (ACoA) aneurysms have diverse configurations and anatomical variations. The evaluation and operative treatment of these aneurysms necessitates a perfect surgical strategy based on review of three-dimensional (3D) angioarchitecture using several radiologic imaging methods. We analyzed the influence of 3D virtual reality (VR) reconstructions versus conventional computed tomography angiography (CTA) scans on the identification of vascular anatomy and on surgical planning in patients with unruptured ACoA aneurysms. Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative CTA scans were retrospectively reconstructed to 3D-VR images and visualized via VR software to detect the characteristics of unruptured ACoA aneurysms. A questionnaire was used to evaluate the influence of VR on the identification of aneurysm morphology and relevant arterial anatomy and on surgical strategy. Twenty-six patients were included and 520 answer sheets were evaluated. The 3D-VR modality significantly influenced detection of the aneurysm-related vascular structure (p = 0.0001), the recommended head positioning (p = 0.005), and the surgical approach (p = 0.001) in the planning of microsurgical clipping. Thus, reconstruction of conventional preoperative CTA scans into 3D images and the spatial presentation in VR models enabled greater understanding of the anatomy and pathology, provided realistic haptic feedback for aneurysm surgery, and influenced operation planning and strategy.

Evaluation of Surgical Approaches for Tumor Resection in the Deep Infratentorial Region and Impact of Virtual Reality Technique for the Surgical Planning and Strategy.

OBJECTIVE: Tumors in the deep infratentorial region can be accessed via the supracerebellar-infratentorial (SCIT) or suboccipital-transcerebellar (SOTC) approaches in the sitting or prone position. Diagnosis of tumors in this region and review of their therapies are inseparably connected with cranial tomographic imaging. We retrospectively evaluate a cohort of patients who underwent tumor resection in this region and correlate complication rates to the literature, and evaluate the potential influence of a virtual reality (VR) visualization technique on surgery planning and strategy. METHODS: Patient files were retrospectively analyzed regarding operative performance parameters, histopathological findings, surgical outcomes, and complications. Preoperative magnetic resonance imaging scans were visualized via VR software. The influence of 3-dimensional VR images compared to 2-dimensional magnetic resonance imaging scans on surgical planning and surgical strategy was evaluated using a questionnaire. RESULTS: Ninety-three patients were included, 80% placed in a sitting and 20% in a prone position. The SCIT approach was performed in 59% patients and SOTC approach in 41%. Surgical tumor resections were associated with an overall complication rate comparable to the literature. Image presentation using VR had a significant influence on the recommended surgical approach (P = 0.02), but no influence on the recommended patient positioning (P = 0.37) or placement of craniotomy (P = 0.09). CONCLUSION: Tumor resection in the deep infratentorial region, despite frequent use of the sitting position and SCIT approach, was associated with a complication rate comparable to the literature. Preoperative surgical planning using VR technology may increase understanding of the anatomy and pathology, and thus influence operation planning.

Comparison of stand-alone cage and cage-with-plate for monosegmental cervical fusion and impact of virtual reality in evaluating surgical results.

OBJECTIVES: After ventral decompression of monosegmental cervical spondylotic stenosis, a stand-alone cage (SC) or cage-with-plate (CP) can be inserted for fusion. Postoperative radiological evaluation can be achieved using different imaging modalities. We retrospectively compared complications, as well as clinical and radiological outcomes for both fusion techniques, and analyzed the possible role of virtual reality (VR) in evaluating the postoperative results. PATIENTS AND METHODS: One hundred seventeen patients were included (SC/CP: 54/63). Complications, as well as clinical and radiological outcomes of both fusion techniques were compared. Computed tomography (CT) scans were visualized via VR to measure the smallest cross-sectional area of the intervertebral neuroforamen in the lateral resection region, and to assess the degree of the intersegmental ossification. RESULTS: There were no significant differences between the two fusion techniques regarding perioperative complication rates, fusion rates, or pain parameter (visual analogue scale (VAS) of arm pain, neck disability index). However, advantages regarding subsidence, kyphosis, and VAS of neck pain were found when using the CP versus SC. Using the VR technique, there was no significant difference between the two fusion techniques in the mean size of the cross-sectional area at the end of follow-up. CONCLUSION: Due to the long-term advantages of CP fusion, we prefer a monosegmental cervical spinal fusion using CP. Reconstruction of postsurgical two-dimensional CT images into three-dimensional images, and the spatial and anatomical presentation in VR models, improved the evaluation of these postoperative results.

Mobile phone-based alerting of CPR-trained volunteers simultaneously with the ambulance can reduce the resuscitation-free interval and improve outcome after out-of-hospital cardiac arrest: A German, population-based cohort study.

