Background and Objectives: Various publications have compared outcomes among open (OPDs), laparoscopic (LPDs), and robotic pancreaticoduodenectomies (RPDs); however, the number of randomized controlled trials (RCTs) remains limited. This study aims to conduct a systematic review and analyze the outcomes between these approaches from randomized controlled trials. Materials and Methods: We performed a systematic literature search across PubMed/MedLine, Cochrane Library, ClinicalTrials.gov, and Google Scholar to identify relevant RCTs. The systematic review was conducted using the reporting items for systematic reviews and network meta-analyses guidelines (PRISMA-NMA) and registered in Prospero (CRD420251024475). For statistical analysis R software (version 4.3.2) was used. Results: Eight RCTs involving 1416 patients (706 OPDs, 600 LPDs, 110 RPDs) were included. LPD had a significantly longer operative time than OPD, while RPD showed no significant difference compared to OPD. Blood loss was reduced in both minimally invasive approaches. LPD showed a higher R0 resection rate and lower pancreatic fistula rate, whereas RPD had the lowest mortality. No significant differences were observed in major complications, reoperation, or readmission. LPD shortened hospital stay; RPD showed no difference. Conclusions: Although open pancreaticoduodenectomy remains a well-established standard, both laparoscopic and robotic approaches offer safe alternatives with distinct advantages. LPD is associated with shorter hospital stay and lower pancreatic fistula rates, whereas RPD demonstrates the lowest mortality. The lack of direct randomized comparisons between LPD and RPD highlights the need for further head-to-head trials.

Trigeminal neuralgia (TN), characterized by recurrent episodes of intense facial pain, poses diagnostic and therapeutic challenges. TN can be triggered by many factors, with rare cases (< 0.05% of the general population) associated with vertebrobasilar dolichoectasia (VBD). Our study analyzes a 74-year-old male patient with 10 years of constant unbearable left-sided facial pain, unresponsive to medications and multiple glycerol rhizotomies, performed in other centers which prompted the patient to seek care at our clinic. The confirmation of left-sided VBD by magnetic resonance imaging, computed tomography angiography, and the patient's overall satisfactory health status favored open surgery with microvascular decompression (MVD). We performed a retrosigmoid suboccipital craniotomy to reach the cerebellopontine angle, ensuring that it is the dolichoectatic basilar artery applying compression to the trigeminal nerve. We inserted a shredded Teflon implant into the trigeminal cistern following its opening. Care was exercised to ensure that there were no remaining factors causing compression. Postoperatively, pain relief was achieved, sustained at an 8-month follow-up. Treating TN arising from VBD can be difficult. The patient's overall health status and assessment play a key role in determining the appropriate course of treatment. Opting for MVD is the optimal and most effective choice, regardless of age, according to the recent literature. In cases where surgery is not feasible, the treatment options will involve medications and less invasive therapeutic approaches such as peripheral rhizotomies or stereotactic radiosurgery. Our case highlights the efficacy of MVD in addressing TN associated with VBD, underscoring the need for advanced treatment modalities and expertise in managing complex cases.

The renin-angiotensin system (RAS) is an important regulator of functions in various systems, including the brain. A classic pathophysiological consequence of RAS imbalance is hypertension, but the system is also involved in the control of behaviour and the development of neurodegenerative diseases and psychiatric disorders. Angiotensin-converting enzyme type 2 (ACE2) is an important member of the protective arm of the RAS. We hypothesized that ACE2 blockade may alter the systemic balance controlling brain functions. The present study aimed to characterize the effect of systemic acute ACE2 blockade on some behavioural parameters and nociception in mice. Experiments were performed on male ICR mice treated acutely with the selective ACE2 inhibitor MLN-4760. We used a battery of behavioural tests: the “Elevated Plus Maze” for anxiety behaviour, the “Open Field” for exploratory behaviour, the “Hot Plate”, and formalin tests for thermal and chemical nociception, respectively. The results showed that acute treatment with the ACE2 inhibitor MLN reduces normal anxiety-like behaviour in a novel environment, as expressed by increased time spent in the open arms of the Elevated Plus Maze and increased distance in the central area of the Open Field Test. Short-term blockade of ACE2 produced antinociception in the acute thermal test and the inflammatory second phase of the formalin test. In summary, we can conclude that ACE2 is involved in the regulation of complex brain functions, such as motivational behaviour and pain perception.

Penetrating spinal cord injuries from arrows are rare. Arrowhead extraction can be challenging due to proximal critical neurovascular structures and tip variation. Our study highlights the most appropriate management plan based on our experience and current literature. Literature search on PubMed and Google Scholar was performed. This review examines optimal surgical management strategies, mean arterial pressure (MAP) evaluation, antibiotic protocols, and recovery timelines. Additionally, we investigate spinal cord decompression, focusing on its potential to reduce edema and accelerate recovery. Our study includes one case of a 32-year-old cervical penetrating spine injury caused by an arrow. Literature recommends maintaining an MAP of 85 to 90 mm Hg for 7 days following blunt spinal cord injury. Evidence for penetrating injuries is limited and suggests no improvement with MAP augmentation. Prophylactic broad-spectrum antibiotics, for 48 hours, appear effective in preventing infection and early surgical intervention. Our patient had an incomplete spinal cord injury with preserved motor function in the right (dominant) hand and decreased motor function (3/5) in the left C8–T1 level. Careful planning must consider the shape of the arrow and the anatomy. Removal of the arrow tip requires proximal control, with additional consideration for dural repair. This case underscores the rarity and challenges of treating arrow-induced spinal cord injuries, particularly in resource-limited settings. Unlike blunt trauma, insufficient evidence supports elevated MAP or decompression for penetrating injuries. The primary management goal remains the safe, timely removal of the arrow and prophylactic antibiotics. Further research is needed to develop a standardized management protocol.

