Stereotactic and Functional Neurosurgery最新文献

Introduction: Functional neurosurgery covers a wide array of neurological disorders with an equally vast array of treatment modalities, including neuromodulation, decompressive, and ablative therapies for disparate pathologies such as pain, neuromodulation, disconnection, and refractory epilepsy. One of the most common functional treatments is deep brain stimulation for movement disorders and select psychiatric diseases. Functional neurosurgery treats patients with reduced quality of life from pathological neuronal pathways. Optimal patient selection by preoperatively identifying high-risk patients is critical for avoiding as many operative complications as possible, in addition to managing complications better once they occur. Frailty indices have demonstrated superior discrimination in predicting adverse postoperative outcomes across the spectrum of neurosurgical subspecialties when compared to increasing patient age. This systematic review describes multiple different frailty indices utilized by patients undergoing functional neurosurgery procedures.

Methods: A systematic review of literature was performed using PubMed. The Newcastle Ottawa Scale (NOS) was used to assess for risk of bias and studies with NOS >6 were considered high-quality. An initial search identified 541 articles through our search strategy and, after screening and review, five met criteria for inclusion The 5-factor modified frailty index (mFI-5) and Risk Analysis Index (RAI) were most frequently utilized (n = 5). One study utilized single-hospital databases in contrast to the nationwide databases utilized by the other four studies.

Results: RAI was found to have superior predictive ability as frailty metric when compared to the mFI-5. All five studies were considered high-quality based on the NOS. Frailty indices have demonstrated the ability to predict adverse outcomes in patients undergoing procedures from across the spectrum of neurosurgical subspecialties.

Conclusion: Our review identified articles that utilized frailty indices in predicting outcomes among patients undergoing functional neurosurgery procedures.

Introduction: Deep brain stimulation (DBS) was approved for essential tremor by the Food and Drug Administration (FDA) in 1997. Since that time, technological advancements in implanted hardware and operative technique have changed the landscape of functional neurosurgery. Interventional MRI-guided DBS lead placement is an emerging technique that can be used to treat ET patients, though the data are limited due to the perceived difficulty of direct targeting the ventral intermediate nucleus (VIM) relative to other structures. Here we review the experience of a single surgeon with interventional MRI-guided DBS targeting of the VIM in ET patients under general anesthesia in a community setting.

Method: We conducted a retrospective chart review of ET patients who underwent DBS under general anesthesia using an MRI-guided ClearPoint surgical technique at Willis-Knighton Health System between 2016 and 2021. Demographics, radial error, procedure details, complications, and clinical outcomes were collected. Clinical outcome measures included postoperative medication reduction, the Quality of Life in Essential Tremor Questionnaire (QUEST), and a reduced 19-item version of the Fahn-Tolosa-Marín (FTM) tremor rating scale (upper-limb items from parts A-C; maximum 76 points).

Results: A total of 113 ET patients (50 females [44.2%]; mean age 68.1 ± 9.4) underwent placement of 175 DBS leads. The 2D radial error was 0.43 ± 0.33 mm with only 2 leads requiring more than one pass. Following DBS placement, 69.2% stopped or reduced medication. On the reduced 19-item FTM (maximum 76 points), scores improved from 34.0 preoperatively to 8.9 postoperatively (-76.4%, p < 0.001). The QUEST Summary Index improved from 47.1 preoperatively to 29.4 postoperatively with an average improvement of 77.8%.

Conclusion: Interventional MRI-guided DBS lead placement under general anesthesia is a feasible and effective technique for ET patients that may expand the reach of DBS therapy to those with significant anxiety regarding traditional, awake surgery.

Introduction: Subthalamic deep brain stimulation (STN-DBS) is an established treatment for Parkinson's disease (PD); however, long-term motor outcomes vary, affecting patients' quality of life. Identifying the factors that influence these heterogeneous motor outcomes is essential. This study investigated the factors influencing heterogeneous motor outcomes in patients with PD after STN-DBS and developed predictive models using preoperative demographic and clinical factors.

Methods: We studied 92 patients with PD who underwent bilateral STN-DBS at the Beijing Tiantan Hospital between 2020 and 2022. Motor outcomes were assessed preoperatively and 1 and 12 months postoperatively. Patients were grouped based on different motor outcomes (change in Unified Parkinson's Disease Rating Scale Part III scores) between the 12- and 1-month assessments: those achieving minimal clinically significant motor improvement (MCID+) and those who did not (MCID-). Machine-learning models were used to predict outcomes based on preoperative factors.

Results: The MCID+ group (n = 46) showed significantly better motor outcomes at the 1-year follow-up than the MCID- group (n = 46, mean difference 10.47, p < 0.001). A lower levodopa equivalent daily dose (p < 0.01), reduced anxiety (p < 0.05), reduced depression (p < 0.001), and milder freezing of gait (p < 0.05) were associated with better motor outcomes. Predictive models using logistic regression and XGBoost achieved a high accuracy (82%) in forecasting motor outcomes.

Conclusions: Preoperative non-motor factors, particularly emotional status, significantly affected motor outcomes following STN-DBS. Machine-learning models enhance prognostic accuracy and offer the potential for personalized treatment strategies.

Introduction: Bilateral temporal lobe epilepsy represents a subset of patients with medically intractable epilepsy that is particularly difficult to treat. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of three neuromodulation techniques - vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) - in refractory bilateral temporal lobe epilepsy (BTLE).

Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a thorough electronic literature search using Ovid MEDLINE, Ovid Embase, and PubMed databases. Data from the selected studies were extracted, analyzed, and a quality assessment was performed. Meta-analysis was performed comparing mean seizure reduction rates in VNS, RNS, and DBS.

