Background: Asleep deep brain stimulation (aDBS) implantation replaces microelectrode recording for image-guided implantation, shortening the operative time and reducing cerebrospinal fluid egress. This may decrease pneumocephalus, thus decreasing brain shift during implantation. Objective: To compare the incidence and volume of pneumocephalus during awake (wkDBS) and aDBS procedures. Methods: A retrospective review of bilateral DBS cases performed at Oregon Health & Science University from 2009 to 2017 was undertaken. Postimplantation imaging was reviewed to determine the presence and volume of intracranial air and measure cortical brain shift. Results: Among 371 patients, pneumocephalus was noted in 66% of wkDBS and 15.6% of aDBS. The average volume of air was significantly higher in wkDBS than aDBS (8.0 vs. 1.8 mL). Volumes of air greater than 7 mL, which have previously been linked to brain shift, occurred significantly more frequently in wkDBS than aDBS (34 vs 5.6%). wkDBS resulted in significantly larger cortical brain shifts (5.8 vs. 1.2 mm). Conclusions: We show that aDBS reduces the incidence of intracranial air, larger air volumes, and cortical brain shift. Large volumes of intracranial air have been correlated to shifting of brain structures during DBS procedures, a variable that could impact accuracy of electrode placement.

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Purpose: The main objective of this study was to display the morphologic properties of the anterior clinoid process (ACP) in human fetuses in term of early childhood surgeries. Methods: Twenty-four (10 females and 14 males) fetal cadavers aged from 16th to 28th weeks of gestation (at mean, 21.54 ± 3.11 weeks) were included in the present study. The dimensions of ACP were measured with a digital image analysis software. Results: Taking into account the length, width, and angle of ACP, it was classified as Type 1 in 20.83% (10 cases), Type 2 in 10.42% (5 cases), Type 3 in 10.42% (5 cases), Type 4 in 2.08% (1 case), Type 5 in 8.33% (4 cases), Type 6 in 16.67% (8 cases), Type 7 in 8.33% (4 cases), and Type 8 in 22.92% (11 cases). According to the attachment site of the optic strut (OS) relative to ACP, OS was identified as the anterior 3/5 in 16.67% (8 cases), anterior 4/5 in 68.75% (33 cases), and posterior 1/5 in 14.58% (7 cases). Neither right-left nor male-female significant differences were observed between the quantitative values belonging to ACP and OS. Conclusion: The percentage of the most complex and challenging type of ACP (the long, narrow, and narrow-angled ACP) in fetuses was found to be close to adults. Thus, routine adult surgical procedures such as anterior clinoidectomy might be successfully used in young children and infants. The attachment site of OS relative to ACP in adults was more anterior according to fetuses probably due to postnatal development such as the pneumatization of the sphenoid bone. In this regard, for pediatric neurosurgeons to avoid iatrogenic injuries and to select appropriate surgical approaches, further studies conducted on the attachment of OS relative to ACP in children are needed.

OBJECTIVEDespite rapid development and expansion of neuromodulation technologies, knowledge about device and/or therapy durability remains limited. The aim of this study was to evaluate the long-term rate of hardware and therapeutic failure of implanted devices for several neuromodulation therapies.METHODSThe authors performed a retrospective analysis of patients’ device and therapy survival data (Kaplan-Meier survival analysis) for deep brain stimulation (DBS), vagus nerve stimulation (VNS), and spinal cord stimulation (SCS) at a single institution (years 1994–2015).RESULTSDuring the study period, 450 patients underwent DBS, 383 VNS, and 128 SCS. For DBS, the 5- and 10-year initial device survival was 87% and 73%, respectively, and therapy survival was 96% and 91%, respectively. For VNS, the 5- and 10-year initial device survival was 90% and 70%, respectively, and therapy survival was 99% and 97%, respectively. For SCS, the 5- and 10-year initial device survival was 50% and 34%, respectively, and therapy survival was 74% and 56%, respectively. The average initial device survival for DBS, VNS, and SCS was 14 years, 14 years, and 8 years while mean therapy survival was 18 years, 18 years, and 12.5 years, respectively.CONCLUSIONSThe authors report, for the first time, comparative device and therapy survival rates out to 15 years for large cohorts of DBS, VNS, and SCS patients. Their results demonstrate higher device and therapy survival rates for DBS and VNS than for SCS. Hardware failures were more common among SCS patients, which may have played a role in the discontinuation of therapy. Higher therapy survival than device survival across all modalities indicates continued therapeutic benefit beyond initial device failures, which is important to emphasize when counseling patients.

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Objective:The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure.Materials and Methods:Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18–87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner.Results:Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1–C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion.Conclusions:Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.

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