Stereotactic and Functional Neurosurgery最新文献

Introduction: One of the challenges in directional deep brain stimulation (DBS) is to determine the orientation of implanted electrodes relative to targeted regions. Post-operative images must be aligned with a model of the implanted lead, usually a computer-based model provided by the manufacturer. This paper shows that models can alternatively be obtained by capturing images of individual leads using micro-CT, a high-resolution CT technique. Contrary to computer-aided design models, lead models generated this way provide realistic X-ray contrast and finer details.

Methods: We scanned DBS leads from various vendors using a Bruker SkyScan 1276 micro-CT system. To reduce beam-hardening artefacts, samples were scanned at maximum X-ray tube voltage (100 kV) and with copper filtering. Images were made publicly available for download and 3D visualisation.

Conclusion: Detailed images of single DBS leads can be generated using standard micro-CT systems. Their use as reference models could improve lead orientation algorithms, in particular those dedicated to X-ray modalities. Furthermore, the possibility to share models online could broaden access for clinical research.

Introduction: Direct targeting in deep brain stimulation (DBS) has remarkably impacted the patient's experience throughout the surgery and the overall logistics of the procedure. When the individualised plan is co-registered with a 3D image acquired intraoperatively, the electrodes can be safely placed under general anaesthesia. How this applies to a general practice scenery (outside clinical trials and in a moderate caseload centre) has been scarcely reported.

Methods: Prospective single-centre study of patients treated with asleep subthalamic DBS for Parkinson's disease between January 2021 and December 2022. Clinical, motor, medication-dependence, and quality-of-life outcomes were evaluated after optimal programming (6 months). Wilcoxon test was used to compare pre- versus post-repeated measures. Surgical-related parameters were also analysed.

Results: Eighty-nine patients primarily operated for DBS were included in the study. Intraoperative electrode replacement was not necessary. Mean surgical duration was 217 (SD 44) minutes, including the implantation of the generator; and mean length of stay was 3 (SD 1) days. There was one surgical-related complication (delayed infection). Significant and clinically relevant improvement was seen in UPRS III (mean decrease 62%) (p < 0.001) and PDQ-8 (50% increase) (p < 0.001) after 6 months. Daily doses of medication were decreased by a mean of 68%, p < 0.001).

Conclusion: DBS can be safely performed under general anaesthesia in a pragmatic clinical environment, provided a multidisciplinary committee for patient selection and a dedicated surgical and anaesthetic team are available. The effectiveness in ameliorating motor symptoms, the ability to reduce the drug load, and the improvement in quality of life demonstrated in clinical trials could be reproduced under more generalised conditions as in our centre. The need for a team learning curve and the progressive evolution in, and adaptation to, trajectory planning software, anaesthetic management, intraoperative imaging, DBS device upgrades, and programming schemes should be contemplated in the transition process to direct targeting.

Introduction: Direct targeting in deep brain stimulation (DBS) has remarkably impacted the patient's experience throughout the surgery and the overall logistics of the procedure. When the individualised plan is co-registered with a 3D image acquired intraoperatively, the electrodes can be safely placed under general anaesthesia. How this applies to a general practice scenery (outside clinical trials and in a moderate caseload centre) has been scarcely reported.

Methods: Prospective single-centre study of patients treated with asleep subthalamic DBS for Parkinson's disease between January 2021 and December 2022. Clinical, motor, medication-dependence, and quality-of-life outcomes were evaluated

Background: Cancer pain is a complex and multifactorial phenomenon that significantly impairs quality of life, particularly in advanced stages of malignancy. Although systemic pharmacologic therapies remain the cornerstone of management, a substantial proportion of patients experience refractory pain or intolerable side effects. Intrathecal drug delivery (ITDD) offers a targeted method of analgesia by administering medications directly into the cerebrospinal fluid, enabling effective pain control at lower doses while minimizing systemic toxicity.

Summary: This review explores the physiological mechanisms underlying cancer pain, the rationale for intrathecal therapy, and the pharmacological profiles of commonly used intrathecal agents. Patient selection criteria, timing of therapy integration, and the technical aspects of device implantation are discussed in detail. Although ITDD significantly improves pain control and quality of life, potential complications, mechanical, pharmacological, infectious, and surgical, necessitate careful procedural planning, rigorous follow-up, and multidisciplinary management.

