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Functional disorders of the central nervous system (CNS) are diverse in terms of their etiology and symptoms, however, they can be quite debilitating. Many functional neurological disorders can progress to a level where pharmaceuticals and other early lines of treatment can no longer optimally treat the condition, therefore requiring surgical intervention. A variety of stereotactic and functional neurosurgical approaches exist, including deep brain stimulation, implantation, stereotaxic lesions, and radiosurgery, among others. Most techniques are invasive or minimally invasive forms of surgical intervention and require immense precision to effectively modulate CNS circuitry. Focused ultrasound (FUS) is a relatively new, safe, non-invasive neurosurgical approach that has demonstrated efficacy in treating a range of functional neurological diseases. It can function reversibly, through mechanical stimulation causing circuitry changes, or irreversibly, through thermal ablation at low and high frequencies respectively. In preliminary studies, magnetic resonance imaging-guided high-intensity focused ultrasound (MRgHIFU) has been shown to have long-lasting treatment effects in several disease types. The technology has been approved by the FDA and internationally for a number of treatment-resistant neurological disorders and currently clinical trials are underway for several other neurological conditions. In this review, the authors discuss the potential applications and emerging role of MRgHIFU in functional neurosurgery in the coming years., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Fiani et al.)

Introduction Surgical residents play vital roles in day-to-day patient care as well as in the operating room. However, there is a paucity of literature regarding patients' perspectives on neurosurgical residents and their participation in their care. This current study investigates the knowledge, attitudes, and beliefs of patients regarding neurosurgical residents and their involvement in their healthcare process. Methods Patients older than 18 years who had undergone brain or spine surgery were requested to complete a survey questionnaire. The 7-point Likert scale response ranging from "strongly agree", "agree", "more or less agree", "undecided", more or less disagree", "disagree" to "strongly disagree" was used. The primary objective was to assess patient understanding and attitudes towards resident participation in surgical and medical care within the specialty of neurosurgery. The duration of the study was eight months. Patients having prior exposure to an informed-consent procedure by a neurosurgery team within a year prior to this study were excluded. Data were analyzed using Student's t-test, one-way analysis of variance (ANOVA), and standard averaging of responses. Results Fifty-one patients who had undergone elective surgery participated in the study survey. The majority of these respondents were between the ages of 46 and 60 years. Most of the responses were similar across gender and different age groups for most of the questions on the Likert scale questionnaire. Overall, when asked to assess their comfort level in medical and surgical care participation by residents, patients responded positively (strongly agree: 80.4%; agree: 92.2%). Patients also either disagreed or strongly disagreed (76%) about residents lacking medical knowledge. Patients overwhelmingly disagreed (91.5%) when asked if residents were unprofessional. In addition, 72.5% of the patients were able to accurately define a resident's role. Conclusion Well-formatted surveys can offer a convenient route for patients to provide objective as well as subjective feedback. The results indicate that patients had an overall positive attitude toward having residents involved in their care. These trends also indicate that patients knew the role that residents played in their healthcare process and they were comfortable with them doing so. Further studies may expand the trial to include a larger number of patients, as well as other specialties, to expand the scope of the study. Patient survey questionnaires could be thought of as a useful tool by the Accreditation Council for Graduate Medical Education (ACGME) to incorporate as part of the evaluation process of resident physicians., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Fiani et al.)

Introduction Burnout is common among clinical specialties and has implications on the residents' well-being and mental health. Evidence suggests that optimism and burnout are correlated, but research has not focused on the applicability to medical residents. The objective of the study was to define burnout in residents and correlate it with optimism. Methods The authors conducted a correlational, prospective cross-sectional study using self-reported single item burnout (1-10) and Life Oriented Test-Revised (LOT-R) (0-24) survey instruments among residents of neurosurgery, neurology, internal medicine, family medicine and emergency medicine at a community-based hospital. Residents were asked to fill out the survey once in the 2018 academic year and once again in the 2019 academic year. Burnout and optimism scores were correlated and compared across subgroups for each year. Results There was no statistical significance found amongst any subgroups in burnout in 2018 but significance was found for both internal medicine (t = 3.74, p = 0.001) and neurosurgery (t = -3.07, p = 0.01) in 2019. Mean burnout increased from 2018 to 2019 from 4.39 to 5.1. Optimism remained constant from 2018 to 2019 (16.7 and 16.76, respectively) and there was no difference across subgroups. There was a statistically significant negative correlation between burnout and optimism in both 2018 (r = -0.364, p = 0.006) and 2019 (r = -0.39, p = .001). Conclusion Burnout and optimism are negatively correlated. Although burnout increased over time, optimism remained constant indicating the stability of this trait and implication for future interventions., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Fowler et al.)

