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PubMed2005

Motor cortex stimulation for central and neuropathic facial pain: a prospective study of 10 patients and observations of enhanced sensory and motor function during stimulation.

OBJECTIVE: For more than a decade, motor cortex stimulation has been used to treat difficult central and peripheral neuropathic pain syndromes. This prospective study uses the McGill Pain Questionnaire, a visual analog scale (VAS) score, and an inventory of drug consumption to review the results of treating patients with trigeminal neuropathic pain via motor cortex stimulation. METHODS: Ten patients underwent motor cortex stimulation between 1999 and 2002. Implantation was performed via intraoperative neuronavigation and cortical mapping for stimulation site targeting. Nine patients had trigeminal neuropathic pain from postherpetic neuralgia, surgical injury, or unknown cause, and one patient had pain of central origin. Patients were evaluated with multimodality scales before, immediately after, and at designated intervals after surgery. Eight patients underwent permanent implantation after a trial evaluation. In two patients, the stimulating electrodes were removed after an unsuccessful trial. One of these patients had a lateral medullary infarct leading to central pain, and in another patient, there was no explanation for the pain. RESULTS: The average duration of pain before surgery was 6 years. Postoperatively, there was an 88% rate of immediate pain relief (>50% on VAS) and a 75% rate of pain relief at mean follow-up of 10 months (range, 3-24 mo). Mean preoperative McGill Pain Questionnaire total pain rating index was 57 (higher than that observed in causalgia) for patients who did not undergo implantation and 53 for those who underwent implantation. Mean McGill Pain Questionnaire pain rating index at mean follow-up of 10 months was 24 (55% decrease). Mean VAS preoperatively was 9 in patients with stimulator implants and 8 in those whose stimulator was removed after the trial. Immediate postoperative mean VAS score was 1. This score stabilized 3 months after surgery. Patients with implanted stimulators reduced their pain medication dose by a mean of more than 50%. Three patients with facial weakness and sensory loss regained both strength and discriminative sensation during stimulation. In another patient, dysarthria improved. In a review of the literature, 29 (76%) of 38 patients with neuropathic facial pain treated with motor cortex stimulation achieved greater than 50% pain relief. CONCLUSION: These results provide further support for the use of motor cortex stimulation in facial neuropathic pain and document pain improvement as measured by multidimensional scales. Observations of motor and sensory improvements during stimulation suggest that stimulation alters cortical plasticity and inhibits thalamic hyperactivity.

Adult↗

PubMed2005

Robotic long-distance telementoring in neurosurgery.

OBJECTIVE: To test the feasibility of long-distance telementoring in neurosurgery by providing subspecialized expertise in real time to another neurosurgeon performing a surgical procedure in a remote location. METHODS: A robotic telecollaboration system (Socrates; Computer Motion, Inc., Santa Barbara, CA) capable of controlling the movements of a robotic arm, of handling two-way video, and of audio communication as well as transmission of neuronavigational data from the remote operating room was used for the telementoring procedures. Four integrated services digital network lines with a total speed of transmission of 512 kilobytes per second provided telecommunications between a large academic center (Halifax, Nova Scotia) and a community-based center (Saint John, New Brunswick) located 400 km away. RESULTS: Long-distance telementoring was used in three craniotomies for brain tumors, a craniotomy for an arteriovenous malformation, a carotid endarterectomy, and a lumbar laminectomy. There were no surgical complications during the procedures, and all patients had uneventful outcomes. The neurosurgeons in the remote location believed that the input from the mentors was useful in all of the cases and was crucial in the removal of a mesial temporal lobe glioma and resection of an occipital arteriovenous malformation. CONCLUSION: Our initial experience with long-distance robotic-assisted telementoring in six cases indicates that telementoring is feasible, reliable, and safe. Although still in its infancy, telementoring has the potential to improve surgical care, to enhance neurosurgical training, and to have a major impact on the delivery of neurosurgical services throughout the world.

Academic Medical Centers↗

PubMed2005

Volumetric image guidance for motor cortex stimulation: integration of three-dimensional cortical anatomy and functional imaging.