AIM: To test the hypothesis that simultaneous mobile phone-based alerting of CPR-trained volunteers (Mobile-Rescuers) with Emergency Medical Service (EMS) teams leads to better outcomes in out-of-hospital cardiac arrest (OHCA) victims than EMS alerting alone. METHODS: The outcomes of 730 OHCA patients were retrospectively analysed, depending on who initiated CPR: Mobile-Rescuer-initiated-CPR (n = 94), EMS-initiated-CPR (n = 359), lay bystander-initiated-CPR (n = 277). An adjusted analysis of the intervention and their main outcomes (emergency response time, return of spontaneous circulation, hospital discharge rate, neurological outcomes) was performed (Propensity Score Method with patient matching). RESULTS: Recruited and trained Mobile-Rescuers (n = 740) arrived at the scene in 46% of all triggered alarms. There was a significant difference in response time between Mobile-Rescuers (4 min) and EMS teams (7 min), (p < 0.001). Compared to EMS-initiated-CPR, Mobile-Rescuer-initiated-CPR patients more frequently showed a return of spontaneous circulation, but statistical significance was narrowly missed (p = 0.056). The hospital discharge rate was significantly higher with the Mobile-Rescuer (18%) vs. EMS (7%), (p = 0.049). Good neurological outcomes (Cerebral Performance Categories Score 1 and 2) were seen in 11% of Mobile-Rescuer patients and 4% of EMS patients (p = 0.165). There were no significant differences compared with lay bystander-initiated-CPR. CONCLUSION: Simultaneous alerting of nearby CPR-trained volunteers complementary to professional EMS teams can reduce both the response time and resuscitation-free interval and might improve hospital discharge rate and neurological outcomes after OHCA.

Early autologous cranioplasty: complications and identification of risk factors using virtual reality visualisation technique.

Background: Cranioplasty (CP) of autologous bone flap after decompressive craniectomy (DC) is known to be associated with a high complication rate, particularly bone flap resorption (BFR). In a retrospective study, we used a novel virtual reality (VR) visualisation technique to identify and evaluate risk factors associated with CP.Method: Twenty-five patients underwent early autologous CP. All complications were recorded. Cranial computed tomography scans were visualised via the VR software to access the fitting accuracy of the bone flap (bone flap size, gap width at trepanation cutting edge, extent of osteoclastic extension).Results: An overall complication rate of 44% was seen, and BFR was the most common (36%). Only 'osteoclastic extension of trepanation' (p = .04) was a significant risk factor for BFR. The factors 'indication for DC' (p = .09) and 'size of bone flap' (p = .09) had a tendency towards influencing the rate of BFR, while 'age' (p = .68), 'time interval between DC and CP' (p = 1.00), and 'gap width' (p = .50) were not considered to influence the BFR rate.Conclusions: DC and subsequent CP is a complication-prone procedure. Therefore, it is relevant to identify and quantify probable risk factors for the most common complications, such as BFR. Here, we found that the extent of osteoclastic extension may impair the patient's healing process. Our investigation was made considerably easier by using the novel VR visualisation technique, which allows parallax free measurements of distances in 3D space.

Virtual Reality-Based Evaluation of Surgical Planning and Outcome of Monosegmental, Unilateral Cervical Foraminal Stenosis.

BACKGROUND: Foraminal cervical nerve root compression can be caused by lateral disk herniation or osteophyte formation of the vertebrae. Improved diagnosis and evaluation can be achieved using different imaging techniques: radiographs, computed tomography (CT), and magnetic resonance imaging. We retrospectively evaluated the potential influence of a virtual reality (VR) visualization technique on surgery planning and evaluation of postoperative results in patients with monosegmental, unilateral osseous cervical neuroforaminal stenosis. METHODS: Seventy-three patients were included. Ventral decompression of the neuroforamen was performed in 41 patients, dorsal decompression in 32 patients. Patients' files were evaluated. CT scans were visualized via VR software to measure the smallest cross-sectional area of the intervertebral neuroforamen in the lateral resection region. A questionnaire evaluated the influence of VR technique on surgical planning and strategy. RESULTS: The VR-technique had a moderate influence on the choice of the approach (ventral or dorsal), a significant influence on the ventral approach strategy, and no influence on the positioning of the patient or the dorsal approach strategy. A significant difference was found in the size of the smallest cross-sectional area of the intervertebral neuroforamen in the lateral resection region between ventral and dorsal approaches, with no correlation to the clinical outcome. CONCLUSIONS: Reconstruction of pre- and postoperative 2D-CT images of the cervical spine into 3D images, and the spatial and anatomical reconstructions in VR models, can be helpful in planning surgical approaches and treatment strategies for patients with cervical foraminal stenoses, and for evaluation of their postoperative results.

