Stereotactic and Functional Neurosurgery最新文献

Background: Gamma Knife Radiosurgery (GKRS) is an established effective treatment for medically intractable trigeminal neuralgia (TN), but outcome predictors remain controversial. Notably, the influence of neurovascular conflict (NVC) evident on magnetic resonance imaging on the outcomes of radiosurgery is debated. This study aims to evaluate whether a NVC with the trigeminal nerve in the posterior fossa influences pain and sensory outcomes after primary GKRS for TN.

Methods: A retrospective review of our GKRS database identified 148 patients who underwent GKRS as the initial treatment for medically intractable TN between 2014 and 2024. Background medical history, treatment outcomes and complications, and dosimetric data were collected through chart review. NVC was graded based on high-resolution magnetic resonance images obtained prior to treatment, according to a 4-tier severity scale.

Results: After GKRS, 132 (89%) patients achieved Barrow Neurological Institute (BNI) grade IIIb or better pain relief. At a median follow-up of 39 months, pain recurred in 27 (20%) patients, and 47 (32%) developed facial sensory disturbances, which were bothersome in 18 (12%). Estimated rates of pain relief at 1, 3, 5, 7 years were 77%, 72%, 68%, and 64%, respectively. The median maximum dose was 85Gy. The presence and severity of NVC did not predict pain or sensory outcomes after GKRS, whereas facial sensory disturbances were associated with long-term pain relief.

Conclusions: GKRS is an effective treatment for medically intractable TN but may lead to facial sensory disturbances. The presence or severity of NVC with the trigeminal nerve in the posterior fossa did not influence the outcomes of primary GKRS.

The article "Anatomical Group-Level Studies of the Volume of Tissue Activated by Deep Brain Stimulation in Parkinson's Disease: A Model for Targeting?" [Stereotact Funct Neurosurg. 2025; https://doi.org/10.1159/000549455] by Wiggerts et al. was published with the wrong open access license. The correct license of the article is CC-BY.The original article has been corrected.

Introduction Deep brain stimulation (DBS) is a well-defined therapeutic intervention for various neurological and psychiatric disorders; however, there are limited data comparing the costs associated with the various advanced stereotactic techniques employed in DBS surgery. In this study, we assessed the specific factors driving the variability in costs at a single institution across stereotactic approaches for DBS and aimed to highlight potential areas for cost optimization. Methods Inflation-adjusted cost data for patients undergoing DBS from 2012 to 2023 were retrospectively accessed using the University of Utah's Value Driven Outcomes (VDO) tool. Patients who underwent bilateral DBS surgery with and without same-stage internal pulse generator implantation were included. Surgical approaches to DBS implantation were separated into four techniques by the type or lack of frame and intraoperative imaging used: 1) frame with C-arm fluoroscopy; 2) frame with intraoperative computed tomography (iCT); 3) robotic stereotaxy with iCT; and 4) frameless with intraoperative magnetic resonance imaging (iMRI [ClearPoint™]). Total reported costs for each technique were also split into four subcategories (imaging, facility, supply, services) and expressed as a percentage relative to the total cost for the staged frame with C-arm method. Results Our study included 256 patients who underwent surgical procedures for DBS. The median (interquartile range) cost percentages were 171.0% (±29.0%) for frameless with iMRI, 121.7% (±14.9%) for frame with iCT, and 117.5% (±14.0%) for robotic stereotaxy with iCT procedures. Only the iMRI-based method demonstrated a significantly increased cost (p<0.05) when compared with all other methods. Similarly, the iMRI-based method demonstrated notably higher costs than all other methods across imaging and supply subcategories. Conclusion The iMRI method's imaging likely costs significantly more because iMRI procedure times are longer than other methods. Supply costs for the iMRI-based method were not statistically correlated with procedure length, highlighting a potential area for cost-saving measures. Future inclusion of technical accuracy, revision and readmission rates, perioperative complications, and other postoperative outcomes may more fully evaluate the most cost-effective approach.

Introduction: Epileptic Encephalopathy with Spike-and-Wave Activation in Sleep (EE-SWAS) is a rare childhood-onset epileptic encephalopathy, defined by a typical electrographic pattern with mostly continuous slow spike-wave complexes during non-REM sleep. It may be cryptogenic or secondary to genetic or structural etiology. It might be related to progressive and irreversible cognitive deterioration; under these circumstances, there is an urgency for fast adequate treatment. Polymicrogyria is a common brain malformation and epilepsy can occur in up to 90% of the patients. Extensive polymicrogyria can be a cause of EE-SWAS and treatment refractoriness. In these patients, surgical treatment might be considered.

Case presentation: We report on an eight-year-old child who presented with electrographic findings compatible with EE-SWAS and hemiparesis associated with right hemispheric polymicrogyria who successfully underwent hemispherectomy as primary treatment. Surgery is rarely considered for these patients.

Conclusion: This report highlights the importance of considering surgery as an early treatment modality in selected cases.