OBJECTIVE: Epidural electrical stimulation of the motor cortex is a promising treatment option in patients with intractable pain. Varying rates of success in long-term pain relief have been attributed to inaccurate positioning of the electrode array, partly because the sulcal landmarks are not directly visualized. We describe an integrated protocol for precise electrode placement, combining functional image guidance and intraoperative electrical stimulation in the awake patient. METHODS: Volumetric rendering of a three-dimensional (3-D) magnetic resonance data set was used to visualize the cortical surface and to superimpose functional magnetic resonance imaging data in six patients with refractory chronic pain. The intraoperative positioning of the quadripolar electrode array was monitored by functional 3-D image guidance. Continuous electrophysiological monitoring and clinical assessment of the motor effects complemented the procedure. RESULTS: Volumetrically rendered 3-D images were advantageous for the location of the burr hole over the perirolandic area by revealing individual cortical morphological features (e.g., the hand knob) and function at the same time. The exact position of the electrodes was verified reliably by cortical stimulation. No complications were observed throughout the procedures. CONCLUSION: The combination of 3-D functional neuronavigation, intraoperative electrical stimulation, and continuous motor output monitoring in awake patients provides optimal information for the identification of the appropriate somatotopic area of motor cortex. This combined imaging and stimulation approach for electrode positioning offers a safe and minimal invasive strategy for the treatment of intractable chronic pain in selected patients.

Adult↗

PubMed2005

Cushing's disease in children and adolescents: 20 years of experience in a single neurosurgical center.

OBJECTIVE: This is a retrospective analysis of 25 consecutive pediatric patients with Cushing's disease who underwent transsphenoidal surgery performed by a single neurosurgeon in a specialist center during a 20-year period. This article discusses the presentation of Cushing's disease, the endocrinological investigation with particular reference to bilateral inferior petrosal sinus sampling (BIPSS), the operative management with reference to specific pediatric difficulties of the transsphenoidal approach and the use of intraoperative image guidance, and the analysis of these cases as regards postoperative complications and outcomes of this rare condition in young patients. METHODS: All patients underwent detailed endocrine investigation and imaging in the form of computed tomography and/or magnetic resonance imaging. BIPSS was performed in 19 patients (76%), with successful lateralization of the side of the microadenoma in 14 (74%) and prediction of a central tumor in four (94% total prediction rate). Surgical removal was via the sublabial, paraseptal, transsphenoidal route. RESULTS: There were 15 male and 10 female patients, with a mean age of 13.4 years (range, 6.6-17.8 yr). Weight gain was the most common presentation (100%), and then growth impairment (96%), fatigue and skin changes (64%), and hypertension (32%). Postoperative complications included growth hormone deficiency (36%), transient diabetes insipidus (12%), panhypopituitarism (4%), and transient cerebrospinal fluid rhinorrhea (4%). The median follow-up period was 59.5 months (range, 6-126 mo). Overall, 15 patients (60%) achieved surgical cure or remission, of which 14 outcomes were obtained using the results of BIPSS. Ten patients (40%) required postoperative radiotherapy to achieve "remission." There were no cases of meningitis, no neurological deficits, no reoperations, and no mortality. CONCLUSION: Cushing's disease in children and adolescents is a rare illness. The accurate preoperative localization of the adenoma is essential for achieving good results. In this series, BIPSS was far more accurate in localizing the adenoma than computed tomography or magnetic resonance imaging. Imaging, however, is useful for the exclusion of other intracranial problems. Transsphenoidal surgery was safe and efficacious in achieving cure in the majority of cases. The challenge of transsphenoidal surgery in this age group is the small pituitary fossa and the absence of sphenoid sinus aeration in some cases. We found the use of intraoperative neuronavigation to be an excellent aid in overcoming such anatomic difficulties.

Adolescent↗

PubMed2005

Current treatment approaches to surgery for brain metastases.

The role for surgical treatment of brain metastases continues to evolve. Data have demonstrated survival and quality-of-life benefits for surgical treatment of appropriate lesions in selected patients. With improvements in surgical technique, along with therapeutic improvements in the management of systemic cancers, more patients are now eligible for surgical resection. Selection of patients for surgical treatment depends on performance status, size, location, and number of brain lesions, as well as the status of systemic disease. Although surgery has traditionally been performed for patients with a single brain metastasis, an increasing number of patients with multiple brain metastases may also be treated surgically. Surgical techniques, such as image guidance, intraoperative ultrasound, functional neuronavigation, cortical mapping, and awake craniotomies, have expanded the scope of lesions that can be removed safely to optimize outcomes. Seizures, peritumoral edema, and venous thromboembolic disease all contribute significantly to surgical morbidity and mortality and thus require aggressive treatment around the time of the surgical procedure to improve the quality of life and maximize survival time.

