Stereotactic and Functional Neurosurgery最新文献

Introduction: The number of intracranial depth electrodes implanted in stereoelectroencephalography (SEEG) investigations is primarily driven by the preimplantation hypothesis about SOZ location. Targeting is not standardized and highly variable between centers. Whether some of these electrodes may prove redundant, or target low-yield areas too frequently, is uncertain.

Methods: We identified a retrospective multi-institutional cohort implanted with depth electrodes for iEEG monitoring between 2003 and 2022. We collected preoperative clinical features and iEEG investigation parameters, including the number of depth electrodes and contacts implanted. We built a propensity-matched cohort with respect to these covariates and evaluated outcomes, which included (1) the likelihood of SOZ localization, (2) complications, and (3) seizure-free outcomes as a function of electrode contact coverage. In addition, we aimed to identify brain regions commonly explored in conjunction with each other and identify the likelihood of a region being implicated in initial electroclinical seizure onset.

Results: One hundred and sixty-seven patients were followed for a median of 3.8 (range 2, 18) years after SEEG. Propensity-matched cohorts demonstrated that a higher number of implanted contacts were associated with a greater likelihood of proceeding to treatment, but were not associated with SOZ localization, seizure freedom (Engel I), favorable seizure outcomes (Engel I/II), or complications, per Bayes factor analysis. Lateral orbitofrontal, supramarginal, posterior cingulate, inferior parietal, and inferior temporal areas were least likely to be implicated in initial electrographic onset, whereas hippocampus, caudal middle frontal, pericalcarine, and parahippocampal areas were most likely when controlling for electrode coverage.

Conclusions: SEEG effectively localizes the SOZ in both lesional and non-lesional etiologies, and clinicians are generally optimizing the electrode coverage for hypothetical SOZ localization, leading to further therapeutic surgeries that may confer seizure freedom. Nevertheless, several areas are possibly being explored despite low likelihood (<2.5%) of participation within the SOZ.

Introduction: Hemispheric surgery is a multistep, highly effective, and radical surgical procedure in the treatment of drug-resistant epilepsy due to extensive unilateral hemispheric disease. The procedure ranges from a resective procedure (hemispherectomy) to disconnection (hemispherotomy) and has developed substantially over the last century from morbid to elegant, minimally invasive, and routinely practiced procedures. Bearing in mind the numerous articles that have been published on hemispherectomy and hemispherotomy, we aimed to highlight the top 100 cited and impactful articles to create familiarity with the topic. We anticipate that this will be a helpful guide for clinicians and academics navigating the literature on this subject.

Methods: A Scopus title-based search on the top 100 most-cited articles on "hemispherectomy" and "hemispherotomy" was performed in September 2023 with no restrictions. The top 100 most-cited articles were then retrieved. The article title, first author, first author's specialty, country of origin, first author's institution at the time of publication, journal of publication, year of publication, citation count, and citations per year were collected. The Google Scholar database citation count for each paper was added for correlation and comprehensive coverage.

Results: The top 100 most-cited articles were cited 92 times per paper on average. The publication dates ranged from 1949 to 2016. The most frequently cited article "Clinical outcomes of hemispherectomy for epilepsy in childhood and adolescence" with 307 citations was published by A.M. Devlin et al. (2003) in the journal Brain. The USA was the highest publishing country (41 articles). The highest-publishing journal was Neurology. The most prolific first authors were A. Smith, J. Schramm, and J. Villemure, each with four publications. The institution with the most contributions was McGill University and its affiliated Health Centers, with nine publications in total. Neurosurgery was the most common specialty among the first authors. Most of the included studies were cohort studies or case series.

Conclusion: We identified the top 100 cited articles on hemispherectomy and hemispherotomy using the Scopus database and supplemented our results with Google Scholar. We highlighted the most prominent authors, institutions, countries, journals, and study designs and illuminated the historical development of hemispherectomy and hemispherotomy procedures, in addition to landmark and currently trending papers.

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.

