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Background For patients with psychiatric illnesses remaining refractory to ‘standard’ therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. Methods To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. Findings The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered ‘established’ in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. Interpretation This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.

Deep brain stimulation electrode placement with interventional magnetic resonance imaging (MRI) has previously been reported using a commercially available skull-mounted aiming device (Medtronic Nexframe MR) and native MRI scanner software. This first-generation method has technical limitations that are inherent to the hardware and software used. A novel system (SurgiVision ClearPoint) consisting of an aiming device (SMARTFrame) and software has been developed specifically for interventional MRI, including deep brain stimulation. To report a series of phantom and cadaver tests performed to determine the capability, preliminary accuracy, and workflow of the system. Eighteen experiments using a water phantom were used to determine the predictive accuracy of the software. Sixteen experiments using a gelatin-filled skull phantom were used to determine targeting accuracy of the aiming device. Six procedures in 3 cadaver heads were performed to compare the workflow and accuracy of ClearPoint with Nexframe MR. Software prediction experiments showed an average error of 0.9 ± 0.5 mm in magnitude in pitch and roll (mean pitch error, -0.2 ± 0.7 mm; mean roll error, 0.2 ± 0.7 mm) and an average error of 0.7 ± 0.3 mm in X-Y translation with a slight anterior (0.5 ± 0.3 mm) and lateral (0.4 ± 0.3 mm) bias. Targeting accuracy experiments showed an average radial error of 0.5 ± 0.3 mm. Cadaver experiments showed a radial error of 0.2 ± 0.1 mm with the ClearPoint system (average procedure time, 88 ± 14 minutes) vs 0.6 ± 0.2 mm with the Nexframe MR (average procedure time, 92 ± 12 minutes). This novel system provides the submillimetric accuracy required for stereotactic interventions, including deep brain stimulation placement. It also overcomes technical limitations inherent in the first-generation interventional MRI system.

Abstract BACKGROUND Stereotactic lesion in the Forel's field H (campotomy) was proposed in 1963 to treat Parkinson disease (PD) symptoms. Despite its rationale, very few data on this approach have emerged. Additionally, no study has assessed its effects on nonmotor symptoms, neuropsychological functions and quality of life. OBJECTIVE To provide a prospective 2-yr assessment of motor, nonmotor, neuropsychological and quality of life variables after unilateral campotomy. METHODS Twelve PD patients were prospectively evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS), the Dyskinesia Rating Scale and the Parkinson's disease quality of life questionnaire (PDQ39) before campotomy, and after 6 and 24 mo. Nonmotor, neuropsychiatric, neuropsychological and quality of life variables were assessed. The impact of PD on global health was also rated. RESULTS A significant reduction in contralateral rest tremor (65.7%, P < .001), rigidity (87.8%, P < .001), bradykinesia (68%, P < .001) and axial symptoms (24.2%, P < .05) in offmedication condition led to a 43.9% reduction in UPSDRS III scores 2 yr after campotomy (P < .001). Gait improved by 31.9% (P < .05) and walking time to cover 7 m was reduced by 43.2% (P < .05). Pain decreased by 33.4% (P < .01), while neuropsychiatric and neuropsychological functions did not change. Quality of life improved by 37.8% (P < .05), in line with a 46.7% reduction of disease impact on global health (P < .001). CONCLUSION A significant 2-yr improvement of motor symptoms, gait performance and pain was obtained after unilateral campotomy without significant changes to cognition. Quality of life markedly improved in parallel with a significant reduction of PD burden on global health.

Frame-based Stereotactic Brain Biopsy (FSBB) is a minimally invasive procedure with a view to increasing the diagnostic yield. The aim of this study was to investigate the accuracy and safety of FSBB with the help of the intraoperative 3D O-ARM system. A preoperative MRI allowed for targeting the tissue to be sampled. A Leksell stereotactic frame was bolted to patient’s skull in the operating room, and we proceeded to the intraoperative 3D O-ARM acquisition. A software platform was used to calculate stereotactic coordinates through combining both exams. A second 3D O-ARM acquisition was performed to control the final needle target point. A total of 79 patients were included in our study population, 68 biopsies (86.1%) yielded the diagnosis. Biopsy-related complications occurred in 11 patients (13.9%), of whom 8 were successfully diagnosed. Per and post-procedure complications occurred in 3 (3.8%) and 8 cases (10.1%) respectively. Mean operating time was 102 min. FSBB using the intraoperative 3D O-ARM system is a promising alternative. The rate of non-contributory biopsies is moderate given that this new procedure is conducted in the operating room from beginning to end. Complications were not directly linked to the procedure and does not compromise the diagnosis.

