Holographic transmission represents a transformative convergence of advanced imaging, augmented reality, and extended reality technologies for real-time education and medical care. We reviewed the current state of holographic transmission, emphasizing its applications in intraoperative guidance, telementoring, teleteaching, and telesupervision. By enabling real-time, life-sized 3-dimensional interaction across distances, holographic systems can democratize access to expertise, especially in underserved or remote areas. We analyzed technical enablers, including high-speed digital cameras, CoaXPress data transmission, graphics processing unit-based reconstruction, and 5G low-latency networks for their role in achieving near real-time fidelity. Two proof of concept demonstrations validate the technology's feasibility: a transcontinental surgical telementoring session between Boston, MA, and São Paulo, Brazil, and a large-scale educational holographic transmission connecting Mayo Clinic (United States) and the G7 Summit (Brazil). Both achieved seamless, bidirectional volumetric communication without perceptible delay, showcasing immersive copresence for clinical and educational collaboration. Despite these advances, barriers persist, most notably high implementation costs, latency sensitivity, limited field of view, and the digital divide that restricts broadband and electrical infrastructure in low-resource regions. Ethical issues surrounding privacy, data ownership, and equitable access also require structured governance. Our discussion highlights holographic telemedicine's potential to establish a borderless educational landscape where knowledge flows freely and health care equity is strengthened globally. Continued innovation, investment in infrastructure, and development of ethical and regulatory frameworks are necessary to create truly global, real-time, and immersive health care without borders.

BACKGROUND:Intraventricular hemorrhage and subarachnoid hemorrhage are associated with neuroinflammation and increased morbidity and mortality. Rapid clearance of blood from the cerebrospinal fluid space may mitigate neuroinflammatory cascades and improve clinical outcomes. This systematic review and meta-analysis aimed to compare the clinical effectiveness of active cerebrospinal fluid exchange, including neuroendoscopic lavage and IRRAflow systems, versus external ventricular drainage in patients with intraventricular hemorrhage or subarachnoid hemorrhage. METHODS:The study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and thoroughly assessed databases, including PubMed, Embase, Scopus, Cochrane, and Web of Science, up to September 18, 2025. Statistical analysis, both fixed-effect and random-effect model analyses, was performed by the Comprehensive Meta-Analysis software. In addition, the Cochran Q test was conducted to determine the statistical heterogeneity. In terms of low heterogeneity, the fixed-effect model is reported. RESULTS:This review included 7 studies with a total sample size of 834. Our analysis showed that active cerebrospinal fluid exchange was associated with significantly higher hematoma clearance (odds ratio, 2.72 [95% CI, 1.22-6.08]; P=0.015), better functional outcomes (odds ratio, 1.66 [95% CI, 1.12-2.48]; P=0.012), lower shunt dependency (odds ratio, 0.22 [95% CI, 0.10-0.50]; P<0.001), and reduced infection rates (odds ratio, 0.22 [95% CI, 0.12-0.42]; P<0.001). Subgroup analysis showed that neuroendoscopic lavage was most effective for hematoma clearance, while IRRAflow reduced infection rates. Also, younger patients had better neurological recovery. CONCLUSIONS:Active cerebrospinal fluid exchange techniques demonstrated superior outcomes over external ventricular drainage in managing intraventricular hemorrhage and subarachnoid hemorrhage, particularly in clot resolution and neurological recovery. Large-scale trials are warranted.

