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Neurosurgical Focus Dec 2022Although magnetic resonance-guided focused ultrasound (MRgFUS) at the ventral intermediate (VIM) thalamic nucleus is a novel and effective treatment for...
OBJECTIVE
Although magnetic resonance-guided focused ultrasound (MRgFUS) at the ventral intermediate (VIM) thalamic nucleus is a novel and effective treatment for medication-refractory essential tremor (ET), it is unclear how the ablation lesion affects functional activity. The current study sought to evaluate the functional impact of MRgFUS thalamotomy in patients with ET, as well as to investigate the relationship between neuronal activity changes and tremor control.
METHODS
This study included 30 patients with ET who underwent MRgFUS thalamotomy with a 6-month follow-up involving MRI and clinical tremor rating. Additional sex- and age-matched healthy people were recruited for the healthy control group. The fractional amplitude of low-frequency fluctuation (fALFF) and regional homogeneity were used to identify functional alteration regions of interest (ROIs). To investigate changes after treatment, ROI- and seed-based functional connectivity (FC) analyses were performed.
RESULTS
Patients with ET had significantly increased fALFF in the right postcentral gyrus (PoCG; ROI 1), regional homogeneity in the left PoCG (ROI 2), and regional homogeneity in the right PoCG (ROI 3, cluster-level p value family-wise error [pFWE] < 0.05), which were recovered and normalized at 6 months after MRgFUS thalamotomy. FCs between ROI 2 and the right supramarginal gyrus, ROI 2 and the right superior parietal gyrus, and ROI 3 and the left precentral gyrus were also found to be increased after treatment (cluster-level pFWE < 0.05). Furthermore, changes in fALFF, regional homogeneity, and FC values were significantly correlated with tremor relief (p < 0.05). Preoperative FC strengths were found to be inversely related to the postoperative tremor control ratio (p < 0.05).
CONCLUSIONS
In patients with ET, the VIM lesion of MRgFUS thalamotomy resulted in symptom-related regional functional recovery associated with sensorimotor and attention networks. Preoperative FC strengths may reflect the postoperative tremor control ratio, implying that this metric could be a useful neuroimaging biomarker for predicting symptom relief in patients with ET following thalamotomy.
Topics: Humans; Essential Tremor; Tremor; Psychosurgery; Ultrasonography; Thalamic Nuclei
PubMed: 36455269
DOI: 10.3171/2022.9.FOCUS22228 -
World Neurosurgery Mar 2023Corpus callosotomy (CC) is a surgical palliative procedure done for a selected group of patients with drug resistant epilepsy (DRE) to stop drop attacks and prevent...
BACKGROUND
Corpus callosotomy (CC) is a surgical palliative procedure done for a selected group of patients with drug resistant epilepsy (DRE) to stop drop attacks and prevent falls.
METHODS
We performed a retrospective chart review of consecutive patients who underwent CC for DRE with drop attacks at our center between 2015 and 2019. Clinical, imaging details and surgical findings were noted. Clinical outcomes and functional status were evaluated.
RESULTS
During the study period, 17 patients underwent corpus callosotomy (Male: Female 14:3). The mean age at surgery was 10.3 years (standard deviation - 5.85, interquartile range [IQR] = 6.5). The mean age at onset of seizure was 2.23 years (standard deviation - 3.42, IQR = 1.5). Preoperative seizure frequency ranged from 2 to 60 attacks per day (median: 20, IQR= 36). All patients had atonic seizures/drop attacks. One patient underwent anterior CC and 16 underwent complete CC. Three patients had complications in the postoperative period. The median follow-up was 26 months. All patients had cessation of drop attacks immediately following surgery. One patient with anterior CC had a recurrence of drop attacks for which she underwent completion CC. Another patient had recurrent drop attacks 3 years later and was found to have a residual callosal connection. Three patients had complete seizure freedom and 4 patients had a <50% reduction in seizure frequency.
CONCLUSIONS
Our study lends additional support to the efficacy of CC in patients with DRE, with the cessation of drop attacks. It also provided a reasonable reduction in seizure frequency. Complete CC led to better control of drop attacks.
Topics: Humans; Male; Female; Child; Drug Resistant Epilepsy; Retrospective Studies; Seizures; Psychosurgery; Syncope; Corpus Callosum; Treatment Outcome
PubMed: 36435385
DOI: 10.1016/j.wneu.2022.11.078 -
Frontiers in Human Neuroscience 2022Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries),...
Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries), SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index (ERBI) and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB.
PubMed: 36092644
DOI: 10.3389/fnhum.2022.958247 -
Stereotactic and Functional Neurosurgery 2022The objectives of this study were to determine long-term patient-reported outcomes with magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for...
INTRODUCTION
The objectives of this study were to determine long-term patient-reported outcomes with magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for medication-refractory essential tremor (ET) and to identify risk factors for a poor clinical outcome.