Existing methods for biopsy of intraparenchymal brain lesions, including stereotactic biopsy and open block biopsy, have advantages and disadvantages. We propose a novel biopsy method, called “boring biopsy,” which aims to overcome the drawbacks of each conventional method. This method is less invasive and allows obtaining continuous specimens of sufficient volume. We aimed to assess the feasibility and efficacy of using boring biopsy for intraparenchymal brain lesions. We included 26 consecutive patients who underwent boring biopsy for intraparenchymal lesions. Columnar continuous specimens from the surface of the normal brain tissue to the tumor margin and the center of the lesion were obtained using the boring biopsy method. We used a catheter introducer with original modifications to create a cylindrical biopsy tool for surgery. Columnar continuous specimens were successfully obtained. Histopathological diagnosis was based on cellular changes and differentiation from normal tissues to the core of the lesion and established in all cases. No permanent deficits, major adverse outcomes, or deaths were observed. This novel technique may improve diagnostic accuracy and reduce invasiveness associated with brain biopsy. This method may become the next standard procedure, particularly in some cases where histological evaluation is paramount, and conventional biopsy methods are not suitable.

Abstract BACKGROUND Surgical site infections (SSIs) after spine and brain surgery present a major burden to patients and hospitals by increasing morbidity, mortality, and healthcare costs. OBJECTIVE To review available literature investigating the role of intrawound powdered vancomycin against SSIs after neurosurgical operations. METHODS All randomized and observational English language studies of intrawound powdered vancomycin use in spinal and cranial surgery were included and analyzed using random-effects modeling. RESULTS In spine surgery (25 studies with 16 369 patients), patients in the vancomycin group had a significantly lower risk for any SSI (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.30-0.57; P < .001; I2 = 47%). However, when separate analyses were conducted for superficial and deep SSIs, a significant difference was found only for deep (OR: 0.31; 95% CI: 0.22-0.45; P < .001; I2 = 29%). Subgroup analyses for different vancomycin powder dosages (1 g vs 2 g vs composite dose) did not point to any dose-related effect of vancomycin. In cranial surgery (6 studies with 1777 patients), use of vancomycin was associated with a significantly lower risk for SSIs (OR: 0.33; 95% CI: 0.18-0.60; P = .0003; I2 = 45%). In meta-regression analysis, trial-level variability of diabetes had no influence on the association of vancomycin powder use with SSIs. CONCLUSION Use of vancomycin powder in spinal and cranial surgery might be protective against SSIs, especially against deep SSIs. No dose-related effect of vancomycin powder was identified. However, caution is needed in the clinical interpretation of these results, owing to the observational design of the included studies in this meta-analysis.

Background Previously, we reported on our single centre results regarding the diagnostic yield of stereotactic needle biopsies of brain lesions. The yield then (1996–2006) was 89.4%. In the present study, we review and evaluate our experience with intraoperative frozen-section histopathologic diagnosis on-demand in order to improve the diagnostic yield. Methods One hundred sixty-four consecutive frameless biopsy procedures in 160 patients (group 1, 2006–2010) were compared with the historic control group (group 2, n  = 164 frameless biopsy procedures). Diagnostic yield, as well as demographics, morbidity and mortality, was compared. Statistical analysis was performed by Student's t , Mann–Whitney U , Chi-square test and backward logistic regression when appropriate. Results Demographics were comparable. In group 1, a non-diagnostic tissue specimen was obtained in 1.8%, compared to 11.0% in group 2 ( p  = 0.001). Also, both the operating time and the number of biopsies needed were decreased significantly. Procedure-related mortality decreased from 3.7% to 0.6% ( p  = 0.121). Multivariate analysis only proved operating time (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.000–1.025; p  = 0.043), a right-sided lesion (OR, 3.183; 95% CI, 1.217–8.322; p  = 0.018) and on-demand intraoperative histology (OR, 0.175; 95% CI, 0.050–0.618; p  = 0.007) important factors predicting non-diagnostic biopsies. Conclusions The importance of a reliable pathological diagnosis as obtained by biopsy must not be underestimated. We believe that when performing stereotactic biopsy for intracranial lesions, next to minimising morbidity, one should strive for as high a positive yield as possible. In the present single centre retrospective series, we have shown that using a standardised procedure and careful on-demand intraoperative frozen-section analysis can improve the diagnostic yield of stereotactic brain biopsy procedures as compared to a historical series.