Key messages: Intrathecal drug delivery is an effective modality for managing refractory cancer pain and can significantly enhance patient quality of life. Early integration into the cancer care continuum, rather than reserving ITDD as a last resort, may provide superior symptom control. Careful patient selection, individualized pharmacologic regimens, and precise surgical technique are critical to minimizing complications and optimizing outcomes. Further research is needed to refine drug combinations, improve device technology, and define best practices for early intervention strategies.

Introduction: Spinal cord stimulation (SCS) is an effective treatment for patients with refractory chronic pain. Despite its efficacy, rates of reoperation after initial implantation of SCS remain high. While revision rates after index SCS surgeries are well reported, less is known about rates and risk factors associated with repeat reoperations. We sought to evaluate patient, clinical, and surgical characteristics associated with repeat reoperation among patients who underwent an initial SCS revision procedure.

Methods: We performed a retrospective review of patients who underwent SCS revision surgery performed at a single institution between 2008 and 2022. Patients were stratified by whether they underwent a single revision (SR) or multiple revision (MR) surgeries. Multivariate logistic regression was performed to determine risk factors associated with repeat SCS revision. Kaplan-Meier survival analysis was used to compare rates of devices requiring revision across groups.

Results: A total of 54 patients underwent an initial SCS revision. Of these, 15 (28%) underwent a second revision. The most common indication for revision surgery was lead migration (65%). No significant differences were observed in age, body mass index, comorbidities, lead type, and revision indication among the SR and MR groups. On multivariate adjusted analysis, only cervical lead position was significantly associated with repeat reoperation (OR 7.10, 95% CI [1.14, 44.3], p = 0.036). Time to reoperation after a single and MR SCS surgeries did not differ.

Conclusions: Among patients who undergo SCS reoperation, a substantial portion requires additional revisions. Cervical lead placement may be associated with a higher risk of repeat revision surgery compared to thoracic lead positioning. Consideration of lead positioning in the decision to perform and undergo reoperation may therefore result in lower revision rates and improved clinical outcomes among SCS patients with MRs.

Introduction: Meningiomas are the most common primary intracranial tumour. Gamma knife radiosurgery (GKRS) is a frequently employed non-invasive method of treatment, with good remission rates and low morbidity in literature. However, the role of GKRS in the management of "large" meningiomas is unclear, with reported outcomes that vary by centre. We aimed to assess the factors that influence long-term outcomes following GKRS in meningiomas >10 cc in volume.

Methods: A retrospectively analysed all patients with meningiomas exceeding 10 cc in volume who underwent GKRS between January 2006 and December 2021 at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Demographic, clinical, radiological, and follow-up data were acquired, and factors associated with progression following GKRS were assessed.

Results: The cohort comprised 76 patients 29 males (38.2%) and 47 females (61.8%) with a mean age of 46.3 ± 11.02 years. Thirty-nine patients had been previously operated (51.3%). Meningiomas were most frequently located in the parasagittal region (26 tumours, 34.2%) and sphenopetroclival region (23 tumours, 30.3%), with mean lesion volume of 12.55 ± 5.22 cc, ranging 10.3 cc-25 cc. The mean dose administered to the tumour margin was 12.5 Gy ± 1.2 Gy (range 6-15 Gy). The median duration of clinical follow-up was 48 months, over which period radiological progression occurred in 14 cases (20%), with unchanged tumour volume in 20 cases (28.6%) and reduction in size of the tumour in 36 cases (51.4%). Progression-free survival after GKRS was 72% at 5 years, was significantly poorer among meningiomas with tumour volume >14 cc (log-rank test p = 0.045), tumours presenting with limb motor deficits (log-rank test p = 0.012), and tumours that underwent prior Simpson grade 3 or 4 excision (log-rank test p = 0.032).

Conclusions: Meningiomas >10 cc in volume appear to display a high rate of progression and subsequent need for surgery following GKRS. Primary surgical resection, when not contraindicated, may be considered with GKRS serving an adjuvant role, especially in tumours exceeding 14 cc in volume, and presenting with limb motor deficits. Long-term clinical and radiological follow-up is essential following GKRS as the response of large meningiomas may be unpredictable.