Brain Neoplasms↗

PubMed2006

A modification of the Mayfield horseshoe headrest allowing pin fixation and cranial immobilization in infants and young children.

OBJECTIVE: Pin fixation and rigid immobilization of the head is desirable in many neurosurgical procedures. However, these techniques are associated with complications in infants and young children. A simple modification of a commonly used cranial fixation system allows rigid, safe immobilization of the head in infants and children. INSTRUMENTATION: A standard Mayfield horseshoe headrest and cranial fixation system was adapted to allow simultaneous use of the headrest and three-point pin fixation. The system is compatible with most neuronavigational systems. RESULTS: The combined horseshoe and pin system was used successfully in more than 30 patients ranging in age from 6 months to 14 years. No complications were encountered. CONCLUSIONS: Rigid immobilization is achievable in the pediatric population, facilitating intracranial and frameless stereotaxy procedures.

Adolescent↗

PubMed2006

Neuroendoscopic management of symptomatic septum pellucidum cysts.

OBJECTIVE: Ten rare cases of symptomatic septum pellucidum cysts in patients who underwent endoscopic fenestration are described. The approaches and techniques used in the management of these cysts and the endoscopic surgical indications are discussed. CLINICAL PRESENTATION: In the past 5 years, 10 patients (age range, 3-60 yr) with symptomatic septum pellucidum cysts underwent neuroendoscopic fenestration. The most common symptom was intermittent headache (seven patients) accompanied by dizziness, vomiting, and epileptic seizures. Two patients presented with epileptic seizures. One patient presented with abnormally increased head circumference. Magnetic resonance imaging scans of 10 patients showed septum pellucidum cysts, two with hydrocephalus, and two with pituitary microadenoma. INTERVENTION: All 10 patients underwent endoscopic fenestration with a rigid endoscope via a frontal approach. Eight cases were performed freehand. Two cases were assisted by a frameless neuronavigation system. Postoperatively, the mass effect of the cysts and the symptoms resolved immediately, and computed tomographic or magnetic resonance imaging scans showed significant decrease in the cyst size and no recurrence during follow-up. Ventricular sizes in the two patients with hydrocephalus were normal. CONCLUSION: Neuroendoscopic pellucidotomy could be an effective, safe, and convenient therapeutic method for symptomatic septum pellucidum cysts. This approach might provide communication between the cyst and the ventricular system, thus avoiding shunting or craniotomy. We consider that it is appropriate to use the rigid endoscope via the frontal approach. It is helpful to fill the ventricles with lactated Ringer's solution and leave an external drain after surgery.

Adolescent↗

PubMed2006

"Target bypass": a method for preoperative targeting of a recipient artery in superficial temporal artery-to-middle cerebral artery anastomoses.

OBJECTIVE: To introduce a method for preoperative targeting of a proper recipient artery in superficial temporal artery-to-middle cerebral artery anastomosis. METHODS: Six operations for superficial temporal artery-to-middle cerebral artery anastomosis in four patients with moyamoya disease or moyamoya-like disease and two operations in two patients with atherosclerotic cerebrovascular occlusive disease accompanied by coronary artery stenosis were performed using our method. Before surgery, a 3-Tesla magnetic resonance imaging study was performed with axial T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient-echo sequences and three-dimensional time-of-flight magnetic resonance angiography. Data on quantitative regional cerebral blood flow were obtained by iodine-123-labeled N-isopropyl-iodoamphetamine single-photon emission computed tomography or positron emission computed tomography. The magnetic resonance angiography and regional cerebral blood flow data sets were registered with the magnetization-prepared rapid acquisition gradient-echo data set by means of the coregistration function of the SPM2 software. We examined the arteries located on or near the cortex where the regional cerebral blood flow had significantly decreased and used the coregistered data set and MRIcro software to select the cortical artery with the largest diameter as the target recipient artery. At the surgery, the data sets were applied to the neuronavigation system and the actual site of the target was confirmed in the operation before scalp incision. The superficial temporal artery was anastomosed with the target through a small craniotomy. RESULTS: Successful bypass surgery to the target was confirmed in all cases. CONCLUSION: The "target bypass" method might be effective for cases with moyamoya disease or for cases requiring surgery through a small craniotomy.