The multicenter trial SETPOINT2 comparing early versus delayed tracheostomy in severe stroke was conducted in Germany and the USA. A pre-specified aim was to assess 6-month patient- and caregiver-reported outcomes to better inform clinical decision-making in the acute phase of care, irrespective of tracheostomy timing. Patients had acute ischemic, hemorrhagic, or subarachnoid hemorrhage (SAH) strokes, respiratory failure, and a predicted necessity for tracheostomy (SETscore > 10). Outcome measures assessed by telephone interview 6 months after hospital admission included the modified Rankin scale (mRS), EuroQol 5D-5L (EQ-5D-5L), EuroQol Visual Analog Scale, Burden Scale for Family Caregivers short form (BSFC-s), and questions related to satisfaction with the treatment results. Of 366 patients with available data at 6 months, 118 (32

ABSTARCT:BACKGROUND: IRRAflow is a novel active cerebrospinal fluid (CSF) exchange system for the treatment of hemorrhagic strokes and intracranial infections. It is a closed system that irrigates various medications dissolved in irrigation solutions at a speed of up to 180 mL/h, expediting resolution. Disrupting this closed system to withdraw CSF samples or infuse medications is necessary in certain circumstances. We report our novel approach for maintaining the sterility of the closed IRRAflow system using a needleless extension and assess the compatibility and safety of this technology throughout treatment. METHODS: We used a needleless extension to withdraw CSF samples and deliver medications to 5 patients treated with the IRRAflow system. We used 1 stopcock with a 3-way valve, 2 neutral needleless connectors, and 2 antiseptic caps. The stopcock was connected between the irrigation and drainage ports of the catheter. The needleless connectors were mounted at the 12 o'clock position of the attached stopcock and the irrigation port with antiseptic caps covering the distal ends. To initiate fluid exchange, the 2 needleless connectors were separated. The extra stopcock valve was connected between the drainage arm, the cassette, and the irrigation arm. The needleless connectors remained mounted at the 12 o'clock position of the stopcock and irrigation port throughout treatment. RESULTS: The needleless connectors mounted on the 12 o'clock position of the stopcock and irrigation port on the drainage and irrigation arms, respectively, provided efficient management of fluid exchange, CSF fluid sampling, and medication delivery. Our needleless extension was compatible with the IRRAflow device and prevented secondary infections despite repeated CSF sampling and medication delivery. CONCLUSION: The needleless extension facilitated a simple and safe interaction with the closed IRRAflow system without compromising the sterile environment during CSF sampling and medication delivery.

Objective To evaluate the safety and tolerability of early mobilization among patients with acute ischemic stroke (AIS) receiving intravenous (IV) tenecteplase (TNK). We hypothesized that physical therapy and occupational therapy would be relatively safe and tolerable when mobilization was attempted shortly after thrombolysis. Patients and Methods In this single-center, single-arm retrospective cohort study, we included adults with AIS treated with IV TNK who underwent first physical therapy or occupational therapy screening and mobilization 13 hours or more but less than 24 hours after thrombolysis. The primary outcome was mobilization-associated adverse events (AEs; screening through the immediate recovery period). Tolerability was defined by whether patients could continue mobilization after screening. We used health record data to determine stroke severity (National Institutes of Health Stroke Scale score, modified Rankin scale score), vital signs, AE type, and symptomatic intracranial hemorrhage occurring after thrombolysis but before mobilization. Results Of 180 patients, 159 (88.3%) underwent early mobilization without any AE. Twenty-one patients (11.6%) had an AE (orthostasis, dizziness, pain, heart rate >120/min, or systolic blood pressure >180 mm Hg); all were mild, transient, and not life threatening. Adverse events were significantly associated with baseline mean arterial pressure (P<.01). Moreover, AE type (pain vs autonomic; P=.01) and initial National Institutes of Health Stroke Scale score (P=.04) were associated with successful mobilization. Three patients had symptomatic intracranial hemorrhage. Conclusion Early mobilization (<24 hours after IV TNK) was relatively safe and well tolerated. Our findings suggest that screening-based early mobilization strategies can be integrated into standardized protocols for select patients with AIS receiving TNK.

