Stereotactic and Functional Neurosurgery最新文献

Introduction: Cerebellar deep brain stimulation (DBS) is gaining traction as a potential treatment for movement disorders and stroke, and there is renewed interest in the cerebellum as a target for neuromodulation. Despite the safety and accuracy of frame-based approaches to the posterior fossa, unconventional stereotactic frame placement may be necessary to allow for low posterior fossa trajectories. Current literature lacks a comprehensive protocol detailing inverted frame placement and targeting.

Methods: Preoperative imaging was acquired prone. An inverted Leksell G frame was applied along with an open-topped CT fiducial box, followed by a prone CT with the scanner set to the "legs first, nose up" configuration. Target coordinates were extracted from navigation software after image fusion. Intraoperatively, the patient was positioned prone, and the stereotactic arc was mounted in the lateral-right orientation, with inverted arc supports. Confirmatory stereotaxy to a scalp staple was performed, and the DBS leads were then inserted.

Conclusion: Our standardized protocol provides a flexible platform for posterior fossa DBS, allowing for low trajectories and multiple electrodes. Unlike conventional upright frame placement, an inverted frame permits an unobstructed view of suboccipital entry sites and incision placement. A conventional frame and regular planning software are sufficient, with no additional mathematical calculations required.

Introduction: Benign adult familial myoclonus epilepsy (BAFME) is an autosomal dominant disorder characterized by adult-onset cortical tremor and infrequent generalized seizures. Treatment options for managing involuntary movements in BAFME remain limited.

Case presentation: Here, we present 2 cases involving individuals with BAFME who underwent Vim thalamotomy for tremor-like myoclonus. Despite the intervention, neither patient experienced any improvement in their symptoms.

Conclusion: These findings suggest that the Vim may not contribute to the pathophysiology of tremor-like myoclonus in BAFME, despite the established efficacy of Vim thalamotomy in the treatment of essential tremor.

Introduction: Stereotactic electroencephalography (SEEG) involves the implantation of intracortical electrodes for the precise localization of the epileptogenic zone and is well-established in terms of its safety and efficacy during implantation; however, there is a notable lack of research comparing different electrode removal techniques, specifically regarding complications and feasibility of these approaches. This study evaluates the feasibility and clinical utility of intraoperative versus extraoperative (bedside) removal of stereotactic electroencephalography (SEEG) electrodes.

Methods: The early feasibility study retrospectively reviewed 117 consecutive SEEG patients at our institution, comparing 101 intraoperative cases with 16 extraoperative cases. A total of 1,624 SEEG electrodes were evaluated. Results related to demographics, feasibility of bedside removal, and occurrence of complications were analyzed and statistically compared between groups.

Results: Our findings reveal comparable patient demographics across both groups and demonstrate low complication rates of 1.98% for intraoperative and 0.00% for extraoperative removals, with a combined rate of 1.71%. Importantly, zero cases of infection were observed in both settings. In addition to the low rates of complication in both the intraoperative and extraoperative explant groups, the study indicates a statistically significantly reduced use of sedation in the extraoperative group, which may enhance patient comfort and eliminate the need for additional sedatives during their ongoing treatment. The extraoperative bedside approach also offers practical benefits, such as removing the need for operating room (OR) resources and staffing, which can prevent OR delays and contribute to shorter hospital stays.

Conclusion: With the appropriate indications, the extraoperative removal of SEEG electrodes appears to be a feasible and safe alternative to the intraoperative method. It presents potential advantages in optimizing patient flow within epilepsy monitoring units, improving operational efficiency, and potentially reducing healthcare costs while promoting patient comfort. Future research is essential to validate these findings further and refine the bedside technique for broader clinical application.

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.

Background: When conservative treatment, including intrathecal infusion of pharmacological agents, or even multimodal therapies are not sufficiently effective, if their respective benefits-risks balances are favorable, Drezotomy and myelotomy, ablative surgeries targeting sensory circuits in the spinal cord, may still have a place today for well-selected patients.