Results: Twenty studies (4 VNS, 7 RNS, 9 DBS) involving 142 BTLE patients were included in the systematic review. Meta-analysis of 12 studies (2 VNS, 5 RNS, 5 DBS) revealed comparable efficacy between VNS (61.69%), RNS (67.51%), and DBS (66.68%), with no statistically significant difference (p = 0.932) between the modalities. All three techniques demonstrated efficacy in seizure reduction. Additionally, complication rates did not significantly differ between VNS, RNS, and DBS.

Conclusion: This study provides a comprehensive assessment of existing data regarding the use of neuromodulation in refractory BTLE. VNS, RNS, and DBS demonstrated comparable efficacy, supporting their consideration in treatment planning. Clinical decision-making should weigh factors such as surgical candidacy, patient preferences, comorbidities, and side effect profiles. Further research, including standardized reporting and head-to-head trials, is vital for optimizing treatment protocols and expanding our understanding of neuromodulation's impact on seizure reduction, quality of life, and cognitive outcomes in patients with BTLE.

Introduction: Tremor-predominant Parkinson's disease (TPPD) generally responds favorably to deep brain stimulation (DBS) targeting the subthalamic nucleus (STN). However, traditional stereotactic targeting of the STN does not universally yield the anticipated intraoperative improvement, prompting exploration of additional targets to achieve optimal results prior to permanent implantation of electrodes. The posterior subthalamic area (PSA), including the caudal zona incerta (cZI), have been associated with tremor suppression and can be easily compared to the neighboring STN intraoperatively.

Methods: We retrospectively compared intraoperative and clinical outcomes in tremor-dominant PD patients who prospectively underwent dual trajectory microelectrode monitor targeting the STN and PSA/cZI. We compared the neurophysiology and tremor response of both the central (STN) and posterior (PSA) trajectories in 22 patients and analyzed outcomes in those who ultimately received traditional STN (16) or PSA/cZI lead implantation (12).

Results: While both groups achieved substantial overall motor improvement under chronic stimulation, intraoperative test stimulation through the posterior path produced more consistent tremor arrest compared with STN. These findings suggest that positioning the DBS lead further posteriorly to engage the PSA can augment tremor suppression in select cases of TPPD without compromising other parkinsonian symptom relief.

Conclusion: Our results emphasize the value of intraoperative physiological feedback in trajectory selection in tremor-predominant patients and are consistent with emerging literature that PSA/cZI DBS is an effective and potentially superior target for management of tremor in PD.

Introduction: High-intensity focused ultrasound (HIFU) has evolved significantly since its introduction to neurosurgery over 15 years ago. In the past decade, its clinical use has expanded to treat a broader range of surgical domains and indications. However, the pace and pattern of this evolution remain poorly characterized within the literature. This systematic review aimed to synthesize global research on HIFU in neurosurgery over the past 10 years, identifying trends across indications and regions.

Methods: Following PRISMA guidelines, we identified clinical studies involving HIFU in neurosurgical practice from January 1, 2014, to November 1, 2024. Studies were categorized by application and country of origin, and a quantitative analysis was performed to assess distribution and trends in these factors.

Results: A total of 498 studies were included. Research output increased over the period, from 13 studies in 2014 to 92 in 2024. While the scope of clinical applications expanded from 6 to 13 domains over this period, a disparity in research volume persisted, with movement disorders - particularly essential tremor (62.0%) and Parkinson's disease (29.9%) - accounting for the majority of publications. Nonetheless, growth was observed in previously underrepresented domains such as neurooncology, psychiatry, epilepsy, chronic pain, and neurovascular disorders. Geographically, the USA accounted for the largest share of publications (38.4%), followed by Switzerland (11.6%) and the UK (8.2%). Over this period, study quality improved with a shift from case reports and pilot studies toward an increasing number of cohort studies and randomized controlled trials.

Conclusion: This review outlines the accelerating, yet uneven, exploration of HIFU in neurosurgical practice over the past decade. While movement disorders remain the central focus of this technology, expanding interest in underexplored indications indicates a shifting landscape. At the same time, the maturation of study designs reflects a strengthening evidence base. As the field advances, increased global collaboration and greater attention to budding applications are necessary.

Introduction: Asleep deep brain stimulation (DBS) is limited by its reliance on interventional/intraoperative MRI in many cases. A frameless stereotaxy system can be used in combination with optical navigation for initial coarse alignment, followed by a navigational iCT scan to enable asleep DBS in standard operating rooms, aiming to improve accessibility and precision.

Methods: This retrospective study analyzed 32 patients (33 procedures) undergoing DBS electrode placement using the SmartFrame OR™ system (ClearPoint Neuro Inc., San Diego, CA). Radial targeting error and operative duration were assessed. Surgical workflows combined O-arm imaging (Medtronic Inc, Minneapolis, MN) and StealthStation™ S8 neuronavigation (Medtronic Inc, Minneapolis, MN, USA). Targets included the ventral intermediate nucleus (VIM), subthalamic nucleus (STN), globus pallidus internus, hippocampus, and thalamic nuclei.

Results: Median radial targeting error was 0.40 mm (range: 0-1.6 mm), with bilateral procedures showing marginally lower errors (0.35 mm vs. 0.50 mm unilateral). The VIM exhibited the highest precision (0.35 mm), while STN targeting had slightly higher error (0.53 mm). Median operative time was 189 min (140-275 min), with bilateral procedures requiring longer durations (190 vs. 155 min, p = 0.001). No major complications occurred, and no revisions were needed.

Conclusion: The ClearPoint SmartFrame OR™ system achieved submillimeter accuracy and operational efficiency comparable to MRI-guided platforms while eliminating MRI dependency. Its integration with O-arm and Stealth Navigation enhances accessibility, reduces costs, and maintains safety, positioning it as a scalable solution for asleep DBS in standard neurosurgical settings.