METHODS
We administered a telephone or mail-in survey to patients who consecutively underwent unilateral MRgFUS thalamotomy for ET at our institution over an 8-year period. Patients were asked to self-report measures of hand tremor improvement, degree of overall postprocedure improvement, activities of daily life, side effects, and willingness to undergo the procedure again. Specific patient characteristics, ultrasound treatment parameters, and postoperative radiological findings from magnetic resonance imaging performed 1 day after the procedure were analyzed, and multivariable linear regression was used to determine if these factors could serve as predictors of clinical outcome.
RESULTS
A total of 85 patients were included in this study with a mean follow-up time of 3.0 years (range 2 months to 1 8.4 years). The mean patient-reported improvement in hand tremor at last follow-up was 66%, and 73% of patients reported meaningful change in their overall condition after the procedure. The percentages of patients reporting normal or only minimal limitations with feeding, drinking, and writing ability at last follow-up were 60%, 71%, and 48%, respectively. In the position of their former selves, 89% of patients would again choose to undergo the procedure. Larger lesions were correlated with a higher risk of adverse events.
DISCUSSION/CONCLUSION
While subjective hand tremor improvement declines with time, willingness to undergo the procedure again following MRgFUS thalamotomy for ET remains very high even several years after the procedure.
Topics: Humans; Essential Tremor; Tremor; Thalamus; Psychosurgery; Magnetic Resonance Imaging; Treatment Outcome
PubMed: 36030772
DOI: 10.1159/000525763 -
Advances and Technical Standards in... 2022In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one... (Review)
Review
In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one hand, it has been solidly demonstrated the impact of gross total resection on life expectancy. On the other hand, the paradigm shift from classical cortical localization of brain function towards connectomics caused by the resurgence of awake surgery and the advent of tractography has permitted safer surgeries focused on subcortical white matter tracts preservation and allowed for surgical resections within regions, such as Broca's area or the primary motor cortex, which were previously deemed inoperable. Furthermore, new asleep electrophysiological techniques have been developed whenever awake surgery is not an option, such as operating in situations of poor compliance (including paediatric patients) or pre-existing neurological deficits. One such strategy is the use of intraoperative neurophysiological monitoring (IONM), enabling the identification and preservation of functionally defined, but anatomically ambiguous, cortico-subcortical structures through mapping and monitoring techniques. These advances tie in with novel challenges, specifically risk prediction and the impact of neuroplasticity, the indication for tumour resection beyond visible borders, or supratotal resection, and most of all, a reappraisal of the importance of the right hemisphere from early psychosurgery to mapping and preservation of social behaviour, executive control, and decision making.Here we review current advances and future perspectives in a functional approach to glioma surgery.
Topics: Brain Mapping; Brain Neoplasms; Broca Area; Child; Glioma; Humans; Neurosurgical Procedures; Wakefulness
PubMed: 35976447
DOI: 10.1007/978-3-030-99166-1_2 -
Stereotactic and Functional Neurosurgery 2022Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the anterior limb of the internal capsule (bilateral anterior capsulotomy - BAC), the supragenual anterior cingulate gyrus and cingulum (bilateral anterior cingulotomy - BACING), and subgenual anterior cingulate gyrus and subcortical orbitofrontal white matter (bilateral subcaudate tractotomy - BST). A combination of BACING and BST is known as limbic leukotomy (bilateral limbic leukotomy - BLL). All procedures claim some success, but cohorts are small, depression assessment instruments differ, and inclusion and outcome criteria and follow-up duration vary. In some cohorts, more than one type of surgery was performed in several patients, further confounding interpreting the available data. Current evidence is equivocal on which surgical target works best. Method and Aim: This systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard on published cohorts was conducted to review and identify which is the best standalone ablative procedure for treatment-resistant depression (TRD) based on response rate (event rate) and adverse-effect profile using the Comprehensive Meta-Analysis software.
RESULTS AND CONCLUSION
As a standalone neurosurgical procedure, we found that BAC appears to be the most effective and safest of all the ablative targets for TRD. A major limitation of this conclusion is the paucity of published case series where sample sizes are small and all are open label.
Topics: Humans; Depression; Depressive Disorder, Treatment-Resistant; Psychosurgery; Neurosurgical Procedures; Gyrus Cinguli
PubMed: 35973404
DOI: 10.1159/000526000 -
Stereotactic and Functional Neurosurgery 2022Serendipity and observations have a noble tradition in medicine, including neurology, and are responsible for many medical treatments (carbamazepine for tic douloureux,... (Review)
Review
BACKGROUND
Serendipity and observations have a noble tradition in medicine, including neurology, and are responsible for many medical treatments (carbamazepine for tic douloureux, amantadine for Parkinson's disease, gabapentin for restless legs…). We aimed at examining the contribution of serendipity and observations to functional neurosurgery. Scholarly publications relevant to the history of functional neurosurgery for movement and psychiatric disorders were reviewed, starting from the pre-stereotactic era. The documents were scrutinized with respect to indications for surgery, surgical methods, and brain targets, in view of determining whether serendipitous discoveries and other observations contributed to various functional neurosurgical procedures.
