Chima O. Oluigbo

A surgeon’s level of technical proficiency plays a significant role in surgical outcomes. Rating scales, such as the objective structured assessment of technical skills (OSATS), have been validated for surgical quality assurance, skills assessment, and training. However, they are subjective, time-consuming, and dependent on experts with busy schedules, limiting scalability. Moreover, experts may face a long delay between procedure completion and their single, unitary rating, preventing continuous feedback on actions performed. Artificial intelligence systems trained on expert ratings may help overcome these limitations. This work demonstrates a comprehensive human-in-the-loop framework for developing a machine-learning system for automated, continuous OSATS ratings, from data collection to algorithm training and real-world applications. We provide demonstrations of AI assessment on two video recordings: (1) removal of an epileptogenic region during intracranial surgery, and (2) resection of a simulated subpial brain tumor. With sufficient training and validation, machine-learning systems may approximate expert assessments and provide real-time, expert-level feedback during procedures to inform surgeons of increasing patient risk and improve operative outcomes.

To clarify the upper limit of epilepsy onset in focal cortical dysplasia (FCD) Type II (FCD)-related epilepsy and to investigate factors affecting long-term surgical outcomes from an open-source database. Patients with FCD Type II pathology were included from the Imaging Database for Epilepsy And Surgery. The primary outcome measure was the incidence of adult-onset FCD-drug resistant epilepsy (DRE). Secondary analyses focused on factors affecting long-term seizure-free outcomes after resective epilepsy surgery for FCD-DRE. Thirty-nine FCD-DRE patients were identified. Pathology was Type IIB (n = 30), Type IIA (n = 8), and Type II Not Otherwise Specified (n = 1). Only 5% had adult-onset DRE; 95% had onset before 15 years. Surgery was associated with 71.4% 5-year International League Against Epilepsy Class I outcome. FCD Type IIB was associated with high rate of seizure-free outcome (OR 13.0, 95% CI [1.36-124], p = 0.03). Focal-to-bilateral-tonic-clonic seizures, focal impaired consciousness seizures, prior status epilepticus, sex, hemisphere, age of epilepsy onset, and age of surgery were not associated with 5-year seizure-free outcome. Prior data show that ∼5% of FCDs are discovered incidentally. This study elucidates that the majority of FCD-DRE (including those patients treated as adults) is childhood-onset. These data demonstrate that FCD Type II (especially Type IIB) is associated with high rates of durable postsurgical seizure-free outcome.

Objective: Use of neuromodulation strategies targeting thalamic nuclei, including deep brain stimulation (DBS) and responsive neurostimulation (RNS), for treatment of pediatric drug‐resistant epilepsy (DRE) is increasing, despite limited evidence for efficacy and safety. We present the initial results from the Comparative Multicenter Evaluation of Thalamic Neuromodulation for Treatment‐Resistant Epilepsy in Children consortium, which was created to study thalamic modulation in children with DRE. Methods: We performed a retrospective cohort study of children who underwent thalamic DBS or RNS for DRE between January 2015 and December 2024 across 12 centers. Primary outcomes were percent seizure reduction, Engel class, and responder rates (>50% seizure reduction) at 3, 6, and 12 months postoperatively. Secondary outcomes included antiseizure medications and surgical complications. Differences were quantified using ordinal logistic regression, generalized estimating equations with center clustering, and mixed‐effects models. Stratified analyses were performed by thalamic target (centromedian vs. anterior nucleus) and epilepsy diagnosis (Lennox–Gastaut syndrome, generalized, focal, and multifocal). Results: Among the 221 included patients (111 DBS, 110 RNS) included, DBS and RNS achieved comparable Engel scores and 12‐month responder rates, but different temporal trajectories were observed. There was a significant device × time interaction (odds ratio = 1.10/month, 95% confidence interval = 1.01–1.20, p = .04), with RNS response rates increasing from 26.9% at 3 months to 55.6% at 12 months (paired p < .001) but with DBS response rates reaching 41.7% at 3 months and remaining comparatively stable over time. DBS achieved significantly higher 12‐month seizure freedom (9.5% vs. 1.2%, p = .03). Neither thalamic target selection nor diagnosis predicted seizure outcome. Safety profiles were equivalent. Significance: This multicenter analysis provides pediatric‐specific data to inform surgical indications, device selection, and preoperative counseling. DBS and RNS were effective for treatment of pediatric DRE, with equivalent 12‐month seizure outcomes but different temporal trajectories. DBS provided earlier seizure control and higher rates of overall seizure freedom.

