Medical management for cerebellar mutism syndrome following posterior fossa surgery: A systematic review.

INTRODUCTION: Cerebellar mutism syndrome (CMS) is a serious complication of posterior fossa surgeries affecting mainly pediatric age group. The pathophysiology is still not fully understood. It adversely affects the recovery of patients. There is no definitive and standardized management for CMS. However pharmacological therapy has been used in reported cases with variable effectiveness. We aim through this review to summarize the available evidence on pharmacological agents used to treat CMS. METHOD: A thorough systematic review until December 2022, was conducted using PubMed Central, Embase, and Web of Science, databases to identify case reports and case series of CMS patients who underwent posterior fossa surgery and received pharmacological treatment. Patients with pathologies other than posterior fossa lesions were excluded from the study. RESULTS: Of 592 initial studies, 8 studies met our eligibility criteria for inclusion, with 3 more studies were added through manual search; reporting on 13 patients. The median age of 13 years (Standard deviation SD=10.60). The most frequent agent used was Bromocriptine. Other agents were fluoxetine, midazolam, zolpidem, and arpiprazole. Most patients recovered within 48 hours of initiating medical therapy. The median follow-up period was 4 months (SD=13.8). All patients showed complete recovery at the end of follow-up period. CONCLUSION: Cerebellar mutism syndrome is reported after posterior fossa surgeries, despite attempts to identify risk factors, pathophysiology, and management of CMS, it remains a challenging condition with significant morbidity. Different Pharmacological treatments have been proposed with promising results. Further studies and formalized clinical trials are needed to evaluate available options and their effectiveness.

Normative parameters of the Evans Index using Computer Tomography in the Saudi population.

OBJECTIVES: To calculate The Evans Index (EI) in normal Individuals. Ventricular enlargement is referred to as hydrocephalus. Computer tomography (CT) scans are commonly used to investigate such intracranial pathologies. The EI is an important parameter for diagnosing hydrocephalus. METHODS: We included all patients who underwent Computer tomography (CT) scan of the brain that was reported as normal. The mean EI was calculated for the whole sample stratified by age, gender, and ethnicity. Patients with an initial report indicating any intracranial pathology, such as hydrocephalus, tumors, hemorrhages, or neurodegenerative disorders, were excluded. RESULTS: A total of 1,330 brain CT scans carried out at our institution were reviewed retrospectively from August 2021 to December 2021. A total of 423 CT scans were screened after excluding 25 patients with abnormal imaging findings and 14 repeated images for the same patients. A total of 384 patients were included. The mean EI for the entire sample was 0.2550±0.0277. There was a minimal but statistically significant difference based on gender, with a mean EI of 0.2588±0.0274 for males and 0.2517±0.0276 for females (p=0.012). There was no statistically significant difference between Saudi and non-Saudi patients. EI increased progressively with age in both genders. CONCLUSION: Our EI values were similar to many of those reported in other countries, which supports the use of the 0.3 cutoff for the diagnosis of hydrocephalus, regardless of gender, age, or ethnicity.

Does exogenous hormonal therapy affect the risk of glioma among females: A systematic review and meta-analysis.

Background: The effect of exogenous hormone replacement therapy (HRT) and oral contraceptive pills (OCPs) on glioma risk in females is unclear despite numerous studies; hence, we conducted a meta-analysis to evaluate this relationship. Methods: Studies investigating the impact of exogenous female hormones on glioma risk were retrieved by searching 4 databases from inception until September 2022. Articles of any design, such as case-control and cohort studies, proving the relative risk (RR), odds ratio (OR), or hazard ratio were included. Summary OR values were calculated using a random effects model. Results: Both HRT and OCP use of any duration decreased the risk of developing glioma [HRT OR = 0.78, 95% CI 0.66-0.91, P = .00; OCP: OR = 0.80, 95% CI 0.67-0.96, P = .02]. When stratified by duration of use, HRT use >1 year significantly reduced glioma risk (<1 year: OR = 0.82, 95% CI 0.63-1.07, P = 0.15; 1-5 years: OR = 0.79, 95% CI 0.67-0.92, P = .00; 5-10 years: OR = 0.80, 95% CI 0.66-0.97, P = .02; >10 years: OR = 0.69, 95% CI 0.54-0.88, P = .00). In contrast, only OCP use for >10 years significantly reduced glioma risk (<1 year: OR = 0.72, 95% CI 0.49-1.05, P = .09; 1-5 years: OR = 0.88, 95% CI 0.72-1.02, P = .09; 5-10 years: OR = 0.85, 95% CI 0.65-1.1, P = 0.21; >10 years: OR = 0.58, 95% CI 0.45-0.74, P = .00). Conclusions: Our pooled results strongly suggest that sustained HRT and OCP use is associated with reduced risk of glioma development.

