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Preoperative MRI findings and prediction of diagnostic utility of foramen ovale electrodes

Sarah K. Bick, Marjan S. Dolatshahi, Benjamin L. Grannan, Andrew J. Cole, Daniel B. Hoch, and Emad N. Eskandar

OBJECTIVE

Foramen ovale electrodes (FOEs) are a minimally invasive method to localize mesial temporal seizures in cases in which noninvasive methods are inconclusive. The objective of this study was to identify factors predicting the ability of FOEs to yield a diagnosis in order to determine optimal candidates for this procedure.

METHODS

All cases of diagnostic investigations performed with FOEs at the authors’ institution between 2005 and 2017 were reviewed. FOE investigation was defined as diagnostic if it led to a treatment decision. Demographic and clinical variables for diagnostic and nondiagnostic investigations were compared using a Wilcoxon rank-sum test for continuous variables and Fisher’s exact test for categorical variables.

RESULTS

Ninety-three patients underwent investigations performed with FOEs during the study period and were included in the study. FOE investigation was diagnostic in 75.3% of cases. Of patients who underwent anterior temporal lobectomy following diagnostic FOE evaluation, 75.9% were Engel class I at last follow-up (average 40.1 months). When the diagnostic and nondiagnostic FOE groups were compared, patients who had diagnostic investigations were more likely to be male (57.1% male vs 26.1% in the nondiagnostic group, p = 0.015). They were also more likely to have temporal lesions on preoperative MRI (p = 0.018).

CONCLUSIONS

FOEs are a useful, minimally invasive diagnostic modality resulting in a treatment decision in 75% of cases. Male patients and patients with temporal lesions on MRI may be most likely to benefit from FOE investigation.

In Journal of Neurosurgery Volume 132: Issue 3 (Mar 2020)

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Neuromodulation for restoring memory

Sarah K. B. Bick and Emad N. Eskandar

Disorders of learning and memory have a large social and economic impact in today's society. Unfortunately, existing medical treatments have shown limited clinical efficacy or potential for modification of the disease course. Deep brain stimulation is a successful treatment for movement disorders and has shown promise in a variety of other diseases including psychiatric disorders. The authors review the potential of neuromodulation for the treatment of disorders of learning and memory. They briefly discuss learning circuitry and its involvement in Alzheimer disease and traumatic brain injury. They then review the literature supporting various targets for neuromodulation to improve memory in animals and humans. Multiple targets including entorhinal cortex, fornix, nucleus basalis of Meynert, basal ganglia, and pedunculopontine nucleus have shown a promising potential for improving dysfunctional memory by mechanisms such as altering firing patterns in neuronal networks underlying memory and increasing synaptic plasticity and neurogenesis. Significant work remains to be done to translate these findings into durable clinical therapies.

In Neurosurgical Focus Volume 40 (2016): Issue 5 (May 2016): Neurorestoration: Re-Animating the CNS

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Editorial: Anterior capsulotomy and deep brain stimulation

Emad N. Eskandar

In Journal of Neurosurgery Volume 122 (2015): Issue 5 (May 2015)

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Hoarding symptoms and prediction of poor response to limbic system surgery for treatment-refractory obsessive-compulsive disorder

Clinical article

Andre F. Gentil, Antonio C. Lopes, Darin D. Dougherty, Christian Rück, David Mataix-Cols, Teagan L. Lukacs, Miguel M. Canteras, Emad N. Eskandar, K. Johan Larsson, Marcelo Q. Hoexter, Marcelo C. Batistuzzo, Benjamin D. Greenberg, and Euripedes C. Miguel

Object

Recent findings have suggested a correlation between obsessive-compulsive disorder (OCD) symptom dimensions and clinical outcome after limbic system surgery for treatment-refractory patients. Based on previous evidence that the hoarding dimension is associated with worse outcome in conventional treatments, and may have a neural substrate distinct from OCD, the authors examined a large sample of patients undergoing limbic surgery (40 with capsulotomy, 37 with cingulotomy) and investigated if symptom dimensions, in particular hoarding, could influence treatment outcome.

Methods

Data from 77 patients from 3 different research centers at São Paulo (n = 17), Boston (n = 37), and Stockholm (n = 23) were analyzed. Dimensional Yale-Brown Obsessive Compulsive Scale (Y-BOCS; São Paulo) or Y-BOCS Symptom Checklist scores (Boston and Stockholm) were used to code the presence of 4 well-established symptom dimensions: forbidden thoughts, contamination/cleaning, symmetry/order, and hoarding. Reductions in YBOCS scores determined clinical outcome.

Results

Mean Y-BOCS scores decreased 34.2% after surgery (95% CI 27.2%–41.3%), with a mean follow-up of 68.1 months. Patients with hoarding symptoms had a worse response to treatment (mean Y-BOCS decrease of 22.7% ± 25.9% vs 41.6% ± 32.2%, respectively; p = 0.006), with no significant effect of surgical modality (capsulotomy vs cingulotomy). Patients with forbidden thoughts apparently also had a worse response to treatment, but this effect was dependent upon the co-occurrence of the hoarding dimension. Only the negative influence of the hoarding dimension remained when an ANOVA model was performed, which also controlled for preoperative symptom severity.