Introduction MRI-guided focused ultrasound (MRgFUS) ablation has become increasingly utilised for movement disorders since its approval by the U.S. Food and Drug Administration (FDA) in the treatment of unilateral essential tremor (ET) in 2016. While most patients achieve significant improvement in their symptoms, a proportion of ET patients experience tremor recurrence. Deep brain stimulation (DBS) is a potential rescue therapy post-MRgFUS. However, the safety profile of such scenarios is currently unknown. Case Presentations Here, we report three ET patients who previously underwent MRgFUS of the ventral intermediate nucleus of the thalamus (Vim) and subsequently had DBS insertion due to tremor recurrence. Three patients (ranging from 58 to 85 years of age; one female) presented with a history of refractory ET. Patient 1 had left Vim MRgFUS and then left Vim DBS. However, the tremor control was still inadequate, and he had a further revision DBS surgery where two electrodes were inserted into left Vim. Patient 2 had two MRgFUS procedures in left Vim and then underwent left Vim DBS insertion due to hand tremor recurrence. Patient 3 had left Vim MRgFUS and then bilateral Vim DBS due to midline tremor. Patients 2 and 3 experienced substantial improvement in symptoms after DBS but Patient 1 only had minimal improvement. There were no surgical complications and no readmission within 30 days. Conclusions This case series demonstrates that insertion of DBS electrodes in the vicinity of prior MRgFUS site can be safe. These findings have important implications for pre-operative counseling of patients with ET with high surgical risks, as well as supporting MRgFUS as a first-line therapy in selected patients. Further studies with larger population will delineate the optimal timeline where DBS may be safely performed in this population, as well as the long-term therapeutic effect of such rescue intervention.

Introduction: Stereoelectroencephalography-guided radiofrequency ablation (sEEG-RFA) has been used to create stereotactic lesions in epileptic networks. The method has been applied as a diagnostic (and at times, palliative) intervention, primarily in European epilepsy programs. To date, the technique has not been widely popularized in the United States given the lack of FDA-approved technology permitting safe usage of in situ sEEG electrodes for this purpose. Recently, the FDA approved a new hollow sEEG electrode and OneRF generator (NeuroOne) featuring real-time thermal monitoring.

Case presentations: The authors present four illustrative, consecutive cases of refractory epilepsy patients undergoing sEEG, who underwent subsequent sEEG-RFA using the new technology. The procedure was diagnostic in all cases, with no adverse events. Importantly, all four patients reported decreased seizure burden following the procedure, with observed improvements informing subsequent surgical decision-making in three patients.

Conclusion: A new FDA-approved, hollow sEEG electrode technology permits safe sEEG-RFA lesioning, with a positive experience for both the patient and clinical team. The authors reaffirm use of this strategic technique as a diagnostic and prognostic tool, with possibility of secondary therapeutic, ablative effects. This development represents a significant advancement in the work-up of patients with intractable epilepsy, who are undergoing sEEG for invasive evaluation.

Deep Brain Stimulation (DBS) has become an increasingly common therapeutic intervention for the management of movement disorders. In addition, weight gain has been reported following DBS implantation. Several case reports and anecdotal experience raises a question of difficulties in recharging batteries in patients with larger body mass, however the relationship between body mass and charge times has not been systematically investigated. In this exploratory cross-sectional study thirty people with DBS underwent a standardised charging protocol to establish the rate of battery charge acquisition. Biometric data, including weight, BMI, and body fat were recorded, to establish relationships between biometric parameters and charge rate. In total, 75% of participants had gained weight since the DBS implantation, with male and female participants gaining on average 6.7 Kg. A strong and statistically significant correlation was found between body fat and the rate of charge of IPG of male participants (r=-0.6, p=0.02), but not for female participants, despite having a greater degree of body fat (p<0.01). Increases in body mass increases the depth of adipose tissue that lies between the implantable pulse generator and the charger, possibly creating greater resistance for the charge to pass through, hence increasing charge time. These findings inform postoperative educational content regarding the importance of maintaining weight following DBS implantation and reduce the need for additional corrective surgeries in future. Further evaluation of the absence of a significant finding in females is required.