Outcomes after laser interstitial thermal ablation for temporal lobe epilepsy: a systematic review and meta-analysis.

Epilepsy is a common condition that affects approximately 1% of the world's population, with about one-third being refractory epilepsy. Temporal lobe epilepsy is the most common type of drug-resistant epilepsy, and laser interstitial thermal therapy (LITT) is an innovative treatment. In this systematic review and meta-analysis, we aimed to summarize the current evidence on outcomes after LITT, including seizure freedom rate, complication rate, and neurocognitive outcome. PubMed and OVID Medline search engines were systematically searched for all indexed publications in the English language up to July15, 2023. The search was limited to human studies. Proportions and 95% confidence interval (CI) values were calculated for seizure, neurocognitive outcome, and complication rate. A total of 836 patients were included. Overall seizure outcomes, regardless of the pathology, included Engel I outcome in 56% (95% CI, 52.4-59.5%), Engel II outcome in 19.2% (95% CI, 15.4-23.6%), Engel III outcome in 17.3% (95% CI, 13.5-21.8%), and Engel IV outcome in 10.5% (95% CI 6.3-17%) of the patients. The overall decline in verbal and visual memory regardless of laterality was 24.2 (95% CI 8.6-52%) and 25.2% (8.3-55.8%). For naming, the decline was 13.4% (6.6-25.4%). The results of the pooled analysis in comparison with available data in the literature showed that seizure outcomes after LITT were slightly inferior to published data after temporal lobectomy. Data on cognitive outcomes after LITT are scarce and heterogeneous.

Programmable Versus Differential Pressure Ventriculoperitoneal Shunts for Pediatric Hydrocephalus: A 20-Year Single-Center Experience From Saudi Arabia.

Background Shunt malfunction is the most common complication after ventriculoperitoneal shunt (VPS) insertion for pediatric hydrocephalus. The incidence of shunt malfunction and the need for VPS revision may be related to the type of valve used in the shunt. Therefore, we aimed to compare the outcome of VPS in the pediatric age group stratified by differential pressure valves (DPV) and programmable shunt valves (PSV). Materials and methods This ethics-approved retrospective study was conducted at a tertiary care hospital in Saudi Arabia. We included 175 children with congenital hydrocephalus who underwent a shunt insertion or revision between 2003 and 2018 and followed them up to December 2022. The VPS complication and revision rates were compared with the patient's demographics and shunt valve types. The Kaplan-Meier method, log-rank test, and univariate and multivariate Cox proportional hazards regression were used to analyze several variables and subsequent shunt revisions. Results Females represented 52% of the study participants, and the mean age of the patients was 21.7 ± 38.4 months. The main indication for VPS was congenital hydrocephalus due to aqueductal stenosis (40%). The differential shunt valve was used in 78.9% and the PSV in 21.1% of the patients. Surgical complications occurred in 33.7% of the patients. Shunt malfunction and infection occurred in 16% and 11.4% of the patients, respectively. The VPS revision rate was significantly lower when PSV was used (odds ratio = 0.39, P < 0.05). Conclusion Overall, one-third of the studied pediatric cohort required shunt revision at some point during the 15-year follow-up. However, children with PSV had fewer revision rate-related complications compared to children with DPV during the first five years of follow-up.

The Impact of Nursing Education on Emergency Bedside External Ventricular Drain Insertion for Patients With Acute Hydrocephalus.

Objectives Acute hydrocephalus is a neurosurgical emergency that requires immediate intervention. With emergency external ventricular drain (EVD) insertion and management, such rapid intervention can be a safe bedside procedure. Nurses play an integral role in patient management. Thus, this study aims to assess the knowledge, attitudes, and practices of nurses from different departments regarding bedside EVD insertion in patients with acute hydrocephalus. Methods EVD and intracranial pressure (ICP) monitoring competency checklists were developed, and a quasi-experimental, single-group, pre/post-test study was conducted at a university hospital in Jeddah, Saudi Arabia, in January 2018 during an educational program. The neurosurgery team determined program efficacy using pre/post-questionnaires. All attendees who agreed to fill in the pre- and post-survey and whose data were complete were included in the study. Results Of the 140 nurses who participated in the study, the data of 101 were analyzed. Knowledge level improved significantly between the pre- and post-test; for example, when asked about administering antibiotics before EVD insertion, the pre-test correct response rate of 65% increased to 94% in the post-test (p<0.001), and 98% considered the session informative. However, the attitude toward bedside EVD insertion did not change after the teaching sessions. Conclusion This study emphasizes the importance of ongoing nursing education, hands-on training, and strict adherence to an EVD insertion checklist to achieve successful bedside management of patients with acute hydrocephalus.