Conclusions

The presence of hoarding symptoms prior to surgery was associated with worse clinical outcome after the interventions. Patients with OCD under consideration for ablative surgery should be carefully screened for hoarding symptoms or comorbid hoarding disorder. For these patients, the potentially reduced benefits of surgery need to be carefully considered against potential risks.

In Journal of Neurosurgery Volume 121 (2014): Issue 1 (Jul 2014)

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The incidence of complications in elective cranial neurosurgery associated with dural closure material

Clinical article

Brian P. Walcott, Jonathan B. Neal, Sameer A. Sheth, Kristopher T. Kahle, Emad N. Eskandar, Jean-Valery Coumans, and Brian V. Nahed

Object

Dural closure with synthetic grafts has been suggested to contribute to the incidence of infection and CSF leak. The objective of this study was to assess the contribution of choice of dural closure material, as well as other factors, to the incidence of infection and CSF leak.

Methods

A retrospective, consecutive cohort study of adult patients undergoing elective craniotomy was established between April 2010 and March 2011 at a single center. Exclusion criteria consisted of trauma, bur hole placement alone, and temporary CSF fluid diversion.

Results

Three hundred ninety-nine patients were included (mean follow-up 396.6 days). Nonautologous (synthetic) dural substitute was more likely to be used (n = 106) in cases of reoperation (p = 0.001). Seventeen patients developed a surgical site infection and 12 patients developed a CSF leak. Multivariate logistic regression modeling identified estimated blood loss (OR 1.002, 95% CI 1.001–1.003; p < 0.001) and cigarette smoking (OR 2.198, 95% CI 1.109–4.238; p = 0.019) as significant predictors of infection. Synthetic dural graft was not a predictor of infection in multivariate analysis. Infratentorial surgery (OR 4.348, 95% CI 1.234–16.722; p = 0.024) and more than 8 days of postoperative corticosteroid treatment (OR 3.886, 95% CI 1.052–16.607; p = 0.048) were significant predictors for the development of CSF leak. Synthetic dural graft was associated with a lower likelihood of CSF leak (OR 0.072, 95% CI 0.003–0.552; p = 0.036).

Conclusions

The use of synthetic dural closure material is not associated with surgical site infection and is associated with a reduced incidence of CSF leak. Modifiable risk factors exist for craniotomy complications that warrant vigilance and further study.

In Journal of Neurosurgery Volume 120: Issue null (Jan 2014)

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Lesion analysis for cingulotomy and limbic leucotomy: comparison and correlation with clinical outcomes

Clinical article

Jimmy C. Yang, Daniel T. Ginat, Darin D. Dougherty, Nikos Makris, and Emad N. Eskandar

Object

Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion–symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures.

Methods

T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small.

The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores.

Results

Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens.

Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores.

Conclusions

Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.

In Journal of Neurosurgery Volume 120: Issue null (Jan 2014)

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Pallidal deep brain stimulation for dystonia: a case series

Clinical article

Melita T. Petrossian, Lisa R. Paul, Trisha J. Multhaupt-Buell, Christine Eckhardt, Michael T. Hayes, Ann-Christine Duhaime, Emad N. Eskandar, and Nutan Sharma

Object

Pallidal deep brain stimulation (DBS) is a treatment option for those with early-onset dystonia. However, there are limited data on long-term outcome and treatment complications. The authors report on the short- and long-term effects of pallidal DBS in a cohort of patients with early-onset dystonia.

Methods

Fourteen consecutive pediatric patients with early-onset dystonia were systematically evaluated and treated. The duration of follow-up ranged from 16 to 84 months.

Results

There were no immediate postoperative complications. At last follow-up, 12 of the 14 patients displayed a significant decline in the Burke-Fahn-Marsden Dystonia Rating Scale motor subscale score, with an average decrease of 62% ± 8.4%. The most common hardware complication was lead fracture (14.3%).

Conclusions

These data provide further evidence that DBS is a safe and effective treatment for those with earlyonset dystonia.

In Journal of Neurosurgery: Pediatrics Volume 12 (2013): Issue 6 (Dec 2013)

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Introduction: Evolving trends in movement disorder surgery

Sameer A. Sheth, Emad N. Eskandar, and Mark A. Liker

In Neurosurgical Focus Volume 35 (2013): Issue 5 (Nov 2013): Controversies in Movement Disorder Surgery

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Letter to the Editor: Obsessive-compulsive disorder and cingulotomy

Vengalathur Ganesan Ramesh and Chandramouli Balasubramanian

In Journal of Neurosurgery Volume 119 (2013): Issue 2 (Aug 2013): Pages 257-A589

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Editorial: Obsessive-compulsive disorder

Nir Lipsman and Andres M. Lozano

In Journal of Neurosurgery Volume 118 (2013): Issue 3 (Mar 2013)