Background: Postoperative pain control in craniotomies poses multiple challenges. Pain must be addressed, but the use of medications must be weighed against risks. Craniotomies risk neurologic injury and so postoperative examinations are critical. Medications used to address pain can alter the neurological examination or cause bleeding leading to misdiagnosis of complications., Objective: Determine if there is a significant difference in postoperative pain from emergent craniotomies vs. non-emergent craniotomies Methods: A retrospective review included 102 cases performed from 2010-2016; pain scores were compared on post-operative days one, two, and three between emergent and non-emergent craniotomies., Results: Pain scores for emergent cases on post-operative days one through three were 5.1 (standard deviation (SD)=2.9), 5.9 (SD=2.1), 4.7 (SD=3.0) respectively. Pain scores for non-emergent cases on post-operative days one through three were 5.7 (SD=2.6), 4.8 (SD=2.8), and 4.6 (SD=3.0) respectively. A one-way analysis of variance (ANOVA) was conducted to compare pain scores between groups for each post-operative day. On post-operative day, one there was no significant difference between the groups [F(1,100)=0.49, p=0.485]. On post-operative day two, there was no significant difference between the groups [F(1,100)=2.17, p=0.143]. On post-operative day three, there was no significant difference between the groups [F(1,98)=0.002, p=0.957]., Conclusion: There is no significant difference in the level of pain on postoperative days one through three between emergent and non-emergent craniotomy patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Albano et al.)

Patient selection is of prime significance when considering intra-arterial thrombectomy (IAT) for patients with basilar artery occlusion (BAO). We present a case of BAO with the clinical locked-in syndrome and "smoggy" appearance diffusion restriction on diffusion-weighted imaging (DWI) in the pons on a hyper-acute magnetic resonance imaging (MRI) scan. A 62-year-old man was admitted with a National Institutes of Health Stroke Scale (NIHSS) of 21. An admission computed tomography angiogram (CTA) showed a mid-distal BAO. As the alteplase was being infused, the patient started declining with an examination suggesting locked-in syndrome. An emergent hyper-acute MRI showed true restricted diffusion on DWI at the entire right anterior inferior cerebellar artery territory, multiple punctate areas in the bilateral posterior inferior cerebellar artery territory, right > left hippocampus, and thalamic region mesial aspect, compatible with an acute posterior circulation infarct. He also had patchy or hazy pontine involvement with slight DWI signal changes but an impressive apparent diffusion coefficient (ADC) darkening in the bulk of pons. The patient was taken to the operating room (OR) for IAT within five hours of the witnessed stroke onset, successfully revascularized, and then discharged on the eighth day with NIHSS of 3. MRI at discharge showed a pronounced DWI restriction in the same areas involved in the hyperacute MRI done at admission. However, now the ADC hyper-intensity was less noticeable, with continued hazy and smoggy pontine signal changes on DWI. On the two-month follow-up, the patient had zero NIHSS and modified Rankin scale (mRS) scores, respectively. DWI-MRI changes in acute ischemic stroke behave differently in tract areas with a density of nerve axons, manifesting as a hazy or smoggy appearance: the "smog sign" on DWI. In hyper-acute MRI, "hazy" or "smoggy" diffusion restriction on DWI in different axonal tract areas like the pons can correlate with good functional outcomes if successful reperfusion therapy is offered., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Ikram et al.)

Background Feedback in physician graduate medical education is not clearly defined. Some parties may view questioning as a form of feedback, others the conversations over lunch, some the comments in the operating room (OR), and still others the written evaluation at planned meetings. The lack of clarity in defining what constitutes feedback is concerning when this is considered a fundamental means of education to enhance practices and care for patients. If residents do not recognize they are receiving feedback, or the response to feedback is met with opposition, then feedback as an educational device can be limited. For this manuscript, feedback is defined as written or verbal comments regarding medical knowledge, performance, technique, or patient care. Objective This study attempts to identify barriers to feedback by identifying attitudes toward feedback processes through a questionnaire. Methods Ten questions were provided to residents at a single institution representing, emergency medicine, family medicine, internal medicine, neurology, and neurosurgery during the 2017-2018 academic year. Response was voluntary and the study was granted exemption by local institutional review board since no identifying information was collected to link responses to specific residents. Questions were formulated to identify how positive or negative a resident felt toward specific aspects of feedback. Results Of the possible 84 resident respondents, 40 residents participated reflecting a response of approximately 48%. Questionnaires revealed that 22.5% of respondents found feedback to be a stressful event. Sixty-seven point five percent (67.5%) of resident respondents associated the prompt that they are about to receive feedback as concerning. Only 2.5% of residents identified a meeting with the program director as a sign that the resident may be doing well. Appointments for feedback were viewed as a positive event in 12.5% of respondents. Ninety-five percent (95%) of residents do not feel that all feedback will affect their permanent record. Ten percent (10%) of residents identified receiving feedback as a positive event. Ninety-five percent (95%) of residents indicated that they have actively tried to change behavior or practices based on feedback. Forty percent (40%) of residents found themselves censoring "negative" feedback. Conclusions Barriers to feedback include the inability to present sensitive subjects in a constructive manner and superficial relationships between the evaluator and resident physician. Research directed at addressing these barriers could lead to improved use of feedback as an educational tool., Competing Interests: The authors have declared that no competing interests exist.