Background and Objectives: Neurosurgery is a distinctive realm with a tight and strict margin of error. IRRAflow (IRRA flow ) is a US Food and Drug Administration–approved active cerebrospinal fluid exchange system that can irrigate up to 180 mL/h. The system is tightly secured, safe, and continuously monitors intracranial pressure, using a 9F dual-lumen catheter. Inserting an IRRAflow catheter is more complex than standard external ventricular drains, with a higher risk of cerebrospinal fluid leak or catheter displacement. Particularly, the extracranial component of the IRRAflow catheter insertion is prone to errors and necessitates dedicated training. We aimed to design an affordable, reusable, and easy-to-use 3-dimensional printed model that simulates the extracranial component of the IRRAflow catheter insertion. Methods: The IRRAsert simulator was designed according to recent publications. The skull was printed with polylactic acid, and the Kocher point was drilled. A mold was cast to make the scalp, and Dragon Skin FX-Pro Part A and Part B (Smooth-On, Inc) was used to create a skin flap to cover the drilled Kocher point. Results: The IRRAsert simulator replicated the external parts of the skull starting from the bone outward. It allowed measurements for designating the Kocher point, incising the skin to reveal the drilled Kocher point, tunneling under the scalp, and creating a 5-cm posterior exit incision. The endogenous property of the mixed 1:1 ratio between parts A and B allowed adhesion with the underlying skull due to the attraction between polylactic acid and silicone in a stick-and-peel fashion. This adhesion allowed for dissection of skin from the bone during tunneling for the catheter under the scalp, as well as lifting and rotating the scalp for the next user. The final cost of our simulator was $20 to print the skull permanently, with another $5 to produce the skin that can be rotated 3 times for 3 different users. Conclusion: IRRAsert is the result of multidisciplinary efforts to produce an affordable simulator for the extracranial component of IRRAflow catheter insertion.

Background/Objective: Maintaining acid-base balance within the central nervous system (CNS) is essential for neuronal homeostasis. Disruptions in this balance can result in respiratory disturbances, elevated intracranial pressure, or coma. These disturbances can occur concurrently with stroke, or CNS infection. However, they are augmented by various neurosurgical procedures involving CSF manipulation, either through direct ventricular irrigation during endoscopic neurosurgical procedures or by CSF exchange technologies. The IRRAflow active cerebrospinal fluid (CSF) exchange system (IRRA flow ) manages acid-base balance changes in the ventricular system through continuous irrigation with fluids and medications and removal of endogenous CSF. We describe a novel clinical syndrome of iatrogenic metabolic acidosis and respiratory compensation in response to exogenous fluid introduction in the ventricular fluid system using IRRAflow. The syndrome was previously seen with endoscopic neurosurgical procedures that require irrigation with normal saline. We also recommend fluid alternatives for more effective use of the IRRAflow system or different endoscopic procedure and increased awareness of CSF derangements. Methods We describe 2 cases involving patients with subarachnoid hemorrhage who developed a syndromic response characterized by tachypnea, conjunctival hyperemia, encephalopathy, and fluctuating language deficits due to continuous 0.9% normal saline irrigation. Results Both patients exhibited reproducible symptoms that persisted despite stable neuroimaging until normal saline was replaced with lactated Ringer solution, after which clinical parameters normalized within 3 hours. We named this condition SALT-CRAMD syndrome (saline acidosis leading to tachypnea, central respiratory alkalosis, and metabolic derangements). Pathophysiologic analysis based on the literature suggests that normal saline induced central hyperchloremia and dilutional acidosis, leading to heightened chemoreceptor activation in the medulla oblongata, triggering excessive respiratory drive and compensatory hypocapnia. Conclusion Awareness of SALT-CRAMD syndrome is crucial for understanding the profound pathophysiologic concepts of CSF dynamics, whether induced during treatment with active CSF exchange, endoscopic neurosurgical procedures, stroke, or CNS infections.