Background and Objectives Deep brain stimulation (DBS) has emerged as a transformative neurosurgical intervention for refractory movement disorders, including Parkinson's disease (PD), essential tremor (ET), and dystonia. While clinical efficacy is well-established, significant variability exists in procedural outcomes across hospitals. This nationwide study investigated the impact of hospital procedural volume on short-term postoperative outcomes and cost following DBS across 234 US hospitals from 2015-2020. Methods We conducted a retrospective analysis of 6,964 DBS procedures (2015-2020) using the Nationwide Inpatient Sample. Hospitals were categorized by six-year DBS volume: high-volume centers (HVCs, ≥450), medium-volume (50-449), and low-volume (<50). Multivariable regression assessed outcomes including prolonged length of stay (pLOS >75th percentile), non-routine discharge (NRD), high charge (>90th percentile), and complications, controlling for patient demographics, comorbidities, and hospital characteristics. Results HVCs showed superior outcomes compared with low-volume centers, with lower rates of pLOS (4.1% vs 8.9%, p<0.001), high charges (6.7% vs 15.3%, p<0.001), and NRD (11.0% vs 16.5%, p<0.001). PD patients had 45% greater odds of pLOS (OR=1.45, 95% CI 1.12-1.88, p=0.004) but 36% lower odds of NRD (OR=0.64, 95% CI 0.49-0.83, p=0.001) compared with ET patients. Dystonia patients had 2.4 times higher odds of pLOS (OR=2.39, 95% CI 1.76-3.25, p<0.001) and 65% higher odds of incurring high charges (OR=1.65, 95% CI 1.22-2.23, p=0.001). In multivariate models, HVCs were significantly associated with reduced risk of NRD, high charge, and pLOS. Conclusion Despite a 6% decline in DBS volume due to fewer PD cases, inflation-adjusted charges rose >30% across centers. The volume-outcome relationship persists, with HVCs showing better efficiency but challenges in discharge disposition, highlighting the need for standardized care pathways for dystonia and closer evaluation of socioeconomic barriers to DBS access and outcomes.

Introduction: Deep brain stimulation (DBS) is a cornerstone treatment for medication-refractory movement disorders. Ventriculomegaly and brain atrophy, common findings in candidates for DBS, present technical challenges, prognostic dilemmas, and potential safety concerns. Their impact on clinical outcomes and procedural risk remains a subject of debate.

Objective: To review the pertinent literature on the relationship between pre-operative ventriculomegaly and brain atrophy, as surrogates for subcortical and cortical neurodegeneration, and their impact on motor outcomes, safety, and surgical complications of DBS.

Methods: A comprehensive literature review was performed using PubMed, Embase, and Scopus databases. Key articles addressing the prognostic and technical implications of ventriculomegaly and brain atrophy in DBS for movement disorders were selected and synthesized to provide an evidence-based perspective on the topic.

Results: Multiple cohort studies demonstrate a significant correlation between larger pre-operative ventricular volumes, cortical atrophy, and subcortical volume loss with poorer motor improvement following DBS, suggesting these morphometric changes are markers of underlying neurodegenerative burden. Critically, direct evidence shows that transgressing the ventricular wall during STN DBS surgery significantly increases the risk of postoperative confusion (Relative Risk = 87). While the overall risk of severe complications like symptomatic hemorrhage remains low (approximately 1.1%), factors such as patient comorbidities, surgical technique, and postoperative electrode displacement are key contributors to adverse outcomes. Nevertheless, case reports confirm that excellent outcomes are achievable in patients with marked ventriculomegaly and brain atrophy, provided that meticulous surgical planning is employed.

Conclusion: Pre-operative ventriculomegaly and brain atrophy are negative prognostic indicators for motor outcomes and direct risk factors for neurological sequelae, particularly postoperative confusion. However, they should not be absolute contraindications. With modern image-guided softwares, careful trajectory planning, and a strong clinical rationale, the risks can be mitigated and favorable outcomes achieved. Importantly, patients may derive significant quality of life benefits even with modest motor improvements. This review provides an evidence-based framework to guide clinical judgment and surgical strategy in this challenging patient population.

Inroduction: Chronic hiccups (singultus) are involuntary diaphragmatic contractions that, when persistent, can cause severe physical and psychological distress. While most cases are benign and self-limited, intractable hiccups may rarely indicate underlying neurological dysfunction. One exceptionally rare cause is diaphragmatic dystonia-a condition for which no established diagnostic criteria or treatment guidelines exist, and which has been described only in isolated case reports. This is the first reported case of diaphragmatic dystonia treated with deep brain stimulation (DBS) targeting the internal (GPi) and external (GPe) segments of the globus pallidus, thereby expanding the scientific understanding of its management.

Case presentation: We present the first known case of deep brain stimulation of the internal and external globus pallidus used to treat chronic, treatment-resistant hiccups. A 70-year-old woman experienced two years of continuous hiccups unresponsive to multiple pharmacologic and surgical interventions. Extensive diagnostics excluded metabolic, neurological, gastrointestinal, and psychiatric causes. Diaphragmatic dystonia was suspected. Bilateral octa-contact DBS electrodes were implanted targeting the GPi and GPe.Intraoperative monopolar stimulation (1.5 mA, 90 µs, 130 Hz) was initiated on day of surgery. Electrodes were accurately placed without complications.

Results: Near-complete resolution of hiccups occurred immediately postoperatively. Quality of life significantly improved: Numerical Rating Scale (NRS) from 8 to 0, EQ-5D-3L from 0.530 to 1.0, Fahn-Marsden Dystonia Scale from 13 to 0, and PHQ-9 from 16 to 4. At the 14-month follow-up, the improvement was fully maintained.

Conclusion: DBS targeting the globus pallidus may represent a novel and effective intervention for refractory chronic hiccups, particularly in cases suspected to involve diaphragmatic dystonia.