Adult↗

PubMed2003

Motor functional MRI for pre-operative and intraoperative neurosurgical guidance.

Functional MRI (fMRI) may provide a means of locating areas of eloquent cortex that can be used to guide neurosurgeons in their quest to maximize intracerebral tumour resection whilst minimizing post-procedural neurological deficits. This work aimed to develop and provide an initial assessment of such a technique. 19 patients with mass lesions close to the primary motor cortex underwent fMRI at 1.5T. A single shot echo planar technique was used to acquire data corresponding to right and left hand movement. Resultant activation maps were used to aid pre-surgical planning. Data was used in conjunction with an intraoperative navigation system in 13 cases. Activation was attributed to primary motor, primary somatosensory or supplementary motor cortex in 17 of 19 subjects. No permanent changes in motor deficit were detected post surgery. The additional information provided by fMRI, particularly when incorporated into a neuronavigation guided craniotomy, was deemed highly valuable to the neurosurgeon as it enabled safe resection of tumour in anatomical locations previously deemed to be too high risk for safe resection using conventional (non-fMRI-guided) technique. This observation is reinforced by the fact that no patients suffered permanent neurological deficit after radical tumour debulking (surgical estimates >90% tumour resection).

Adolescent↗

PubMed2005

Treatment of pituitary tumors: surgery.

Following a century of technical developments and refinements, a variety of standard operation techniques to date are available for the surgical treatment of pituitary tumors. The vast majority of the lesions can be dealt with satisfactorily utilizing transsphenoidal approaches. The goal of surgical treatment is rapid eradication of the tumor mass, decompression of visual pathways, and elimination of hormonal oversecretion while preserving the normal gland and avoiding potential surgical complications. The tumor's size, extension, and configuration and the magnitude of hormonal oversecretion, are the essential factors that decide whether all the goals can be reached. Another important factor is the individual skill and experience of the surgeon. Still, several lesions that are mainly developed outside of the sella require transcranial approaches, of which the pterional and subfrontal routes are the most widely used. With microsurgical techniques and standard approaches, mortality is far below 1% and morbidity is remarkably low. The most favorable surgical results are obtained with microadenomas, which in the MR image are depicted as distinct low intensity lesions. Only recently has the recovery of pituitary function following surgery been convincingly demonstrated. With the extended transsphenoidal approaches, lesions become accessible that previously have been considered contraindications for transsphenoidal surgery. The introduction of new technical gadgets such as neuronavigation, endoscopy, and intraoperative imaging open new avenues and, even more, widen the spectrum of accessible lesions. Indications for surgery, the preoperative workup, surgical techniques, results, limitations, and new technical developments are briefly reviewed in this article.

Adenoma↗

PubMed1996

Modified petrosal approach using cosmetic osteoplastic craniotomy with NEURO-SAT guidance.

The petrosal approach has become a routine procedure for petroclival lesions, but there are some disadvantages such as the time-consuming craniotomy during surgery and depressed deformity of the mastoid area after surgery. To solve these disadvantages, we modified the petrosal approach. Before surgery, the three-dimensional points of the sigmoid sinus and semicircular canals are calculated on computed tomography scan and are input to a computer. A single temporooccipital bone flap is made, and the outer table of bone overlying the mastoid is preserved by forming a narrow groove with a small air drill and cutting the outer table with a chisel. After removing these two free bone flaps, mastoidectomy is performed guided by NEURO-SAT (neuronavigation by computer-assisted frameless stereotaxy). The mastoid bone can be drilled out safely and quickly. The two bone flaps are connected and replaced at the end of the procedure. Osteoplastic petrosal craniotomy guided by NEURO-SAT can achieve a quick craniotomy and satisfactory cosmetic result.

Abducens Nerve↗

PubMed1998

Intracranial cavernomas: indications for and results of surgery.