Background Stereotaxic neurosurgery in animal models has become a prominent experimental technique in many areas of science and research. These approaches, however, require advanced surgical skills, meticulous anesthetic protocols, and thorough analgesic management to ensure scientific accuracy and animal welfare. The specialized anatomy and physiology of birds, combined with high interspecies variability, make the use of anesthetics, analgesics, and other medications particularly challenging, especially in the absence of well-established guidelines. Here, we present an anesthetic-analgesic protocol developed for stereotaxic neurosurgery for neuronal tracer injection in Svalbard rock ptarmigan ( Lagopus muta hyperborea ). Results 6 Svalbard rock ptarmigan underwent stereotaxic neurosurgery and a multimodal anesthetic-analgesic approach was developed, including isoflurane (inhalation, induced with 3–5%, maintained with 1–3%), bupivacaine (2 mg/kg s.c. during anaesthesia, preoperatively), buprenorphine (0.05 mg/kg i.m. during anaesthesia, both preoperatively and postoperatively), and meloxicam (0.4 mg/kg i.m. during anaesthesia, postoperatively, followed by 0.4 mg/kg p.o. q24h until euthanasia on day 7). Birds were monitored during surgery for vital signs. Post-mortem analysis was performed to confirm neuronal tracer placement. The multimodal anesthetic-analgesic protocol was effective, with minimal signs of postoperative pain based on regular observations using a customized pain-assessment chart. Vital parameters remained largely within expected ranges, with minor deviations in respiratory rate and temperature. Injections missed the hypothalamic target by 0.5–2 mm, typically landing in the septal region due to interindividual anatomical variation. Conclusions This study demonstrates the feasibility of stereotaxic neurosurgery in Svalbard rock ptarmigan by employing rigorous perioperative monitoring and a carefully tailored anesthetic-analgesic regimen. These results provide valuable guidance for future experimental procedures, improving both animal welfare and the reliability of neurosurgical research techniques in avian species.

Background Stereotactic brain biopsy (SBB) is a technique that allows for definitive diagnosis of brain lesions. Little information is available regarding the diagnostic utility of SBB in dogs with intracranial diseases. Objective To investigate the diagnostic accuracy (DA) of SBB in dogs with brain tumors. Animals Thirty‐one client‐owned dogs that underwent SBB followed by surgical resection or necropsy examinations. Methods Retrospective observational study. Two pathologists blinded to SBB and reference standard diagnoses reviewed histologic specimens and typed and graded tumors according to World Health Organization and revised canine glioma classification criteria. Agreement between tumor type and grade from SBB were compared to reference standards and assessed using kappa statistics. Patient and technical factors associated with agreement also were examined. Results Stereotactic brain biopsy specimens were obtained from 24 dogs with gliomas and 7 with meningiomas. Tumor type agreement between SBB and the reference standard was observed in 30/31 cases (κ = 0.95). Diagnostic concordance was perfect for meningiomas. Grade agreement among gliomas was observed in 18/23 cases (κ = 0.47). Stereotactic brain biopsy underrepresented the reference standard glioma grade in cases with disagreement. The DA of SBB was 81%, with agreement noted in 56/69 biopsy samples. Smaller tumors and fewer SBB specimens obtained were significantly associated with diagnostic discordance. Conclusions and Clinical Importance The DA of SBB readily allows for the diagnosis of common brain tumors in dogs. Although glioma grade discordance was frequent, diagnoses obtained from SBB are sufficient to currently inform therapeutic decisions. Multiple SBB specimens should be collected to maximize DA.

We report a case of multiple brain abscesses’ puncture, employing the ROSA™ Brain surgical robot (Zimmer Biomet) and the O-arm® O2 Imaging System (Medtronic). A 51-year-old man was diagnosed with multiple supratentorial ring enhancing cystic lesions consistent with brain abscesses. A neurological deterioration occurred despite broad spectrum antibiotic therapy, due to mass effect of the abscesses. Stereotactic aspiration was performed using the described technique, allowing a single stage puncture of the cerebral lesions. In this case, the robot-assisted and image-guided procedure permitted an accurate, quick, and efficient targeting of the multiple abscesses for drainage.