Restless legs syndrome (RLS) is a chronic neurological disorder affecting a growing number of people. Patients describe an irresistible urge to move their lower limbs in times of immobility. Due to its vague symptoms and similarity to other disorders, it has become increasingly difficult for primary care clinicians to properly diagnose and manage RLS. As a result, patients with RLS are routinely misdiagnosed and continue their lives without proper management. This literature review examines the current understanding of the disorder, provides key points to assist clinicians in differentiating RLS from similar disorders, and explores recently updated evidence-based guidelines for the effective management of RLS., Competing Interests: The authors have declared that no competing interests exist.

Interleukin (IL)-37 is a new member of the IL-1 cytokine family with a defined role as a negative feedback inhibitor of proinflammatory responses. IL-37 has yet to be evaluated in non-immune-mediated neurological diseases, such as ischemic or hemorrhagic strokes. This study aimed to measure urine and serum IL-37 levels in patients with ischemic stroke. Twelve patients consented for our study. Two sets of serum and urine samples were obtained and analyzed, one upon admission to the hospital and the second the next morning. The trends in serum levels of IL- 37 in six stroke patients and the trends in the urine levels of eight stroke patients were measured by real-time polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Our pilot study showed IL-37 levels in urine in stroke patients ranging between 210 and 4,534. Serum IL-37 levels were in the range of 44 - 5,235 in patients with ischemic stroke. Three patients who presented within three hours of stroke onset had IL-37 serum levels of 2,655 pg/ml, 3,517 pg/ml, and 5,235 pg/ml, respectively. In all others, it ranged much less than that, with the trend of delayed presentation giving lower IL-37 levels. The study shows a rather stable early elevation of serum IL-37 levels post-ischemic stroke. IL-37 plays a certain role in mediating post-stroke inflammation with a significant increase in serum levels of this novel cytokine observed in ischemic stroke patients. Further large-scale studies need to be done to establish its definite role. A prospective "CRISP" trial is registered with the ClinicalTrials.gov (Identifier: NCT03297827) to determine the role of IL-37 in modulating post-stroke inflammation., Competing Interests: The authors have declared that no competing interests exist.

Introduction Pedicle screw insertion is the mainstay of thora-cic and lumbosacral posterior spinal instrumentation. However, it may be associated with complications such as screw mal-positioning. The purpose of this study was to develop a pilot study to compare the accuracy of robot-guided screw insertion versus hand-guided screw placement for spinal instrumentation. The hand-guided screws were placed with assistance from computerized tomography (CT) stealth guidance or fluoroscopy. Materials and methods A retrospective analysis of medical records was done for all patients that had pedicle screw insertion for instrumentation between the dates of December 2013 and January 2016 with post-screw placement CT imaging. The analysis was conducted on screw accuracy between the two categories based on the Gertzbein-Robbins classification. Results A total of 49 screws were analyzed for accuracy in six patients. There was no statistically significant difference between the accuracy of hand-placed pedicle screws versus the robotically placed screws (p = 0.311). There was no statistically significant difference in blood loss (p = 0.616), length of procedure (p = 0.192), or post-operative length of stay (p = 0.587). Conclusion The findings of our pilot study agree with most prior studies that there was no statistically significant difference in the accuracy of pedicle screw placement between the two methods of screw placement. Therefore, the techniques are equivocal in accuracy. The new technology (robotic-guidance) is as safe as conventional techniques for screw placement. Just like in any surgery, the technique preference should remain surgeon dependent. The results are only from a small sample size in the development of a pilot study so a strong reliance on the data would not be suggested. The study was a preliminary study that will be used as a template and learning process to create a future prospective study to investigate CT stealth and robotically guided screw placement versus "free hand" guided screws., Competing Interests: The authors have declared that no competing interests exist.