SUMMARY
James Parkinson's observation that tremors disappeared in the arm of a person with shaking palsy after a hemiparetic stroke encouraged neurosurgeons in the first half of the 20th century to perform ablative procedures on central motor pathways. Following a lobotomy performed by Browder that extended too far medially in a psychiatric patient with coexisting Parkinson's disease (PD), it was noted that the Parkinsonian signs improved. This encouraged Russel Meyers to carry out open surgery on the caudate nucleus and basal ganglia in PD. Cooper introduced ligation of the anterior choroidal artery as a treatment for PD following a surgical accident during a pedunculotomy. Cooper later started to perform stereotactic surgery on the ventrolateral thalamus following the pathological finding that an intended pallidal lesion had in fact targeted the thalamus. Leksell discovered the ideal location of a pallidal lesion being in the posteroventral area empirically, long before the advent of the basal ganglia model of PD. Modern Deep Brain Stimulation (DBS) that started in the thalamus for tremor was the result of an observation by Benabid that intraoperative high-frequency stimulation during a thalamotomy reduced tremor. Both the discoveries of the anterior limbic subthalamic nucleus as a DBS target for OCD and the medial forebrain bundle as a DBS target for depression occurred by chance. Hamani and Lozano observed memory flashbacks in a patient who was undergoing DBS for obesity, which led to the discovery of the fornix as a potential DBS target for Alzheimer's disease.
KEY MESSAGES
In the history of functional neurosurgery, serendipity and observations have resulted in discoveries of several procedures, brain targets for lesioning or DBS as well as new clinical surgical indications. In this era of neuromodulation, this technology should be exquisite in allowing potential serendipitous discoveries, provided that clinicians remain both observant and prepared.
Topics: Deep Brain Stimulation; History, 20th Century; Humans; Neurosurgery; Observation; Parkinson Disease; Psychosurgery; Stroke; Tremor
PubMed: 35882210
DOI: 10.1159/000525794 -
Progress in Brain Research 2022It is known that in present time heroin addiction is the most widespread and difficult to treat. It includes two factors: physical and psychological addiction. The vast...
It is known that in present time heroin addiction is the most widespread and difficult to treat. It includes two factors: physical and psychological addiction. The vast majority of patients remained mentally addicted to drugs after physical drug addiction has been eliminated and the organism has been completely detoxed. It is an indomitable desire to take drugs. Neurophysiological mechanisms are in base of psychological dependence. It is similar to those that implement obsessive states (obsessive-compulsive disorders). The central role in these neurophysiological mechanisms is played by limbic system of the brain that provides emotional and motivational behavior of humans (and animals). It was shown that the treatment of medical-resistant forms of obsessive-compulsive disorders requires stereotactic impacts on various structures of the limbic system, including cingulate gyrus. According to literature data, there was several hundred stereotactic effects on the cingulate gyrus in the world. About 1000 stereotactic operations have been performed in our country as a mental addiction of heroin dependent patients' treatment. The efficiency was of about 70%.
Topics: Animals; Gyrus Cinguli; Humans; Limbic System; Patient Selection; Psychosurgery; Substance-Related Disorders; Syndrome
PubMed: 35667808
DOI: 10.1016/bs.pbr.2022.03.006 -
Progress in Brain Research 2022Ethical problems of psychosurgery are debated since 1970s. The issues of informed consent, political and commercial abuses, lacking evidence and needed regulation are...
Ethical problems of psychosurgery are debated since 1970s. The issues of informed consent, political and commercial abuses, lacking evidence and needed regulation are overviewed. New surgical techniques provoke new discussions on goals and limits of psychosurgery.
Topics: Humans; Psychosurgery
PubMed: 35667803
DOI: 10.1016/bs.pbr.2022.03.004 -
Progress in Brain Research 2022Stereotactic cingulotomy and capsulotomy have been used to treat obsessive-compulsive disorders (OCD) and treatment-resistant depression since the 1950s-60s. To date,...
Stereotactic cingulotomy and capsulotomy have been used to treat obsessive-compulsive disorders (OCD) and treatment-resistant depression since the 1950s-60s. To date, these surgical procedures have gained a number of advancements due to progress of neuroimaging and upgrading of stereotactic technique. The effectiveness of operations is related to the restoration of the normal level of limbic regulation in treated patients. In cases of OCD, capsulotomy is somewhat more effective, while cingulotomy has a more favorable safety profile. Moreover, clinical experience shows that these procedures may be efficient for management not only OCD itself, but for obsessive-compulsive symptoms in cases of other mental diseases, such as Tourette syndrome and schizophrenia, thus may be considered in carefully selected patients. An individualized treatment strategy, including staged stereotactic interventions, seems most promising for attainment of the best possible outcomes, and may allow to achieve socialization of 75% of the operated patients with minimal pharmacological support. Other potential stereotactic targets for management of OCD, which selection may depend on detail of clinical manifestation of disease, include thalamic nuclei, nucleus accumbens, globus pallidus, the amygdala, etc., and are currently under active evaluation, and their use is tremendously facilitated by the development of deep brain stimulation techniques. Nevertheless, cingulotomy and capsulotomy still remain highly relevant for treatment of patients with therapy-resistant mental disorders.
Topics: Humans; Imaging, Three-Dimensional; Obsessive-Compulsive Disorder; Psychosurgery
PubMed: 35667796
DOI: 10.1016/bs.pbr.2022.03.010