Background: The National Coverage Determination (NCD) by the Centers for Medicare and Medicaid Services (CMS) for deep brain stimulation requires that a patient have "advanced idiopathic Parkinson's disease (PD) as determined by Hoehn and Yahr (HY) stage or the Unified Parkinson's Disease Rating Scale part III motor subscale (UPDRS III)." How to apply the HY or UPDRS III scales to define "advanced" PD is unclear.

Summary: There is an ongoing recovery audit by the CMS of deep brain stimulation cases that were covered by Medicare but are deemed not to have met the NCD requirements and therefore not to have been medically necessary. Whether a hospital is asked to refund Medicare often hinges upon whether medical documentation supports the diagnosis of advanced PD. However, neither the HY nor the UPDRS III scales use "advanced" to define or describe stages of PD. The NCD has an accompanying National Coverage Analysis that reviews the studies that inform the NCD. These studies use "advanced" as well as the HY and UPDRS III scales. This review identifies how the HY and UPDRS III scales were used to categorize advanced PD in the studies that were cited in the National Coverage Analysis.

Key messages: In the studies used for the NCD for deep brain stimulation for PD, an HY score ≥3 or a UPDRS III score ≥30 was used to describe patient cohorts considered to have advanced PD.

Introduction: Ablative surgery is an intervention of last resort for treatment-resistant obsessive-compulsive disorder (TROCD). Our center has been using bilateral anterior capsulotomy (BAC) for the past 20 years for patients eligible for limbic surgery. This report details our experience with BAC for TROCD.

Method: Five patients with OCD met eligibility criteria for BAC. Entry protocols were complex and took around 6 months to complete. Stereotactic radiofrequency was used to produce the capsulotomies. Lesion length varied between 5.7 and 16.9 mm in the coronal plane. Patients were followed between 4 and 20 years.

Results: All 5 patients (100%) were responders as defined by the widely accepted criteria of a reduction of ≥35% in Yale-Brown Obsessive Compulsive Scale (YBOCS) score at 18-month follow-up. Four patients remained responders at the 48 months. One patient was lost to follow-up. Responder status when viewed from the perspective of the YBOCS was sustained over the 4- to 20-year follow-up with one relapse 19 years postsurgery when medications were discontinued. Real-world psychiatric outcomes were different as other vulnerabilities surfaced illustrating the multifactorial determinants of mental health. No patient had any significant long-term neurocognitive or physical side effects.

Conclusion: BAC should remain an option of last resort for patients with severe OCD who remain unresponsive to all other interventions.

Introduction: Neuromodulation is an important treatment modality for patients with drug-resistant epilepsy who are not candidates for resective or ablative procedures. However, randomized controlled trials and real-world studies reveal that a subset of patients will experience minimal reduction or even an increase in seizure frequency after neuromodulation. We describe our experience with patients who undergo a second intracranial neuromodulation procedure after unsatisfactory initial response to intracranial neuromodulation.

Methods: We performed a retrospective chart review to identify all patients who had undergone deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) or responsive neurostimulation (RNS), followed by additional intracranial neuromodulatory procedures, with at least 12 months of follow-up. Demographic and clinical data, including seizure frequencies, were collected.

Results: All patients had temporal lobe epilepsy. Six patients were treated with concurrent ANT DBS and temporal lobe RNS, and 3 patients transitioned between neuromodulation systems. Of the patients treated concurrently with ANT DBS and temporal lobe RNS, 5 of the 6 patients experienced additional reduction in seizure frequency after adding a second neuromodulation system. Of the patients who switched between neuromodulation modalities, all patients experienced further reduction in seizure frequency.

Conclusions: For patients who do not experience adequate benefit from initial therapy with ANT DBS or temporal lobe RNS, the addition of a neuromodulation system or switching to a different form of neuromodulation may allow for additional reduction in seizure frequency. Larger studies will need to be performed to understand whether the use of multiple systems concurrently leads to improved clinical results in patients who are initially treatment resistant to neuromodulation.