Outcome of Anterior and Posterior Endoscopic Procedures for Cervical Radiculopathy Due to Degenerative Disk Disease: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Cervical spine endoscopic discectomy and decompression have gained popularity in the last decade. This review aimed to shed light on the current outcomes of cervical spine endoscopic procedures for degenerative disc disease (DDD) and to calculate a pooled estimate of various outcome measures. METHODS: We retrieved articles published in English related to endoscopic cervical spine procedures from 3 central databases from inception until September 2020. A subgroup analysis based on the anterior versus the posterior approach was performed. RESULTS: Thirty-one articles fulfilled the eligibility criteria and included 1,410 patients. A successful outcome was observed in 91.3% (88.6-93.4%, P = 0.000). This percentage was lower for the anterior approach (89.6% [85.8-92.5%], P = 0.000) than for the posterior approach (94.2% [90.4-96.5%], P = 0.000). A higher percentage of poor outcomes was reported for the anterior approach (5.7% [3.2-10.1%], P = 0.000 vs. 2.3% [1-5.5%], P = 0.000 for the posterior approach). The overall complication rate was 7.2% (5.2-9.8%, P = 0.000). There was a slightly higher complication rate for the anterior approach (7.9% [4.5-13.3%], P = 0.000) than for the posterior approach (6.7% [4.4-10%], P = 0.000). The revision rate was 4.2% (2.6-6.8%, P = 0.000); and 4.2% (1.8-9.7%, P = 0.000) for the anterior approach and 4.00% (2.2-7.4%, P = 0.000) for the posterior approach. CONCLUSIONS: There is a higher success rate and lower complication rate with the posterior approach than with the anterior approach. However, high-quality randomized controlled trials are vital to evaluate the efficacy of these procedures.

Pattern of neurosurgical practice at a university hospital in KSA during COVID-19 pandemic.

Objective: The coronavirus disease 2019 (COVID-19) pandemic affected both medical services as well as hospital admissions. Scholars have attempted to study the effect of the pandemic on the services of multiple specialities. In this study, we aim to examine the pandemic's impact on the neurosurgical service provided at the King Abdulaziz University Hospital in Jeddah over an eight-month period. Methods: In this retrospective, single-centre case series study, we included all the consecutive neurosurgical patients who underwent a surgical intervention in the 8-month period starting on 3rd March, 2020 and ending on 3rd November, 2020. The demographics, diagnosis, surgery type, priority category, and mortality data of the patients were collected. Results: A total of 147 patients underwent surgery during the study period. The mean age was 30.8 years. Forty-nine percent of the study population were men. Oncology (31.3%) and hydrocephalus (23.8%) recorded the highest number of cases. More than half of the cases were Priority 1 (immediate and within 24 h). The mortality rate was 4.1% among all the performed cases. Conclusion: By describing this local neurosurgical experience during the COVID-19 pandemic, we hope to bring out some of the difficulties we encountered and improve what we learned during the pandemic.

Accuracy of Pedicle Screw Placement Using Intraoperative CT-Guided Navigation and Conventional Fluoroscopy for Lumbar Spondylosis.

Background Transpedicular screws are a common adjunct for lumbar spine fusion. Accurate screw placement to prevent neurological injury has been the subject of many studies. The adoption of spine neuronavigation has shown a significant decrease in screw malposition morbidity. We aim to evaluate the accuracy of pedicle screw insertion using intraoperative CT-guided navigation in lumbar spondylosis. Methods We reviewed a prospective registry-based cohort study. This included patients who underwent transpedicular screws insertion for lumbar spondylosis under intraoperative CT-guided navigation (iCT-Nav) and compared it to another group operated using conventional fluoroscopy (FS) over one year. In addition, the correlation between clinical outcome using the visual analog scale (VAS) and short 12 physical component scores (SF-12 PCS) and hospital stay was reported. Results Fifteen patients were included in the iCT-Nav group compared to 42 patients in the FS group. The median age of the iCT-Nav group was 59.3 years old (27-76 years) versus 45 years old (20-60 years) in the FS group. The number of screws was 98 in the iCT-Nav group and 252 screws in the FS group. Based on more than 2-mm breach increments measured on CT images, lumbar pedicular screw placement accuracy was 100% in the iCT-Nav group and 86.9% in the FS group. None of the patients in the iCT-Nav group had to undergo any postoperative revisions. On the other hand, two patients of the FS group developed new postoperative symptoms related to displaced screws and required readmission and revision surgery. Conclusion In a commonly performed pedicular fixation in lumbar spondylosis, iCT-Nav has been shown to improve the accuracy of pedicle screw placement, hospital stay, and functional outcomes compared to FS.

