Stereotactic and Functional Neurosurgery最新文献

Introduction: 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: 3,288 patients from 37 studies were included (2,537 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.

Conclusion: 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: 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 ventrooral nucleus.

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: In patients receiving deep brain stimulation (DBS) therapy, the longevity of the implanted pulse generator (IPG) is influenced by multiple factors, including patient diagnosis, therapeutic target, neurostimulator type, number of implanted leads, and stimulation settings. Recent advancements in DBS technology include longer-lived batteries, both standard and rechargeable. This study assessed the estimated IPG longevity of Medtronic, Inc., Percept™ PC neurostimulator in Parkinson's disease (PD) and explores factors associated with IPG lifespan.

Methods: Retrospective analysis of Percept™ devices in 31 PD patients who underwent bilateral DBS targeting either the internal globus pallidus or the subthalamic nucleus (STN). The analysis included demographics, clinical information, stimulation settings, lead locations, and total effective energy delivered (TEED).

Results: The median IPG longevity was 75.9 months (51.6-92.3). Among stimulation parameters, frequency demonstrated the strongest inverse correlation with longevity (r = -0.49, p < 0.01), followed by pulse width (r = -0.39, p < 0.01), TEED (r = -0.35, p < 0.01), current amplitude (r = -0.33, p < 0.01), and voltage (r = -0.25, p = 0.04), regardless of laterality. In STN-targeted patients, a significant association was observed between the Z-coordinate of the right lead and the presence of side effects (p = 0.04). Monopolar stimulation on the dominant side showed significantly longer IPG longevity compared to bipolar stimulation (80.6 vs. 49.6 months, p = 0.01).

Conclusion: Significant negative correlations were observed between longevity and various stimulation parameters regardless of laterality. Monopolar stimulation on the dominant side was associated with increased longevity.

Introduction: The effect of multi-contact independent current control (MICC) spinal cord stimulation (SCS) on patient-reported outcomes in those who have lost therapeutic efficacy of a conventional SCS is not well described. We prospectively evaluated self-reported pain, disability, and quality of life in patients with persistent spinal pain syndrome type 2 (PSPS-2) who were converted from a conventional to MICC SCS.

Methods: Patients with PSPS-2 who had lost therapeutic efficacy with a constant current control (CCC) or voltage control (VC) system were enrolled, and had a MICC generator implanted. All participants were followed prospectively with standardized assessments of pain (Visual Analog Scale [VAS]), condition-specific function (Oswestry Disability Index [ODI]), and quality of life (Short-Form-36) at 3 and 6 months post-implantation.

Results: Fifteen participants were eligible for inclusion; 3 were lost to follow-up. Mean VAS scores were significantly decreased at 3 months (5.3 ± 2.5, p = 0.009) and 6 months (5.1 ± 2.8, p = 0.005) relative to pre-implantation (VAS 8.3 ± 0.8). At 30 months, mean VAS remained significantly decreased (5.8 ± 1.6, p < 0.001). The mean disability score was significantly decreased at 6 months (ODI 40.5 ± 14.7, p = 0.029) compared to the mean preoperative score (53.6 ± 14.7). At 6 months, the minimum clinically important difference for VAS was met by 90% of patients and for ODI by 100%.

Conclusion: This exploratory study suggests that MICC programming may represent a reasonable short-term salvage option for patients with PSPS-2 who have lost therapeutic efficacy with a CCC or VC SCS system. A larger study is required to evaluate superiority in terms of long-term pain control of MICC versus conventional SCS.