Beyond sustaining life, breathing is a vital physiological rhythm that shapes cognition, perception, emotional regulation, and mental health. Breathing has a direct effect on neuronal excitability and is coupled to neural oscillations across a variety of brain regions. Notably, both respiration and neural oscillations are asymmetric and not perfectly rhythmic: for example, every breath has a different shape and duration, and is interspersed with variable pauses. Here, we examined the coupling between breathing and the brain by quantifying the nonsinusoidal features of each breath and comparing it to the shape of each corresponding neural oscillation cycle. By leveraging invasive human brain recordings from 16 participants, we found respiration-neural waveform coupling on a breath-by-breath, cycle-by-cycle basis across limbic and cortical forebrain regions. For decades, the dominant perspective on cognition and mental health have focused on the brain, but recent work is highlighting the importance of brain-body interactions. Our results show that the coupling between breathing and neural activity is much richer than previously appreciated, and our approach opens new avenues for studying these peripheral-to-central nervous system interactions in a more robust, temporally precise manner.

Hypothalamic hamartomas (HH) are rare brain lesions associated with epilepsy and numerous comorbidities. Worldwide treatment is varied. There is a paucity of high-quality evidence to guide treatment. This study aimed to establish expert consensus on the evaluation and management of HH. A modified Delphi survey was designed by the Medical Advisory Board of Hope for Hypothalamic Hamartomas and was conducted among 17 International League Against Epilepsy level II epilepsy surgery centers. The survey included 257 questions in round 1 and 81 refined questions in round 2, covering domains of diagnosis, imaging, medical and surgical treatment, neuropsychological and psychiatric evaluation, and care. Consensus was defined as ≥75% agreement using a 9-point Likert scale. Consensus was achieved on 82% of the questions. Key findings include the following: Diagnosis: Gelastic and dacrystic seizures are strongly associated with HH; 3T epilepsy protocol MRI is essential. Evaluation: Preoperative neuropsychological and endocrinologic assessments are important. Evaluation with further imaging (PET, SPECT, and magnetoencephalography) and intracranial EEG is not useful. Treatment: No consensus was achieved on first-line, second-line, or third-line antiseizure medications (ASMs). Surgical evaluation should begin at the start of the first ASM, with surgery recommended after failure of 2 ASMs. LITT is preferred for Delalande II and III HH. Postoperative care: MRI follow-up at 6-12 months recommended. Preoperative and postoperative cognitive, behavioral, psychosocial, and endocrinologic evaluations are emphasized. Domains: IQ, language, attention, executive function, academic achievement, adaptive function, and behavior (tantrums, rage, anxiety, and depression) are important. This Delphi process highlights an international consensus on aspects of HH management. Gelastic/dacrystic seizures are important at diagnosis. A 3T epilepsy protocol MRI is essential. Early epilepsy surgery evaluation is advised. Surgery should be pursued either by disconnective, ablative, or resective techniques. HH location, size, and surgical experience are essential for good outcomes. Postoperative MRI should be obtained 6-12 months and/or if ongoing seizures. Neuropsychological testing should be obtained at baseline, and 6-12 months postsurgically. Findings support a multidisciplinary, protocol-driven approach to optimize outcomes in patients with HH. Areas lacking consensus, such as specific endocrine testing and timing of certain interventions, warrant further research and standardization.

This practice guideline from the American Epilepsy Society provides evidence-based recommendations for pharmacological, dietary, and surgical therapies for epilepsy for infants and children from 1 month of age to <36 months. The multidisciplinary panel updated an existing systematic review, which was funded by the Patient-Centered Outcomes Research Institute and conducted by ECRI (formerly the Emergency Care Research Institute) on behalf of the Agency for Healthcare Research and Quality. The updated review used the same search strategy, inclusion/exclusion criteria, and Grading of Recommendations Assessment, Development and Education methodology, and added studies from August 2021 through September 2025 that were not in the original systematic review. As with the previous review, West syndrome and infantile spasms were excluded from this guideline, as existing treatment guidance is already available for infantile epileptic spasms. While many of the recommendations are conditional due to low certainty of evidence, the panel made two strong recommendations: (1) hemispherectomy/hemispherotomy surgery is recommended for infants and children <36 months of age with drug resistant epilepsy secondary to select underlying lesional pathologies, including but not limited to hemimegaloencephaly, Rasmussen's encephalitis, Sturge-Weber syndrome, perinatal stroke, and hemispheric cortical dysplasia; and (2) intralobar, multilobar, or focal resections or posterior disconnections for drug-resistant focal or lesional epilepsy in this same age range. A treatment algorithm was developed based on evidence and expert opinion as part of the guideline to help place pharmacological, dietary, and surgical recommendations in a clinical context. The limited number of studies and low certainty of evidence in this population underscores the need for higher-quality data and etiology-specific treatments. More research is needed to evaluate effective therapies for infants with epilepsy, as well as the impact these therapies have on long-term developmental and mortality outcomes.

