•Two epilepsy patients did not have seizures during three weeks of intracranial EEG.•They were implanted with a device that enables chronic electrocorticography.•Seizures were localized by ictal ...recordings at long intervals after implantation.
To present two patients with medically-refractory focal epilepsy who, following non-diagnostic intracranial monitoring studies, had seizures localized by chronic ambulatory electrocorticography with an implanted neurostimulation device.
Case reports with clinical details and electrocorticograms showing seizures.
Using electrodes placed at the suspected seizure onset zones, the neurostimulator recorded seizures in both patients at long intervals following implantation (49 days and 7.5 months).
Chronic ambulatory electrocorticography can provide valuable diagnostic information when there is a narrow hypothesis about seizure localization, though there are important caveats related to limited spatial sampling.
Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to treat a variety of intracranial lesions. Utilization of robotic assistance with stereotactic procedures has gained ...attention due to potential for advantages over conventional techniques. The authors report the first case in which robot-assisted MRI-guided LITT was used to treat radiation necrosis in the posterior fossa, specifically within the cerebellar peduncle. The use of a stereotactic robot allowed the surgeon to perform LITT using a trajectory that would be extremely difficult with conventional arc-based techniques. A 60-year-old man presented with facial weakness and brainstem symptoms consistent with radiation necrosis. He had a history of anaplastic astrocytoma that was treated with CyberKnife radiosurgery 1 year prior to presentation, and he did well for 11 months until his symptoms recurred. The location and form of the lesion precluded excision but made the patient a suitable candidate for LITT. The location and configuration of the lesion required a trajectory for LITT that was too low for arc-based stereotactic navigation, and thus the ROSA robot (Medtech) was used. Using preoperative MRI acquisitions, the lesion in the posterior fossa was targeted. Bone fiducials were used to improve accuracy in registration, and the authors obtained an intraoperative CT image that was then fused with the MR image by the ROSA robot. They placed the laser applicator and then ablated the lesion under real-time MR thermometry. There were no complications, and the patient tolerated the procedure well. Postoperative 2-month MRI showed complete resolution of the lesion, and the patient had some improvement in symptoms.
The landscape of medicine in the United States has been slowly progressing toward a more holistic and individualized approach to healing. Part of this progress has been the integration between ...western and alternative forms of medicine, a concept that has been described as "integrative medicine." This approach to healthcare incorporates a patient's mind, spirituality, and sense of community into the healing process. Integrative medicine has been typically well received and the demand has been steadily increasing in primary US hospitals. Here we cover a number of topics that include the definition of integrative medicine, its potential benefits, current examples of successful implementations, and potential barriers to its expansion. The aim was to give a primary on integrative medicine and its current state for healthcare providers.
Proximal junctional kyphosis (PJK) is a common complication following long-segment thoracolumbar fusions for patients with adult spinal deformities. PJK is described as a progressive kyphosis at the ...upper instrumented vertebra or 1 or 2 segments adjacent to the instrumented vertebra. This condition can lead to proximal junction failure, which results in vertebral body fractures, screw pullouts, and neurological deficits. Revision surgery is necessary to address symptomatic PJK. Research efforts have been dedicated to elucidating risk factors and prevention strategies. It has been postulated that minimally invasive surgery (MIS) techniques may help prevent PJK because these techniques aim to preserve the soft tissue integrity at the top of the construct and maintain posterior element support. In this article, the authors define PJK, describe MIS strategies to prevent PJK, and compare PJK rates after MIS with PJK rates after open approaches for long-segment thoracolumbar fusion.
Spinopelvic parameters have hitherto dictated much of adult spinal deformity (ASD) correction. The Roussouly classification is used for the normal adult spine. We evaluated whether a correlation ...would be found between the Roussouly type and the rate of revision surgery in patients with ASD undergoing circumferential minimally invasive spinal (cMIS) correction.
A multicenter retrospective review of patients who had undergone cMIS surgery for ASD was performed. The inclusion criteria were age ≥18 years and 1 of the following: coronal Cobb angle >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, pelvic incidence (PI) to lumbar lordosis (LL) mismatch >10°, cMIS surgery, and a minimum of 2 years of follow-up data available. The patients were classified by Roussouly type, and the clinical and radiographic outcomes were evaluated.
