Stereotactic and Functional Neurosurgery最新文献

Introduction Stereoencephalography (SEEG) has emerged as the most common technique for invasive monitoring as part of the pre-operative workup for epilepsy surgery. The use of intracranial implants has the potential for vascular injury giving rise to pseudoaneurysm, followed by unpredictable, delayed hemorrhage. However, while this has been suspected in cases of severe, delayed hemorrhage after SEEG implantation, no case of confirmed pseudoaneurysm has been shown to arise secondary to a SEEG implant. Case Presentation A patient was evaluated over the course of two SEEG implantations before the decision to proceed with deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) to treat their drug-resistant epilepsy. Pre-operative imaging for DBS revealed a pseudoaneurysm proximal to an SEEG craniostomy site. The lesion was treated with excision and vascular bypass, and the patient ultimately underwent DBS as planned. Retrospective analysis strongly implicated the SEEG implantation in pseudoaneurysmal formation, most likely via arterial collision resulting from entry site deviation from the planned stereotactic trajectory. Conclusion Pseudoaneurysm may be a more prevalent complication of SEEG than existing literature would suggest, as the delayed formation of these lesions can allow them to escape recognition on routine postoperative imaging. Though likely still uncommon, this may suggest the prudence of additional radiological surveillance. This complication is potentially devastating if unrecognized and untreated, but otherwise does not preclude further surgical therapies for epilepsy.

Background There is a lack of evidence to guide the choice between stereotactic radiosurgery (SRS) and neuroablative procedures for patients with medically refractory trigeminal neuralgia (TN). This meta-analysis aims to identify the outcomes of these interventions for TN. Methods Studies identified through PubMed, MEDLINE, and Embase, were cohort studies or clinical trials, had ≥20 participants, and had a ≥12-month follow-up. All participants were ≥16 years old and had primary refractory TN. Studies reported outcomes using the Barrow Neurological Institute (BNI) scale. The Shapiro-Wilk test, Mann-Whitney U test, two-tailed T Test, Spearman's R, and ANCOVA were used to test statistical significance. Screening was done according to PRISMA guidelines. Bias assessment was according to the Newcastle-Ottawa Scale. Results 3288 patients from 37 studies were included (2537 SRS, 751 neuroablative). Overall reporting of BNI I, II, III, IV, and V was 36.0%, 17.4%, 23.9%, 11.7%, and 10.9% respectively in the SRS cohort, and 63.6%, 10.4%, 11.1%, 7.3%, and 7.6% respectively in the neuroablative cohort (p<0.0001). Recurrence was 41.6% in the SRS cohort and 22.5% in the neuroablative cohort (p<0.001). The neuroablative cohort reported significantly higher rates of hypoesthesia (18.6% vs. 50.5%, p<0.0001), and minor (19.6% vs. 2.2%, p<0.0001) and major (3.4% vs. 1.3%, p<0.001) adverse effects compared to SRS. Conclusions The findings suggest improved pain relief and reduced recurrence with neuroablative procedures compared to SRS, albeit conferring a higher rate of adverse effects. Neuroablative techniques may be more appropriate for patients with medically refractory TN who are unsuitable for microvascular decompression.

Introduction: In 2015, directional leads have been released in Europe for deep brain stimulation (DBS) and have been particularly used for subthalamic nucleus (STN) DBS for Parkinson's disease (PD). In this study, we aimed to compare an omnidirectional and directional leads cohort of PD patients when it comes to clinical effectiveness and to assess the correlation with volume of tissue activated-target overlap (VTA-target).

Methods: A total of 60 consecutive patients were retrospectively included. Twenty-seven patients with bilateral directional leads were compared to 33 patients with bilateral omnidirectional leads. MDS-UPDRS part III scores, levodopa equivalent daily dose (LEDD), and VTA overlaps using both motor STN region and motor improvement sweet spot volume were compared at 12 months after surgery.

Results: There is a significantly higher LEDD reduction in the directional leads group (51.3% reduction vs. 42.7% reduction, p = 0.042) when compared to the omnidirectional group, with similar MDS-UPDRS III motor scores at 12 months. Omnidirectional leads patients had a significantly superior VTA-motor STN overlap volume than directional leads patients (32.01 mm3 vs. 20.38 mm3, p = 0.0226). In directional leads patients, LEDD reduction was correlated to VTA overlap with the overall motor improvement mean map sweet spot (R = 0.36, p = 0.036), which was not the case for omnidirectional leads patients (R = 0.11, p = 0.276). Forty-one percent of patients implanted with directional leads had a directional stimulation setting at 12 months, compared to 33% at 3 months follow-up. In directional leads patient's subgroup analysis, there was no significant difference in MDS UPDRS III scores, LEDD reduction, VTA overlaps with motor STN, or overall motor improvement mean map sweet spot between patients stimulated omnidirectionally and directionally at 12 months.

Conclusion: At 12 months, when compared to omnidirectional leads, directional leads manage with smaller VTA-target overlaps to obtain comparable MDS-UPDRS III scores with greater LEDD reduction in STN DBS for PD patients.