Introduction: The present study aimed to define a structural network of stroke-induced and spasticity-related lesions and to relate this network to target sites and reported effects of deep brain stimulation (DBS) to treat poststroke spasticity.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed (online suppl. Table 2). We performed two separate systematic literature reviews, collecting data from previously published voxel-based lesion-symptom mapping (VLSM) studies for poststroke spasticity patients searching the Medline database on Pubmed using the keywords "stroke," "spasticity," and "lesion mapping" as well as data from previously published cohorts undergoing DBS for poststroke spasticity using the keywords "brain stimulation" and "spasticity." Data collected from each study included patient demographic characteristics, stroke diagnosis, movement disorder, DBS target, stimulation parameters, complications, and outcomes. Data from VLSM studies were used to calculate coordinate-based activation likelihood clusters, which were then used as seeds for enhanced fiber tracking to analyze affected networks.

Results: Data from five studies on voxel-based lesion-symptom mapping for stroke-induced spasticity were included in the analysis. Meta-analytical mapping of stroke-related lesions identified significant clusters located in the basal ganglia-thalamo-cortical network which were predominantly connected to the sensorimotor cortex. We identified eight studies (four retrospective case series, two prospective open-label non-randomized trials, and two prospective double-blind trials) fulfilling our inclusion and exclusion criteria on DBS for spasticity reporting on 107 patients in total. Most studies reported outcomes in patients with cerebral palsy, a condition associated with both stroke-related spasticity and hypertonia-related dystonia, which are difficult to differentiate clinically. Target sites included different parts of the cerebellum and the motor thalamus with overall mixed results.

Conclusion: Because all reported effective DBS target sites are situated along the cerebello-thalamo-cortical network, we hypothesize that the therapeutic effect of DBS on spasticity might be induced by resetting a functional imbalance between the basal ganglia-thalamo-cortical and the cerebello-thalamo-cortical networks in patients with a supraspinal etiology of spasticity. However, the results need to be interpreted cautiously due to the inevitable inclusion of stroke-related dystonia.

Introduction: In Parkinson's disease (PD) patients, modulation of the fibre tracts of the cortico-basal ganglia-thalamo-cortical loop is the presumed mechanism of action of deep brain stimulation (DBS) of the subthalamic nucleus (STN). Therefore, we explored patient-individual cortical structural connectivity of the volume of tissue activated (VTA), as well as DBS-induced modulation of fibre tracts connecting the STN with cortical and subcortical nodes, and their correlation with therapeutic effects.

Methods: A retrospective cohort of n = 69 PD patients treated with bilateral DBS of the STN was analysed. Clinical response was assessed from the DBS-induced change in the UPDRS-III motor scores (total and symptom-specific sub-scores) under regular medication after a median follow-up of 9.0 (range 2.6-20.2) months. Tractography based on patient-individual diffusion-weighted MRI was employed in two ways. Whole-brain tractography was used to identify the cortical connections of fibres passing the VTAs, and reconstruction of specific white matter pathways of the motor loop connecting the STN with the basal ganglia and cortex was used to identify the proportion of fibres within these pathways which was modulated by STN-DBS. This proportion of pathway modulation was used in a correlative analysis with clinical outcomes.

Results: Fibres traversing the VTAs were primarily connected to the supplementary motor area (SMA) and to a lesser degree to the premotor cortex. Within the pathways connecting the STN with the cortical and subcortical nodes, on average 30-40% (range 10-80%) of the fibres were modulated by STN-DBS. This proportion correlated significantly with the percentage change in UPDRS motor score for fibres connecting the STN with the SMA (ρ = 0.28), pre-SMA (ρ = 0.26), ventral and dorsal premotor cortices (ρ = 0.26 and ρ = 0.29, respectively), and the globus pallidus externus (ρ = 0.26) and internus (ρ = 0.29). Also, good clinical responses for both tremor and rigidity were associated with a significantly (p < 0.05) higher proportion of modulated fibres for the same cortico- and sub-cortico-STN connections.

Conclusion: Patient-individual tractography reveals that, in PD, most of the cortical fibres traversing the VTA are connected to the SMA. In addition, clinical efficacy is related to the proportion of DBS-affected fibres connecting the STN with nodes of both the hyperdirect (cortex-STN) and the indirect pathways (STN-basal ganglia). As such, patient-specific tractography, in particular in the basal ganglia, could be used in a clinical context as a tool to guide therapy.