Tactile sensor-based real-time clustering for tissue differentiation.

PURPOSE: Reliable intraoperative delineation of tumor from healthy brain tissue is essentially based on the neurosurgeon's visual aspect and tactile impression of the considered tissue, which is-due to inherent low brain consistency contrast-a challenging task. Development of an intelligent artificial intraoperative tactile perception will be a relevant task to improve the safety during surgery, especially when-as for neuroendoscopy-tactile perception will be damped or-as for surgical robotic applications-will not be a priori existent. Here, we present the enhancements and the evaluation of a tactile sensor based on the use of a piezoelectric tactile sensor. METHODS: A robotic-driven piezoelectric bimorph sensor was excited using multisine to obtain the frequency response function of the contact between the sensor and fresh ex vivo porcine tissue probes. Based on load-depth, relaxation and creep response tests, viscoelastic parameters E1 and E2 for the elastic moduli and η for the viscosity coefficient have been obtained allowing tissue classification. Data analysis was performed by a multivariate cluster algorithm. RESULTS: Cluster algorithm assigned five clusters for the assignment of white matter, basal ganglia and thalamus probes. Basal ganglia and white matter have been assigned to a common cluster, revealing a less discriminatory power for these tissue types, whereas thalamus was exclusively delineated; gray matter could even be separated in subclusters. CONCLUSIONS: Bimorph-based, multisine-excited tactile sensors reveal a high sensitivity in ex vivo tissue-type differentiation. Although, the sensor principle has to be further evaluated, these data are promising.

Automated differentiation between meningioma and healthy brain tissue based on optical coherence tomography ex vivo images using texture features.

Brain tissue analysis is highly desired in neurosurgery, such as tumor resection. To guarantee best life quality afterward, exact navigation within the brain during the surgery is essential. So far, no method has been established that perfectly fulfills this need. Optical coherence tomography (OCT) is a promising three-dimensional imaging tool to support neurosurgical resections. We perform a preliminary study toward in vivo brain tumor removal assistance by investigating meningioma, healthy white, and healthy gray matter. For that purpose, we utilized a commercially available OCT device (Thorlabs Callisto) and measured eight samples of meningioma, three samples of healthy white, and two samples of healthy gray matter ex vivo directly after removal. Structural variations of different tissue types, especially meningioma, can already be seen in the raw OCT images. Nevertheless, an automated differentiation approach is desired, so that neurosurgical guidance can be delivered without a-priori knowledge of the surgeon. Therefore, we employ different algorithms to extract texture features and apply pattern recognition methods for their classification. With these postprocessing steps, an accuracy of nearly 98% was found.

A Submammarian Approach for Cosmetically Improved Implantation of Deep Brain Stimulation Generators.

BACKGROUND: Deep brain stimulation (DBS) indications include movement disorders, psychiatric affections, or epilepsy in which patients risk social isolation heightened by abnormal motions or behavioral patterns. Further stigmatization after DBS surgery from head shaving, visible scarring, or disfigurement from bulky lead insertion points should be avoided. OBJECTIVE: We present a cosmetically optimized, adapted submammarian approach for DBS neurostimulator implantation that leaves the décolletage untouched. METHODS: Over 24 months, 61 patients suffering from Parkinson disease, dystonia, or tremor underwent DBS surgery. The modified, submammarian approach was compared with the conventional infraclavicular approach regarding clinical outcome, complications, and limitations over a 5-year follow-up. RESULTS: Neurostimulators were implanted in a paraumbilical (n = 20) or infraclavicular position (n = 41; Parkinson disease, n = 27; dystonia, n = 9; tremor, n = 5), the latter using a standard (n = 16), modified juxta-axillary (n = 6), or submammarian approach (n = 19; 18 women, 1 man with significant gynecomastia). After 12 months, there was no significant difference in the infection rate and one event of rebleeding in each group. Overall, operation time was longer (+20 minutes) for the submammarian versus standard, infraclavicular approach, but acceptable. Neurostimulator replacement was, necessary within 5 years due to advanced battery discharge (n = 32). Battery replacement was easily achieved using the submammarian approach (n = 14), again with increased surgical time (+20 minutes), and iatrogenic damage to extensions was avoidable. CONCLUSIONS: A submammarian approach might be an alternative for infraclavicular implantation of DBS neurostimulators, particularly in female patients in the context of cosmetically optimized surgery. Patients' self-perception and self-esteem may be strengthened, potentially enabling them to better cope with disease.