Summary: In this review article, the rationale and technical principles and their current potential indications, based on their results published, are described. Drezotomy have been reported effective for topographically limited cancer pain caused by well-localized lesion, in particular if nociceptive and neuropathic components are combined. Currently, the open punctate midline is used for patients with intractable visceral cancer pain, abdominal or pelvic, even bilateral. For patients with limited survival, percutaneous myelotomy is recommended, given the less invasive nature of the procedure. However, the technique chosen for myelotomy will ultimately depend on the surgeon's experience and expertise.

Key messages: In spite of data coming only from case series, DREZotomy and myelotomy, that are technically demanding procedures, can be still useful interventions and discussed for well-selected patients suffering from intractable cancer pain.

Background: Epilepsy is a prevalent chronic neurological disease affecting millions. Many patients respond to medical therapies, but a third of patients does not and potentially requires neurosurgical procedures. These can be used to localize the onset of seizures and subsequently treat patients. Robotic technologies have emerged over the last decades to increase the efficacy and safety of epilepsy surgery. We therefore wanted to describe the role that robotics in epilepsy surgery have taken since their introduction more than 30 years ago. Summary: Robotic assistance in epilepsy surgery has evolved for more than 30 years. Its earliest use in stereotactic EEG (SEEG) implantations has now also become its most widely used application. Multiple studies have demonstrated that robotic guidance increases the accuracy while also making the implantation of electrodes faster. Beyond diagnostics, robotics have also gained widespread acceptance in ablative neurosurgical procedures where robotic systems improve the placement and can even aid in the fine-tuning of laser fibers for laser interstitial thermotherapy. Additionally, robotics has been employed in the placement of electrodes for intracranial neuromodulation therapies in epilepsy such as deep brain stimulation and responsive neurostimulation. Ongoing innovations are further expanding the uses of robotic technologies in epilepsy surgery from aiding in endoscopic procedures to automated craniotomies. Key Messages: Robotics in epilepsy surgery has come a long way and has already taken a central role in procedure intended for diagnostic and therapeutic purposes. This narrative review details its many benefits and provides an outlook for future developments.

Background: Epilepsy is a network disorder characterized by dynamic interactions between cortical and subcortical circuits that collectively facilitate seizure initiation, propagation, maintenance, and termination. While cortical structures have traditionally dominated epilepsy research, diagnostic evaluation, and therapeutic targets, recent years have witnessed growth in exploring the role of subcortical structures beyond the well-studied limbic system for several decades. Structures such as the thalamus have emerged as critical nodes in epileptic networks, with growing evidence from neuromodulation studies underscoring its critical role in seizure dynamics. This shift reflects a paradigm change from localized cortical focus models to a more comprehensive understanding of distributed cortical-subcortical networks in epilepsy pathophysiology.

Summary: In this review, we explore different subcortical structures and their involvement in both generalized and focal epilepsies, suggesting that there must be continued research into cortical-subcortical network dynamics. The thalamus (anterior, centromedian, and pulvinar nuclei) is highlighted as a critical hub for seizure dynamics and a validated target for neuromodulation. The cerebellum is recast as an active participant in seizure modulation and a site of pathology, rather than a passive structure. The basal ganglia are detailed as modulators of seizure propagation, while the corpus callosum is identified as a primary pathway for bilateral ictal spread. Hypothalamic hamartomas are presented as a unique model of intrinsic subcortical epileptogenesis. The brainstem's potential role in facilitating seizure propagation and its implication in SUDEP is also discussed. The manuscript further explores the fundamental concept of failed lateral inhibition within cortical-subcortical networks as a key mechanism in epileptogenesis.

Key messages: Subcortical structures are integral components of epileptic networks, with roles ranging from seizure initiation and propagation to modulation and termination. A nuanced understanding of specific subcortical nuclei (e.g., thalamic subnuclei) is essential for advancing targeted neuromodulation therapies like deep brain stimulation. Future research and therapeutic strategies must adopt an integrated cortical-subcortical network perspective to improve surgical outcomes, develop novel treatments, and reduce morbidity in epilepsy.