The effect of induced hypertension (iHTN) on functional outcomes in noncardioembolic acute ischemic stroke (AIS) with early neurological deterioration remains unclear. We performed a systematic review and meta-analysis evaluating the safety and efficacy of iHTN vs medical management. A literature search of PubMed/MEDLINE, Web of Science, Ovid Embase, and Scopus from inception through November 6th, 2025. The protocol was registered in PROSPERO (CRD420261282211). Studies evaluating iHTN within 72 h of AIS onset and reporting 90-day functional independence (modified Rankin Scale [mRS] 0-2) were included. Safety outcome was hemorrhagic transformation. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using random-effects model based on Restricted Maximum-Likelihood (REML) methods. Three studies were included, comprising 366 patients (iHTN, n = 180; control, n = 186). Mean age was 65.8 ± 11.8 years, 60.9% were men, and the mean initial NIHSS was 5.4 ± 3.5. Target systolic blood pressure (SBP) was a 15-25% increase from baseline SBP using phenylephrine. Functional independence at 90-days occurred more often in the iHTN group than in controls (68.8% vs 50.5%; RR = 1.37; 95% CI, 1.09-1.73; P = 0.007). Hemorrhagic transformation was uncommon and did not differ significantly between groups (3.3% vs 0.5%; RR = 2.08; 95% CI, 0.05-88.07; P = 0.70). In our study, phenylephrine-induced hypertension was associated with greater 90-day functional independence in selected AIS subtypes,without a significant increase in hemorrhagic transformation. However, the limited studies, predominance of retrospective designs, exclusively Asian cohorts, and heterogeneity in treatment protocols and populations warrant cautious interpretation and underscore the need for larger multicenter RCTs.

Background Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death. Purpose THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS. Results This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the “REVIVE” phenomenon. Conclusion This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.

Expansion of artificial intelligence (AI) in the field of medicine is changing the paradigm of clinical practice at a rapid pace. Incorporation of AI in medicine offers new tools as well as challenges, and physicians and learners need to adapt to assimilate AI into practice and education. AI can expedite early diagnosis and intervention with real-time multimodal monitoring. AI assistants can decrease the clerical burden of heath care improving the productivity of work force while mitigating burnout. There are still no regulatory parameters for use of AI and regulatory framework is needed for the implementation of AI systems in medicine to ensure transparency, accountability, and equitable access.

Rising US healthcare costs and the COVID-19 pandemic put increased pressure on hospitals to reduce patient length of stay (LOS) while maintaining high-quality care. We aimed to determine if implementing a pathway for same-day discharge after elective neuroendovascular procedures to a monitored hotel setting is safe, feasible, and cost-effective. We evaluated patient outcomes after elective neuroendovascular procedures and same-day discharge to an on-campus Care Hotel. The study enrolled patients aged ≥18 years from October 1, 2020, to February 28, 2023. Exclusion criteria comprised major comorbidities, additional care necessitating hospitalization, absence of a caregiver, insurer-mandated hospitalization, or patient refusal of the Care Hotel model. Primary outcomes were readmission rate or prolonged LOS, new ischemic or hemorrhagic complications rate, and death rate from vascular causes within 6 months. Secondary outcomes included adverse events and deaths related to causes other than vascular complications within 6 months and changes in modified Rankin Scale score by 1 or more points at last follow-up. Healthcare cost savings associated with same-day discharge were analyzed using a control group. The study included 42 patients discharged to the Care Hotel and 84 controls. The average age was 61 years in the Care Hotel group and 64 years in the control group, and aneurysm treatment was the most frequent neuroendovascular procedure (83.3% and 79.8%, respectively). The readmission and extended LOS rates were 4.8% for the Care Hotel group. The rate of new ischemic or hemorrhagic complications was 4.8%. Cost analysis estimated savings of $7730.12 per procedure. This study suggests that the Care Hotel model is a safe, feasible, and cost-effective option for carefully selected patients undergoing elective neuroendovascular interventions. Adherence to discharge readiness criteria and meticulous patient selection are critical to minimizing complications and readmissions.

This article explores how artificial intelligence (AI), particularly generative AI (GenAI), can enhance extended reality (XR) applications in medical education (MedEd) metaverses. We compare traditional augmented reality/virtual reality methods with AI-enabled XR metaverses, highlighting improvements in immersive learning, adaptive feedback, personalized performance tracking, remote training, and resource efficiency.