Background: Chronic pain is a prevalent and often undertreated issue for adult cancer survivors, lasting well beyond the completion of curative treatment or during prolonged maintenance therapy. Historically, pain management in this population has followed strategies similar to those used for active cancer pain - primarily systemic opioids - despite the long-term risks of functional decline, endocrine disruption, and misuse during periods of survivorship that may span decades.

Summary: This review examines the evolving role of neuromodulatory and functional neurosurgical interventions for chronic pain in adult cancer survivors. It focuses on five core modalities: spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRGS), peripheral nerve stimulation (PNS), intrathecal drug delivery systems (IDDSs), and cortical stimulation. These interventions are placed in context with three survivor groups: those cured of disease, those living with stable disease on chronic therapy, and survivors of hematopoietic cell transplantation. Emerging clinical evidence supports the use of SCS for treatment-related neuropathic and mixed pain syndromes, while DRGS and PNS show promise in addressing focal neuropathic conditions. IDDS offers a means to deliver targeted analgesia in patients suffering from diffuse or opioid-refractory pain, and cortical stimulation is currently being investigated for highly refractory cases. Each modality is examined in relation to common pain syndromes in survivorship, including chemotherapy-induced peripheral neuropathy, post-surgical neuropathy, radiation fibrosis, graft-versus-host disease-related pain, and musculoskeletal or myofascial pain. The review also explores unique survivorship considerations such as immunosuppression, device longevity, healing complications, and disparities in access and coverage.

Key messages: Neuromodulation and functional neurosurgical techniques represent an emerging approach for managing chronic pain in adult cancer survivors, providing alternatives to systemic pharmacotherapy that may enhance quality of life and functional independence. The clinical application of these interventions should be guided by pain phenotype, underlying pathophysiology, and long-term survivorship needs. Their integration into cancer survivorship care necessitates careful consideration of patient selection, device management over time, procedural risks in immunocompromised individuals, and the ethical imperative for informed, shared decision-making.

Introduction: Tumor-related trigeminal neuralgia (TN) is a challenging condition to manage that can be treated with gamma knife radiosurgery (GKRS) by targeting the tumor, the trigeminal nerve, or both. However, data regarding the efficacy of this treatment are somewhat limited. The aim of this study was to report outcomes of GKRS for tumor-related TN from a cohort study.

Methods: Retrospective review of our GKRS database identified 41 patients with benign tumor-related TN treated with GKRS between 2014 and 2024. Background medical history, treatment outcomes and complications, and dosimetric data were obtained by chart review.

Results: The tumor, the trigeminal nerve alone, or a combination of both was targeted in 28, 7, and 6 patients, for a total of 47 GKRS procedures. Eight (24%) patients had pain control before GKRS targeting the tumor. Thirty (88%) and 11 (85%) patients had pain control after GKRS targeting the tumor and the trigeminal nerve, respectively. After a median follow-up of 63 months, pain recurred in 8 (24%) and 3 (23%) patients in the two groups. After tumor- and nerve-targeted GKRS, estimated rates of pain control at 1, 4, 7, and 10 years were 82%, 69%, 56%, and 56%, and 77%, 67%, 50%, and 50%, respectively. When GKRS targeting the tumor and the trigeminal nerve was considered as part of the same treatment, estimated rates of pain control at 1, 4, 7, and 10 years were 83%, 75%, 71%, and 71%. After tumor- and nerve-targeted GKRS, respectively, 5 (15%) and 3 (23%) patients developed persistent non-bothersome facial hypesthesia.

Conclusions: GKRS targeting the tumor is an effective, well-tolerated treatment for patients with tumor-related TN. More durable relief is achieved in some patients with second-stage GKRS targeting the trigeminal nerve but with additional facial sensory disturbances.