A total of 104 patients were included in the present analysis. Of the 104 patients, 41 had Roussouly type 1, 32 had type 2, 23 had type 3, and 8 had type 4. Preoperatively, the patients with type 4 had the highest PI (P = 0.002) and LL (P < 0.001). Postoperatively, the PI-LL mismatch, Cobb angle, and sagittal vertical axis were not different among the 4 groups. However, the patients with type 2 had had the highest rate of complications (type 1, 29.3%; type 2, 61.3%; type 3, 34.8%; type 4, 25.0%; P = 0.031). The reoperation rates were comparable (type 1, 19.5%; type 2, 38.7%; type 3, 13.0%; type 4, 12.5%; P = 0.097). The reoperation rates for adjacent segment degeneration or proximal junctional kyphosis were also comparable (P = 0.204 and P = 0.060, respectively).
We did not find a clear correlation between Roussouly type and the rate of revision surgery for adjacent segment disease or proximal junctional kyphosis in patients who had undergone cMIS surgery for ASD.
Summary
Objective
Lowering the length of stay (LOS) is thought to potentially decrease hospital costs and is a metric commonly used to manage capacity. Patients with epilepsy undergoing intracranial ...electrode monitoring may have longer LOS because the time to seizure is difficult to predict or control. This study investigates the effect of economic implications of increased LOS in patients undergoing invasive electrode monitoring for epilepsy.
Methods
We retrospectively collected and analyzed patient data for 76 patients who underwent invasive monitoring with either subdural grid (SDG) implantation or stereoelectroencephalography (SEEG) over 2 years at our institution. Data points collected included invasive electrode type, LOS, profit margin, contribution margins, insurance type, and complication rates.
Results
LOS correlated positively with both profit and contribution margins, meaning that as LOS increased, both the profit and contribution margins rose, and there was a low rate of complications in this patient group. This relationship was seen across a variety of insurance providers.
Significance
These data suggest that LOS may not be the best metric to assess invasive monitoring patients (i.e., SEEG or SDG), and increased LOS does not necessarily equate with lower or negative institutional financial gain. Further research into LOS should focus on specific specialties, as each may differ in terms of financial implications.
Hemispherectomy is a successful and well-described treatment option for pediatric patients with hemispheric ictal onset, but adult outcomes have been far less studied. We describe the outcomes in ...adult patients with medically refractory epilepsy and hemispheric disease and the relationship to cerebral peduncle volume.
We retrospectively reviewed adult hemispherectomy patients at our institution from 2015 to 2018. Patient data including demographic information, pathologic changes, seizure-free outcomes, and ipsilateral (i.e., surgical side) and contralateral (i.e., functional side) cerebral peduncle volume data were collected. We identified 4 adult patients who underwent hemispherectomy. The mean age at surgery was roughly 25 years. All patients were categorized as Engel I or II, and motor scores at last follow-up were unchanged. The mean volume for contralateral and ipsilateral cerebral peduncle means were 1.42 and 0.78 cm3, respectively (P = 0.01).
These findings suggest that smaller ipsilateral cerebral peduncle size could potentially be associated with unchanged postoperative hemiparesis. We hypothesize that smaller ipsilateral peduncle size could have represented corticospinal tract reorganization in childhood, implying that the removed brain matter was mostly noncontributory to contralateral motor function.
While nutrient enrichment increases herbivory rates on highly palatable species of tropical algae, it is unclear how nutrient enrichment affects species with differing initial palatabilities. We ...determined that there was a wide range in relative palatability among 5 perennial and common species of Caribbean coral reef algae in a cafeteria-style choice experiment, with overall preference forAcanthophora spiciferathe highest,Dictyota dichotomaandCaulerpa sertularioidesintermediate, andTurbinaria turbinataandSargassum polyceratiumthe lowest, although there were significant differences in grazing rates among algal species between the 2 fringing reef sites tested. We then tested the hypothesis that increased nutrient content in algae increases palatability using choice experiments between enriched and ambient algal samples for each of 3 species along this palatability gradient:A. spicifera,D. dichotoma, andS. polyceratium. For all species, herbivores selected enriched over ambient samples across the 2 sites despite contrasting herbivore guilds (i.e. dominated by sea urchinDiadema antillarumversus herbivorous fishes). However, despite increased palatability of enrichedS. polyceratium, overall herbivory on this species was still relatively low compared to other studies, suggesting thatS. polyceratiumin this system may have stronger chemical defenses, or that a specialist herbivore guild may be missing on this Caribbean reef. Regardless of the mechanism, our study implies that anthropogenic or natural events that result in high supplies of nutrients in coral reef seawater will increase overall seaweed palatability, even of unpalatable species.
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