Chronic hydrocephalus after subarachnoid hemorrhage may become inevitable, necessitating a permanent cerebrospinal fluid shunt. We report a 40-year-old woman with SAH and a CHESS score of 6. We implemented the IRRAflow active irrigation and drainage system which expedited hemorrhage clearance in 4 days compared to one or two weeks longer with standard external ventricular drains. This system reduced the inflammatory load and preserved the arachnoid granulations, which are responsible for CSF resorption. Further, expedited recanalization of the fourth ventricle prevented an exponential increase in intracranial pressure. Collectively, these factors prevented CSF shunt dependency.

ImportanceImplementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies. ObjectiveTo assess the cost utility of introducing a standardized program of awake craniotomies. Design, Setting, and ParticipantsA retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023. ExposureTreatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021). Main Outcomes and MeasuresPatient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis. ResultsA total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis. Conclusions and RelevanceIn this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.

IntroductionThe prevalence of intracranial aneurysms (IA) in patients with acute ischemic stroke (AIS) requiring mechanical thrombectomy (MT) is unclear.ObjectiveTo describe the prevalence of IA in patients with AIS and their influence on MT.Materials & methodsThis is a retrospective cohort study on all patients admitted with a diagnosis of AIS from January 2008 to March 2022 at a tertiary academic center. The records were reviewed for demographic, clinical, imaging, and outcomes data. Only patients who had CTA at admission were included in this analysis.ResultsAmong 2265 patients admitted with AIS, this diagnosis was confirmed in 2113 patients (93.3 %). We included 1111 patients (52.6 %) who had head CTA and 321 (28.9 %) who underwent MT. The observed prevalence of aneurysms on CTA was 4.5 % (50/1111 patients), and 8 (16 %) had multiple aneurysms. MT was performed in 7 patients harboring IAs: 6 ipsilateral (5 proximal and 1 distal to the occlusion)and 1 contralateral aneurysm.. The patient with a contralateral aneurysm had a TICI 2B score In patients with ipsilateral aneurysms, TICI 2B or 3 was achieved in 3 cases (50 %), which is significantly lower than historical control of MT (91.6 %) without IA (p = 0.01). No aneurysms ruptured during MT. The aneurysm noted distal to the occlusion was mycotic.ConclusionIn this analysis, the observed prevalence of IA in patients with AIS was 4.5%. Ipsilateral aneurysms (proximal or distal to the occlusion site) deserve particular attention, given the potential risk of rupture during MT. Aneurysms located distal to the occlusion were mycotic and the rate of recanization in patients with ipsilateral aneurysms was low compared to historical controls. Further studies are needed to improve the outcomes in patients with IA requiring MT.

With increased patient volumes and complexity, stroke occurrence in hospitalized patients has become relatively more common. The process of activating a code stroke in-hospital differs in many institutions. An emergency team-based response to inpatient acute code stroke is warranted, with many protocols modeled similarly to the cardiac arrest response. However, several studies have demonstrated delays in recognition and management of acute stroke in-hospital as compared to those arriving directly to the emergency department (ED). Furthermore, there are several shared challenges with code stroke resuscitation in the ED and the ward, which include the assembly of ad hoc teams and requirement of access to urgent imaging. Delays in activating in-hospital code stroke contributes to increased morbidity, mortality, prolonged hospitalization, and associated health care costs. In the following commentary, we discuss the current landscape of acute in-hospital code stroke protocols, review the differences in neurologic outcomes between inpatient vs ED/out-of-hospital code stroke patients, and propose future directions for in-hospital code stroke paradigms for improved patient outcomes and quality of care.

We conducted this study to identify correlation between aneurysmal subarachnoid hemorrhage (aSAH) volume, and other clinical covariates at the time of presentation with outcome and complications.