BACKGROUND: The authors present a 50-year-old female with high-grade glioma involving the motor cortex as the cause of her drug-resistant epilepsy (DRE). Responsive neurostimulation (RNS) was chosen for epilepsy treatment. Due to concerns regarding the generator impeding the regular imaging surveillance required for treatment and monitoring of her glioma, surgeons placed the internal pulse generator (IPG) within an infraclavicular chest pocket.
METHODS: Implantation of the RNS device and IPG within the infraclavicular pocket was uneventful. However, both subdural and depth electrodes were used and connected to the IPG, and subdural electrodes are considerably shorter than depth electrodes (37 vs 44 cm). The shorter strip leads presumably generated significant tension, leading to fracture of the leads. Therefore, surgery was repeated using only depth electrodes for more length and less tension. The device has good-quality electrocorticography signals that continue to be used for device programming. The seizure burden was reduced, and quality of life improved for the patient.
CONCLUSIONS: The RNS system with infraclavicular IPG placement reduced the seizure burden and improved the quality of life of a patient with glioma-associated epilepsy. Surgeons may consider the infraclavicular location as an alternative site for implantation for RNS candidates who require recurrent intracranial magnetic resonance imaging.

BACKGROUND: Intrathecal baclofen, delivered via implanted pump, has been used to manage spasticity for approximately 40 years. The device is typically subcutaneously or subfascially implanted in the abdominal wall. There are very few cases reported of the pump being implanted in other locations.
METHODS: This case describes the complicated course of a patient presenting with multiple episodes of catheter malfunction related to pump flipping in the abdominal pocket. The patient was successfully treated with repositioning of the pump into the infraclavicular fossa.
CONCLUSIONS: Infraclavicular placement of the implanted pump allowed for a more secure pocket base for this patient and less strain applied to the pump, minimizing the risk of disruption of pump positioning and interruption of drug delivery.

Currently, numerous invasive procedures are preferred in cephalic vein (CV) and axillary vein (AV) than other veins in the neck. Anatomical variations of these veins in the axilla and delto-pectoral region may result in failure and postoperative complications of the procedures. A thorough knowledge of possible variations of AV and CV may immensely contribute to the success of any such procedures where the veins are involved. We report the variations of the CV, tributaries of AV and median cubital vein. We observed a venous circle formed by the tributaries of AV in the infra-clavicular region, deep to the pectoral muscles. Cephalic vein joined proximal end of venous circle just before ending into AV. Further, duplication of the median cubital vein was observed.

Variations in the arrangement and distribution of brachial plexus and its branches in the infraclavicular part are common and have been reported by several investigators since the 19th century. These variations are significant for the neurologists, surgeons, anesthetists and the anatomists. During routine anatomical dissection of the right axilla and infraclavicular region of a 45-year-old male cadaver, the medial root of the median nerve was found to receive a supplementary branch from the medial aspect of the terminal portion of the lateral cord of brachial plexus and the branch was passing infront of the axillary artery from lateral to medial side. The median nerve was formed by joining of the lateral and medial roots from the lateral and medial cords of brachial plexus, infront of brachial artery, lower down, at the junction of upper one-third and lower two-third of the arm, instead in the axilla. This variation could be one of the cause of pressure symptom which occurs on the axillary artery and also the injury which occurs on the lateral cord or upstream to the lateral cord, which may sometimes lead to an unexpected presentation of weakness of forearm flexors and thenar muscles.