Between April 1991 and April 1997, 46 patients were treated in our department presenting with intracranial cavernomas. Initial symptoms were focal seizures, bleeding episodes, and/or headaches. Mean age was 41 year (range 9 to 68 years). There were 24 female and 22 male patients. Computed tomography and magnetic resonance imaging were performed in order to establish the diagnosis, angiography was only indicated when the hemorrhaged area was so close to the subarachnoid space in the vicinity of the basal cisterns that an aneurysm had to be ruled out. Aggressive indication for surgery also in brainstem cavernomas was based on the natural history of the lesion, since the majority of patients presenting with intracranial bleeding had suffered several (up to six) episodes of previous hemorrhages. Patients' clinical status upon admission and accessibility of the cavernoma were taken into account for planning the operation. The operative planning and approach were greatly facilitated by using a neuronavigational device and intraoperative electrophysiological monitoring particularly in cavernomas located in the brainstem, thalamus, and medulla oblongata. Surgical removal of the lesions resulted in a new permanent neurological deficit only in two patients (4%). These data show that patients benefit from modern neurosurgical techniques in contrast to conservative approach in this disease of rather prolonged natural course.

Adolescent↗

PubMed1999

Spinal instrumentation for unstable C1-2 injury.

Seventeen patients with unstable C1-2 injuries were treated between 1990 and 1997. Various methods of instrumentation surgery were performed in 16 patients, excluding a case of atlantoaxial rotatory fixation. Posterior stabilization was carried out in 14 cases using Halifax interlaminar clamp, Sof'wire or Danek cable, or more recently, transarticular screws. Transodontoid anterior screw fixation was performed in four cases of odontoid process fractures, with posterior instrumentation in two cases because of malunion. Rigid internal fixation by instrumentation surgery for the unstable C1-2 injury avoids long-term application of a Halo brace and facilitates early rehabilitation. However, the procedure is technically demanding with the risk of neural and vascular injuries, particularly with posterior screw fixation. Sagittal reconstruction of thin-sliced computed tomography scans at the C1-2 region, neuronavigator, and intraoperative fluoroscopy are essential to allow preoperative surgical planning and intraoperative guidance.

Adolescent↗

PubMed2000

Primary thumb sensory cortex located at the lateral shoulder of the inverted omega-shape on the axial images of the central sulcus.

Useful landmarks on magnetic resonance (MR) images were identified for preoperative prediction of the relationship of a tumor to the primary sensory cortex of the thumb. Functional MR (fMR) imaging and magnetoencephalography were used to retrospectively localize the hand-digit sensorimotor area in four patients who underwent tumor resection around the central sulcus with intraoperative neurophysiological mapping. fMR imaging revealed the hand-digit motor cortex in the so-called "precentral knob" inside the characteristic inverted-omega on axial MR images. Equivalent current dipoles of the N20 m response in somatosensory evoked fields (SEFs) of the thumb, median nerve, and ulnar nerve stimuli were localized at the lateral portion of the inverted omega-shape from the lateral to medial directions. The SEF-based thumb sensory cortex was verified by intraoperative functional mapping with a neuronavigation system. The hand-digit somatosensory cortices were localized at the lateral shoulder of the inverted-omega, in the lateral anterior inferior position to the hand-digit motor cortices in the precentral knob. Axial MR imaging can provide useful preoperative planning information for the surgical treatment of tumors within or adjacent to the motor-somatosensory cortex.

Adult↗

PubMed2006

Surgical treatment of non-ruptured giant occipital arteriovenous malformations with frequent migraine-like headache.

Two patients with giant occipital arteriovenous malformation (AVM) underwent microsurgical treatment among 294 patients with intracranial AVM treated between 1981 and 2004. The patients were aged 52 and 65 years and showed common symptoms consisting of long-term frequent migraine-like headaches with visual aura and recent homonymous hemianopia. Common neuroimaging findings were abundant dural feeders plus feeders from the posterior, middle, and anterior cerebral arteries, and deep drainers to the galenic system. Both patients underwent preoperative staged embolization and total microsurgical removal of the nidus with a neuronavigation system. Both patients returned to ordinary life without the need for assistance. These findings emphasize that giant occipital AVM, even if unruptured, is surgically treatable with acceptable morbidity.

Aged↗

PubMed2003

Model of surgical procedures for multimodal image-guided neurosurgery.