The longitudinal impact of COVID-19 pandemic on neurosurgical practice.

OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5-8). The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4-18) to 6 (IQR: 3-13) to 5 days (IQR: 2-8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

Different modalities of invasive neurostimulation for epilepsy.

Epilepsy affects 1% of the general population, about one-third of which is pharmacologically resistant. Uncontrolled seizures are associated with an increased risk of traumatic injury and sudden unexpected death of epilepsy. There is a considerable psychological and financial burden on caregivers of patients with epilepsy, particularly among pediatric patients. Epilepsy surgery, when indicated, is the most promising cure for epilepsy. However, when surgery is contraindicated or refused by the patient, neurostimulation is an alternative palliative approach, albeit with a lower chance of entirely curing patients of seizures. There are many options for neurostimulation. The three most commonly used invasive neurostimulation procedures that consistently show evidence of being safe and efficacious are vagal nerve stimulation, responsive neuro stimulation, or anterior thalamic nucleus deep brain stimulation. The goal of this review is to summarize the current evidence supporting the use of these three techniques, which are approved by most regulatory bodies, and discuss different factors that may enable epilepsy surgeons to choose the most appropriate modality for each patient.

Neurosurgical Procedures and Safety During the COVID-19 Pandemic: A Case-Control Multicenter Study.

OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

Prevalence of complementary and alternative medicine use in brain tumor patients at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

OBJECTIVES: To determine the prevalence and types of complementary and alternative medicine (CAM) being utilized and the possible factors that prompted the use of CAM in patients with brain tumors. Methods: The study conducted was a questionnaire-based, cross-sectional study of patients diagnosed with brain tumors at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia from January 2011 to May 2018. Patients with primary and secondary brain tumors, were included. Our questionnaire was conducted via phone interviews after obtaining patient consent.  Results: A total of 72 patients were included. The mean age of the participants was 45.89 (±16.52) years. We found that education level significantly affected the use of CAM. Fewer users of CAM held bachelor's degree and patients with lower degrees used CAM more frequently (p=0.027). The most frequent types of CAM were Zamzam (holy water) and Ruqya (Quran reading). Family members were the most frequent source of information about the use of CAM (81.6%).  Conclusion: Education level has a significant effect on CAM use. Gender plays a role in the type of CAM used. Future research should focus on the adverse effects of some CAM therapies, how effective CAM therapies are, and the effect CAM may play in delaying patients from seeking medical advice.

Awareness and attitudes toward epilepsy among medical and allied healthcare students - A survey study in a teaching hospital in Jeddah.

PURPOSE: Epilepsy affects individuals of all ages and genders and places high physical, mental, financial, and social burdens on these individuals. In Saudi Arabia, its prevalence is 6.5 cases per 1000 individuals. Physicians and healthcare professionals have a key role in increasing the knowledge and awareness of the general population about epilepsy. The purpose of this study was to assess the level of awareness of different aspects of epilepsy, such as, presentation; causes; social aspects of epilepsy in school, work, and social life; treatment options; and attitudes toward epilepsy of students at King Abdulaziz University (KAU) in medical and allied healthcare specialties. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students to clinical-year students. METHOD: This cross-sectional study included 255 participants from multiple health specialties studying at KAU. Surveys from prior validated publications were used. We divided the respondents into two categories (preclinical [2nd, 3rd, 4th-year students] and clinical [5th, 6th, and internship year]) to evaluate if knowledge and attitude are different among these two groups. RESULTS: In general, medical students had more awareness than did students from other specialties about what to do if someone was having a seizure. A total of 17.3% of medical students answered that they would put a spoon or cloth in the mouth of someone having a seizure, whereas 21% of nursing students thought this answer was appropriate (p = .04). The proportion of clinical-year students who were knowledgable of the symptoms and causes of epilepsy was significantly higher than that of students in preclinical years (p < .0001). Only 12.3% of the clinical-year students thought epilepsy was an untreatable disease versus 35.5% of preclinical-year students (p = .02). Interestingly, nursing students had the highest percentage of respondents who answered yes to surgical options (p = .009) (57.9%, n = 11), followed by dental students (50%, n = 6), medical students (46.4%, n = 78), and finally clinical pharmacy students (45.5%, n = 20). CONCLUSION: The level of awareness among medical students was higher than that among students of other specialties, with progressive improvement over the study years. However, knowledge about surgical options was minimal. Thus, further emphasis is needed in teaching and educational campaigns, particularly for allied healthcare students.