This paper presents the development and cadaveric evaluation of a pneumatically actuated robotic assistant for MRI-guided stereotactic neurosurgery. The robot features two coaxial arcs that provide four degrees of freedom to position and orient a needle within an MRI scanner. It is driven by custom-designed MR-Safe pneumatic stepper motors and powered by in-room compressed medical air, enabling precise interventions under intraoperative MRI guidance. To improve anatomical visualization, two custom MR imaging coils were developed and integrated with the system. A dedicated clinical workflow was also proposed for robot-assisted stereotactic procedures under MRI-guidance. Targeting accuracy was first assessed in free space using an optical tracking system, yielding mean absolute errors of 0.97 ± 0.42 mm for tip position and 0.46 ± 0.23° for needle angle. System-level accuracy was then evaluated in MRI-guided phantom studies, showing errors of 1.38 ± 0.80 mm in tip position and 1.08 ± 0.67° in angle. Finally, a cadaver study validated the clinical workflow, with observed errors of 2.11 mm in position and 3.32° in angle. Quantitative imaging analysis confirmed minimal image degradation, with signal-to-noise ratio (SNR) variation below 12.26% and 2D geometric distortion under 0.20%.

Objective: Despite being safe and effective, surgery for pediatric epilepsy is underutilized. Social determinants of health (SDoH) are important to consider when examining this treatment gap. This study examined the potential systemic inequities at three different stages in the journey toward epilepsy surgery across the Pediatric Epilepsy Research Consortium (PERC). Methods: Any youth in the PERC prospective surgery database (≤18 years) was eligible and included if sociodemographic factors were also available. We examined if there were differences in disparity factors in: (1) referral to Phase I evaluation, (2) offering of surgery, and (3) completion of surgery. Results: Of 1309 patients, the majority were male (53%, p = .04), White (82.2%, p < .001), not Hispanic or Latino (84.3%, p < .001), and privately insured (56.3%, p < .001). Of the youth who were offered surgical treatment ( n = 1103, 84.3%), there were no significant differences in race/ethnicity or sex. Those with a structural lesion were more likely to be offered surgery, and historically marginalized youth were more likely to have a lesion. Of patients who completed surgery ( n = 927, 84.0%), White patients were 1.88 times (95% confidence interval [CI]: 1.14–3.04) more likely than Black patients to complete surgery ( p = .01). Significance: Youth who began surgery evaluation are not representative of the demographics of those with epilepsy in the United States, with greater representation of White, non‐Hispanic male individuals. In addition, youth who began surgery evaluation disproportionally have private insurance. At the next stage of offering surgery, there were no differences based on SDoH. However, there is evidence that underrepresented youth that were magnetic resonance negative were less likely to be referred for surgical workup and that Black youth were less likely to undergo surgery. Therefore, efforts to provide equitable opportunity for all youth with refractory epilepsy should be concentrated at the referral for surgery evaluation point of care; however, additional efforts are also needed at later stages.

Objective The pediatric neurosurgical literature supports the placement of a ventricular access device (VAD) in the premature infant with posthemorrhagic ventricular dilatation as a temporizing measure prior to definitive diversionary shunting. However, there is an absence of data identifying the clinical utility and significance of VADs left in situ at the time of permanent shunt placement. The potential risks of leaving an initial VAD at the time of definitive contralateral cerebral spinal fluid (CSF) diversion and the benefits of a concomitant VAD in these patients with regard to potential life-saving or temporizing aspirations are not well documented. Methods Retrospective cohort review of premature infants (< 37 weeks gestational age) treated for PHH at a tertiary pediatric neurosurgery center from January 2005 to December 2021. Patients were grouped by whether a previously placed VAD was retained during permanent shunt insertion. Outcomes measured: number and outcome of VAD taps, shunt revisions, shunt infections. Statistical comparison between the two groups; p < 0.05 considered significant. Results Seventy-two premature patients (gestational age < 37 weeks) were identified. This cohort included 40 (55.55%) patients with both a VAD and shunt and 32 (44.44%) patients with a shunt only (12 with VAD removed at shunt insertion; 20 with no VAD insertion). Of the 40 patients with a shunt and VAD in situ, 17/40 (42.5%) had their VADs tapped at the time of shunt failure, resulting in 29 total VAD taps. There were 23 emergent VAD taps, of which 17/23 (73.91%) were successful. Leaving the VAD in situ did not result in increased rates of total shunt infections or revisions (p = 0.215; p = 0.129). Conclusions Based on this analysis, VADs placed for initial management of post-hemorrhagic IVH may serve an important role in children with subsequent proximal shunt malfunctions, potentially lifesaving. A high percentage of shunted patients with VADs benefited without increased risk of shunt revisions or infections. The decision for a VAD to remain in situ at the time of permanent shunt placement in these patients should be strongly considered.