Alzheimer's disease (AD), a form of dementia, presents a global concern. This study investigates the connection between hypertension and AD and the effects of the peptide novokinin (NVK), an AT2 receptor agonist in spontaneously hypertensive rats (SHRs). The brain's renin-angiotensin system (RAS) influences cognitive and emotional processes, suggesting potential intersections with AD. Streptozotocin (STZ), administered intracerebroventricularly (ICV), is used as a model of late-onset Alzheimer's disease. This model reveals a memory impairment associated with an insulin-resistant brain state, marked by neuroinflammatory processes contributing to cognitive deficits, oxidative stress, and reduced cerebral energy metabolism. NVK is an angiotensin AT2 receptor agonist, studied for its potential neuroprotective role. Female SHRs were used to investigate the effects of STZ-ICV (twice) and chronic NVK-ICV. NVK was administered for 14 days ICV using osmotic minipumps (ALZET®). The control group exhibited strain-typical increased exploratory activity, reduced anxiety in new environments, and impaired spatial memory, as expected for SHRs. The STZ-ICV negative control group showed signs of impaired memory and object recognition. In the `Open Field’ test, STZ-treated groups with and without NVK-ICV displayed heightened exploratory behaviour. Data from the `Elevated plus maze' test showed decreased anxiety in the STZ-ICV group while combining STZ and NVK normalized the anxiety behaviour. In the `T-maze' test, STZ-ICV-treated rats made fewer correct decisions. The STZ+NVK group exhibited enhanced spatial memory and improved anxiety-like behaviour in novel environments, potentially attributable to the proposed neuroprotective effects of NVK. These findings emphasize the association of RAS in the progression of AD and the potential protective role of the brain's AT2 receptors in this type of dementia.

Miyazaki syndrome is a rare and underrecognized complication of long-standing cerebrospinal fluid (CSF) diversion. It usually occurs in patients with chronic CSF overdrainage and is caused by enlargement of the cervical epidural venous plexus, which may compress the spinal cord and cause progressive myelopathy or radiculopathy. Because symptoms develop slowly and may resemble degenerative cervical myelopathy or other neurological conditions, diagnosis is often challenging. We report two illustrative cases from our institution. The first patient was a 57-year-old man with a ventriculoperitoneal (VP) shunt placed at birth for neonatal intraventricular hemorrhage (IVH), who developed progressive spastic paraparesis, sensory ataxia, and increasing wheelchair dependence over several years. MRI showed chronic intracranial hypotension with marked cervical venous engorgement and upper cervical cord compression. He underwent shunt revision with the addition of an anti-siphon device, followed by radiological resolution of venous engorgement and partial clinical improvement. The second patient was a 44-year-old woman with congenital hydrocephalus treated with shunting since childhood, who presented with worsening gait disturbance, recurrent falls, impaired hand coordination, orthostatic headaches, and radicular pain. Imaging showed venous congestion at C2 with cord compression and chronic CSF hypotension. Her shunt was revised with placement of a Codman CERTAS® Plus programmable valve and anti-siphon device (Integra LifeSciences, Princeton, NJ, USA), resulting in improved venous drainage, cord decompression, and meaningful clinical recovery. To place these cases in context, we performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review - registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251048122) - of case reports and case series on Miyazaki syndrome or overshunting-associated myelopathy through May 2025 using PubMed, the Cochrane Library, and Google Scholar. Study quality was assessed with Joanna Briggs Institute tools, and data were extracted on patient characteristics, shunt type, valve configuration, anti-siphon device use, symptom latency, imaging findings, treatment, and outcomes. Thirty-one studies, including 37 patients, met the eligibility criteria. The mean age was 43.9 years, and VP shunts were the most common shunt type. The most consistent imaging finding was cervical epidural venous plexus engorgement with cord compression, often associated with pachymeningeal enhancement and slit ventricles. The median interval from the last shunt procedure to symptom onset was 14 years, and valve adjustability did not significantly influence this latency. Most patients were treated by correcting CSF overdrainage through valve pressure adjustment, conversion to a programmable valve, and/or addition of an anti-siphon or gravitational device. All patients treated with an anti-siphon device improved, and earlier treatment was associated with better outcomes. These findings emphasize that Miyazaki syndrome should be considered in shunted patients with progressive myelopathy and imaging signs of intracranial hypotension or CSF overdrainage. Early recognition and correction of siphoning through valve optimization and anti-siphon device placement may reverse venous congestion, improve neurological function, and prevent permanent spinal cord injury.