Introduction: Functional thalamic surgery is known for alleviating isolated focal hand dystonia; however, the optimal target site in the thalamus is not determined. This study aimed to identify effective sites for thalamic deep brain stimulation (DBS) in treating this condition.

Methods: Four patients presenting with focal hand dystonia underwent thalamic DBS. Effective stimulation sites were identified through a combination of physiological and radiological mapping.

Results: All patients exhibited significant improvement in their hand dystonia. The most effective stimulation sites were localized in the anterior regions of the ventral intermedius nucleus (Vim), involving both Vim and the ventro-oral nucleus (VO).

Conclusion: Thalamic DBS proves highly effective in managing focal hand dystonia. The identified effective stimulation sites suggest the involvement of both the pallidothalamocortical and cerebellothalamocortical pathways in its pathophysiology.

Introduction: There has been rapid advancement in the development of deep brain stimulation (DBS) as a treatment option for adults for neurological and neuropsychiatric conditions. Here, we present a scoping review of completed and ongoing clinical trials focused on DBS in pediatric populations, highlighting key knowledge gaps.

Methods: Three databases (PubMed, OVID, and Embase) and the clinicaltrials.gov registry were queried to identify clinical trials for DBS in pediatric cohorts (age ≤18 years). Prospective and retrospective case series were excluded. No restrictions were placed on the diagnoses or measured clinical outcomes. Individual patient demographics, diagnosis, DBS target, and primary endpoints were extracted and summarized.

Results: A total of 13 clinical trials were included in the final review, consisting of 9 completed trials (357 screened) and 4 ongoing trials (82 screened). Of the completed trials, 6 studied dystonia (both inherited and acquired; participants aged 4-18 years) and 3 studied drug-resistant epilepsy (participants aged 4-17 years). Among the 6 trials for dystonia, 5 used the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) as the primary endpoint. There were a total of 18 adverse events documented across 63 participants, with 5 of 9 studies reporting adverse events. Ongoing clinical trials are evaluating DBS for dystonia (N = 2), epilepsy (N = 1), and self-injurious behavior (N = 1).

Conclusions: This scoping review summarizes the landscape of clinical trials for DBS in children and youth. In dystonia, further research is warranted with more relevant pediatric outcome measures and for understudied patient subgroups and targets. There are also significant gaps in our understanding of evaluating the role of DBS in other neurological and neurodevelopmental disorders in pediatric populations.

Introduction: Photon-counting detector computed tomography (PCD-CT) represents the next generation of CT technology, offering enhanced capabilities for detecting the orientation of directional leads in deep brain stimulation (DBS). This study aims to refine PCD-CT-based lead orientation determination using an automated method applicable to devices from various manufacturers, addressing current methodological limitations and improving neurosurgical precision.

Methods: An automated method was developed to ascertain the orientation of directional DBS leads using PCD-CT data and grayscale model fitting for devices from Boston Scientific, Medtronic, and Abbott. A phantom study was conducted to evaluate the precision and accuracy of this method, comparing it with the stripe artifact method across different lead alignments relative to the CT gantry axis.

Results: Except for the Medtronic Sensight™ lead, where detection was occasionally unfeasible if aligned normal to the z-axis of the CT gantry, a clinically very unlikely alignment, the lead orientation could be automatically determined regardless of its position. The accuracy and precision of this automated method was comparable to those of the stripe artifact method.

Conclusion: PCD-CT enables the automatic determination of lead orientation from leading manufacturers with an accuracy comparable to the stripe artifact method, and it offers the added benefit of being independent of the clinically occurring orientation of the head and, consequently, the lead relative to the CT gantry axis.

Introduction: Complex epilepsy networks with multifocal onset zones that overlap with eloquent cortex may benefit from combined surgical approaches. However, limited data exist on outcomes associated with performing these therapies in tandem. In this case series, we report on 6 patients who underwent combination surgery with either resection or laser interstitial thermal therapy (LITT) and neuromodulation with responsive neurostimulation (RNS) or deep brain stimulation (DBS).

Methods: We performed a retrospective review of adult patients with medically refractory epilepsy who underwent staged combination epilepsy surgeries during the same admission at our institution. Six cases treated between 2019 and 2023 were identified. All patients underwent a presurgical work-up including invasive intracranial monitoring and underwent a combined approach with either surgical resection, LITT, RNS, or DBS. We extracted data on demographic, clinical, and surgical characteristics. The primary outcome was change in seizure frequency from baseline.

Results: The mean age was 42.7 years old (4 female). All patients had at least one epileptogenic zone in the temporal lobe, two in extratemporal neocortex, two in periventricular nodular heterotopia. For the staged combination approach, 3 patients underwent LITT followed by RNS, two underwent resection and RNS, and one received LITT and DBS. The mean reduction in seizure frequency per month at last follow-up was 90%. Postoperatively, 1 patient experienced superior visual field deficits related to LITT, and another had postoperative deep vein thrombosis.

Conclusion: All patients experienced at least an 83% reduction in seizures. This case series demonstrates the potential benefits of a combined surgical approach in patients with multifocal seizures and at least one lesion that can be safely resected or ablated. Future prospective studies are warranted.