Robot-Assisted Responsive Neurostimulator System Placement in Medically Intractable Epilepsy: Instrumentation and Technique.

BACKGROUND: The management of medically refractory epilepsy patients who are not surgical candidates has remained challenging. Closed loop-or responsive-neurostimulation (RNS) is now an established therapy for the treatment of epilepsy with specific indications. The RNS® system (NeuroPace Inc, Mountainview, California) has recently been shown to be effective in reducing the seizure frequency of partial onset seizures. The electrode design consists of either intracerebral depth electrodes or subdural strip electrodes, and stereotaxis is typically used to guide placement into the EZ. Details on the operative techniques used to place these electrodes have been lacking. OBJECTIVE: To address the advantage of using a robotic-assisted technique to place depth electrodes for RNS® system placement compared to the typical frame-based or frameless stereotactic systems. METHODS: We retrospectively reviewed our single center, technical operative experience with RNS® system placement using robotic assistance from 2014 to 2016 via chart review. RESULTS: Twelve patients underwent RNS® system placement using robotic assistance. Mean operative time was 121 min for a median of 2 depth electrodes with mean deviation from intended target of ∼3 mm in x, y, and z planes. Two patients developed wound infections, 1 of whom was reimplanted. Seizures were reduced by ∼40% at 2 yr, similar to the results seen in the open label portion of the pivotal RNS trial. CONCLUSION: Robotic-assisted stereotaxis can be used to provide a stable and accurate stereotactic platform for insertion of intracerebral RNS electrodes, representing a safe, efficient and accurate procedure.

Techniques for placement of stereotactic electroencephalographic depth electrodes: Comparison of implantation and tracking accuracies in a cadaveric human study.

OBJECTIVE: Stereotactic electroencephalography (SEEG) is used for the evaluation and identification of the epileptogenic zone (EZ) in patients suffering from medically refractory seizures and relies upon the accurate implantation of depth electrodes. Accurate implantation is critical for identification of the EZ. Multiple electrodes and implantation systems exist, but these have not previously been systematically evaluated for implantation accuracy. This study compares the accuracy of two SEEG electrode implantation methods. METHODS: Thirteen "technique 1" electrodes (applying guiding bolts and external stylets) and 13 "technique 2" electrodes (without guiding bolts and external stylets) were implanted into four cadaver heads (52 total of each) according to each product's instructions for use using a stereotactic robot. Postimplantation computed tomography scans were compared to preimplantation computed tomography scans and to the previously defined targets. Electrode entry and final depth location were measured by Euclidean coordinates. The mean errors of each technique were compared using linear mixed effects models. RESULTS: Primary analysis revealed that the mean error difference of the technique 1 and 2 electrodes at entry and target favored the technique 1 electrode implantation accuracy (P < 0.001). Secondary analysis demonstrated that orthogonal implantation trajectories were more accurate than oblique trajectories at entry for technique 1 electrodes (P = 0.002). Furthermore, deep implantations were significantly less accurate than shallow implantations for technique 2 electrodes (P = 0.005), but not for technique 1 electrodes (P = 0.50). SIGNIFICANCE: Technique 1 displays greater accuracy following SEEG electrode implantation into human cadaver heads. Increased implantation accuracy may lead to increased success in identifying the EZ and increased seizure freedom rates following surgery.

Neuroimaging of neuropathic pain: review of current status and future directions.

The goal of this review is to discuss the various imaging modalities to study neuropathic pain and its future implication in understanding pain network, for the diagnosis and management of patients with chronic neuropathic pain. Neuropathic pain is characterized by pain secondary to lesions or dysfunction of the central nervous system (CNS) or the peripheral nervous system. Neuropathic pain is generally chronic and disabling, and responds poorly to conventional treatment. Although our understanding of the imaging changes in chronic pain state is evolving, we still face practical challenges in implementing these finding to objectively diagnose and follow treatment response in patients with chronic pain and to guide targeted and individualized treatment to each chronic pain condition.