OBJECTIVE: Improvement of the planning stage of image-guided surgery requires a better anticipation of the surgical procedure and its anatomical and functional environment. This anticipation should be provided by acquisition of multimodal medical images of the patient and by a better understanding of surgical procedures. In this paper, we propose improvements to the planning and performance of multimodal image-guided neurosurgery through the use of information models related to neurosurgical procedures. MATERIALS AND METHODS: A new generic model of surgical procedures is introduced in the context of multimodal image-guided craniotomies. The basic principle of the model is to break down the surgical procedure into a sequence of steps defining the surgical script. In the model, a step is defined by an action. The model assigns to each surgical step a list of image entities extracted from multimodal preoperative images (i.e., anatomical and/or functional images) which are relevant to the performance of that particular step. A semantic validation of the model was performed by instantiating the model entities for 29 surgical procedures. RESULTS: The resulting generic model is described by a UML class diagram and a textual description. The validation showed the relevance of the model, confirming the main underlying assumptions. It also provided some leads to improve the model. CONCLUSION: While further validation is needed, the initial benefits of this approach can already be outlined. It should add real value to the different levels of image-guided surgery, from preprocessing to planning, as well as during surgery. Models of surgical procedures can manage image data according to the surgical script, which should lead to better anticipation of surgery through the development of simulation tools. Furthermore, the models may improve the performance of surgery using microscope-based neuronavigation systems by making it possible to adapt both visualization and interaction features of multimodal preoperative images according to the model.

Humans↗

PubMed2003

Remote computing environment compensating for brain shift.

OBJECTIVE: Anatomical and functional image data become invalid during an operation due to brain shift. Compensation is achieved by using intraoperative imaging to update anatomical information. To accelerate the registration and visualization of pre- and intraoperative image data, the presented work focuses on remote computing capabilities. The underlying framework efficiently combines local desktop computers and remote high-end graphics workstations exploiting expensive hardware. METHODS: By performing all computations on the remote computer, the MR volumes are rigidly aligned via voxel-based registration. Using graphics hardware for acceleration, all interpolation operations are performed with 3D texture-mapping hardware. A new approach then transforms functional markers from preoperative measurements to the intraoperative situation using an automatic tracking algorithm to identify corresponding sulci. Communicating Java viewers are suggested for analyzing the results interactively on a local computer, with all calculations being performed exclusively on the remote computer. RESULTS: The suggested approach was successfully applied in 5 cases using MR data containing functional markers of MEG and fMRI measurements identifying eloquent brain areas. Remote large-scale graphics hardware was thereby efficiently made available for fast registration and interactive direct volume rendering in neurosurgery. CONCLUSION: Overall, the presented framework demonstrates efficient access of expensive high-end hardware remotely controlled by thin clients, and further emphasizes the need to compensate for brain shift in functional neuronavigation.

Brain↗

PubMed2003

Fast and adaptive finite element approach for modeling brain shift.

OBJECTIVE: In this paper we introduce a finite element-based strategy for simulation of brain deformation occurring during neurosurgery. The phenomenon, known as brain shift, causes a decrease in the accuracy of neuronavigation systems that rely on preoperatively acquired data. This can be compensated for with a computational model of the brain deformation process. By applying model calculations to preoperative images, an update within the operating room can be performed. METHODS: One of the crucial concerns in the context of developing a physical-based model is the choice of governing equations describing the physics of the phenomenon. In this work, deformation of brain tissue is expressed in terms of a 3D consolidation model for a linearly elastic and porous fluid. The next crucial issue is ensuring stable calculations within the chosen model. For this purpose, we developed a special technique for generating the underlying geometry for the simulation. With this technique an unstructured grid consisting of regular tetrahedra is created, whereupon time-dependent finite element simulation is performed in an adaptive manner. RESULTS: We applied our algorithm to preoperative MR scans and investigated the value of the method. Due to the adaptivity of the method, only 5-10% of the computing time was needed as compared to traditional finite element approaches based on a uniformly subdivided grid. The results of the experiments were compared to the corresponding intraoperative MR scans. A close match between the computed deformation of the brain and the displacement resulting from the intraoperative data was observed. CONCLUSION: A model-based approach for the simulation of brain shift is presented. In this computational model the brain tissue is described as an elastic and porous material using Biot consolidation theory. Validating experiments conducted with MR data provided promising results.

Algorithms↗