Indications, technique, and safety profile of insular stereoelectroencephalography electrode implantation in medically intractable epilepsy.

OBJECTIVE Insular epilepsy is relatively rare; however, exploring the insular cortex when preoperative workup raises the suspicion of insular epilepsy is of paramount importance for accurate localization of the epileptogenic zone and achievement of seizure freedom. The authors review their clinical experience with stereoelectroencephalography (SEEG) electrode implantation in patients with medically intractable epilepsy and suspected insular involvement. METHODS A total of 198 consecutive cases in which patients underwent SEEG implantation with a total of 1556 electrodes between June 2009 and April 2013 were reviewed. The authors identified patients with suspected insular involvement based on seizure semiology, scalp EEG data, and preoperative imaging (MRI, PET, and SPECT or magnetoencephalography [MEG]). Patients with at least 1 insular electrode based on the postoperative 3D reconstruction of CT fused with the preoperative MRI were included. RESULTS One hundred thirty-five patients with suspected insular epilepsy underwent insular implantation of a total of 303 electrodes (1-6 insular electrodes per patient) with a total of 562 contacts. Two hundred sixty-eight electrodes (88.5%) were implanted orthogonally through the frontoparietal or temporal operculum (420 contacts). Thirty-five electrodes (11.5%) were implanted by means of an oblique trajectory either through a frontal or a parietal entry point (142 contacts). Nineteen patients (14.07%) had insular electrodes placed bilaterally. Twenty-three patients (17.04% of the insular implantation group and 11.6% of the whole SEEG cohort) were confirmed by SEEG to have ictal onset zones in the insula. None of the patients experienced any intracerebral hemorrhage related to the insular electrodes. After insular resection, 5 patients (33.3%) had Engel Class I outcomes, 6 patients (40%) had Engel Class II, 3 patients (20%) had Engel Class III, and 1 patient (6.66%) had Engel Class IV. CONCLUSIONS Insula exploration with stereotactically placed depth electrodes is a safe technique. Orthogonal electrodes are implanted when the hypothesis suggests opercular involvement; however, oblique electrodes allow a higher insular sampling rate.

Speech and language adverse effects after thalamotomy and deep brain stimulation in patients with movement disorders: A meta-analysis.

BACKGROUND: The thalamus has been a surgical target for the treatment of various movement disorders. Commonly used therapeutic modalities include ablative and nonablative procedures. A major clinical side effect of thalamic surgery is the appearance of speech problems. OBJECTIVE: This review summarizes the data on the development of speech problems after thalamic surgery. METHODS: A systematic review and meta-analysis was performed using nine databases, including Medline, Web of Science, and Cochrane Library. We also checked for articles by searching citing and cited articles. We retrieved studies between 1960 and September 2014. RESULTS: Of a total of 2,320 patients, 19.8% (confidence interval: 14.8-25.9) had speech difficulty after thalamotomy. Speech difficulty occurred in 15% (confidence interval: 9.8-22.2) of those treated with a unilaterally and 40.6% (confidence interval: 29.5-52.8) of those treated bilaterally. Speech impairment was noticed 2- to 3-fold more commonly after left-sided procedures (40.7% vs. 15.2%). Of the 572 patients that underwent DBS, 19.4% (confidence interval: 13.1-27.8) experienced speech difficulty. Subgroup analysis revealed that this complication occurs in 10.2% (confidence interval: 7.4-13.9) of patients treated unilaterally and 34.6% (confidence interval: 21.6-50.4) treated bilaterally. After thalamotomy, the risk was higher in Parkinson's patients compared to patients with essential tremor: 19.8% versus 4.5% in the unilateral group and 42.5% versus 13.9% in the bilateral group. After DBS, this rate was higher in essential tremor patients. CONCLUSION: Both lesioning and stimulation thalamic surgery produce adverse effects on speech. Left-sided and bilateral procedures are approximately 3-fold more likely to cause speech difficulty. This effect was higher after thalamotomy compared to DBS. In the thalamotomy group, the risk was higher in Parkinson's patients, whereas in the DBS group it was higher in patients with essential tremor. Understanding the pathophysiology of speech disturbance after thalamic procedures is a priority. © 2017 International Parkinson and Movement Disorder Society.

The impact of "early" versus "late" initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis.

BACKGROUND: The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of "early" versus "late" RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic. METHODS: A literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to "early" versus "late"/"standard" criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Thirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with "early" RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384-1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of "early" (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies. CONCLUSIONS: Our conclusion based on this evidence synthesis is that "early" initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.