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Open access

Diplopia associated with loop routing in deep brain stimulation: illustrative case

Yasushi Miyagi and Eiichirou Urasaki

BACKGROUND

Deep brain stimulation (DBS) is a powerful surgical option for drug-resistant movement disorders; however, electromagnetic interference (EMI) from external sources poses a potential risk for implanted electronics.

OBSERVATIONS

A 61-year-old woman with Parkinson’s disease originally had two implantable pulse generators (IPGs) for bilateral subthalamic DBS, which were then replaced with one dual-channel IPG routed in a loop. After the replacement surgery, with the same DBS programming as before the IPG replacement (bipolar setting for right, unipolar setting for left), the patient began to complain of transient paroxysmal diplopia. After multiple attempts to adjust the stimulation parameters, the diplopia was resolved by changing the left unipolar setting to a bipolar setting. At the authors’ institution, before the present case, four other patients had undergone IPG replacement with loop routing. None of these previous patients complained of diplopia; however, two of the four presented with diplopia in an experimental unipolar setting.

LESSONS

Clinicians should be aware that loop-routed circuits may generate distortion of the stimulus field in DBS, even in the absence of external EMI sources.

Open access

Intrathecal baclofen therapy for Lesch-Nyhan disease: illustrative case

Takeshi Satow, Masafumi Ogawa, and Taro Komuro

BACKGROUND

Lesch-Nyhan disease (LND) is a very rare metabolic disorder involving the purine salvage pathway. LND manifests hyperuricemia, self-mutilation, cognitive impairment, and movement disorders such as spasticity and dystonia, whose control is difficult pharmaceutically.

OBSERVATIONS

Intrathecal baclofen (ITB) therapy was received by a 22-year-old male for generalized dystonia. His paroxysmal abnormal dystonic posturing reduced after surgery, making the task of caregivers easier despite the unchanged assignment on the dystonia scale during a follow-up period of 4 years.

LESSONS

ITB may be a safe and feasible option for dystonic symptoms and difficulty with nursing care in patients with LND.

Open access

Trigeminal neuralgia induced by brainstem infarction treated with pontine descending tractotomy: illustrative case

Rachyl M. Shanker, Miri Kim, Chloe Verducci, Elhaum G. Rezaii, Kerry Steed, Atul K. Mallik, and Douglas E. Anderson

BACKGROUND

While cases of trigeminal neuralgia induced by a brainstem infarct have been reported, the neurosurgical literature lacks clear treatment recommendations in this subpopulation.

OBSERVATIONS

The authors present the first case report of infarct-related trigeminal neuralgia treated with pontine descending tractotomy that resulted in durable pain relief after multiple failed surgical interventions, including previous microvascular decompressions and stereotactic radiosurgery. A neuronavigated pontine descending tractotomy of the spinal trigeminal tract was performed and resulted in successful pain relief for a 50-month follow-up period.

LESSONS

While many cases of ischemic brainstem lesions are caused by acute stroke, the authors assert that cerebral small vessel disease also plays a role in certain cases and that the relationship between these chronic ischemic brainstem lesions and trigeminal neuralgia is more likely to be overlooked. Furthermore, neurovascular compression may obscure the causative mechanism of infarct-related trigeminal neuralgia, leading to unsuccessful decompressive surgeries in cases in which neurovascular compression may be noncontributory to pain symptomatology. Pontine descending tractotomy may be beneficial in select patients and can be performed either alone or concurrently with microvascular decompression in cases in which the interplay between ischemic lesion and neurovascular compression in the pathophysiology of disease is not clear.

Open access

Computational hemodynamic analysis of the offending vertebral artery at the site of neurovascular contact in a case of hemifacial spasm associated with subclavian steal syndrome: illustrative case

Keita Tominaga, Hidenori Endo, Shin-ichiro Sugiyama, Shin-ichiro Osawa, Kuniyasu Niizuma, and Teiji Tominaga

BACKGROUND

Hemifacial spasm (HFS) is caused by neurovascular contact along the facial nerve’s root exit zone (REZ). The authors report a rare HFS case that was associated with ipsilateral subclavian steal syndrome (SSS).

OBSERVATIONS

A 42-year-old man with right-sided aortic arch presented with progressing left HFS, which was associated with ipsilateral SSS due to severe stenosis of the left brachiocephalic trunk. Magnetic resonance imaging showed contact between the left REZ and vertebral artery (VA), which had shifted to the left. The authors speculated that the severe stenosis at the left brachiocephalic trunk resulted in the left VA’s deviation, which was the underlying cause of the HFS. The authors performed percutaneous angioplasty (PTA) to dilate the left brachiocephalic trunk. Ischemic symptoms of the left arm improved after PTA, but the HFS remained unchanged. A computational fluid dynamics study showed that the high wall shear stress (WSS) around the site of neurovascular contact decreased after PTA. In contrast, pressure at the point of neurovascular contact increased after PTA.

LESSONS

SSS is rarely associated with HFS. Endovascular treatment for SSS reduced WSS of the neurovascular contact but increased theoretical pressure of the neurovascular contact. Physical release of the neurovascular contact is the best treatment option for HFS.

Open access

Presurgical language mapping in bilingual children using transcranial magnetic stimulation: illustrative case

Savannah K. Gibbs, Stephen Fulton, Basanagoud Mudigoudar, Frederick A. Boop, and Shalini Narayana

BACKGROUND

Presurgical mapping of eloquent cortex in young patients undergoing neurosurgery is critical but presents challenges unique to the pediatric population, including motion artifact, noncompliance, and sedation requirements. Furthermore, as bilingualism in children increases, functional mapping of more than one language is becoming increasingly critical. Transcranial magnetic stimulation (TMS), a noninvasive brain stimulation technique, is well suited to evaluate language areas in children since it does not require the patient to remain still during mapping.

OBSERVATIONS

A 13-year-old bilingual male with glioblastoma multiforme involving the left parietal lobe and deep occipital white matter underwent preoperative language mapping using magnetic resonance imaging-guided TMS. Language-specific cortices were successfully identified in both hemispheres. TMS findings aided in discussing with the family the risks of postsurgical deficits of tumor resection; postoperatively, the patient had intact bilingual speech and was referred for chemotherapy and radiation.

LESSONS

The authors’ findings add to the evolving case for preoperative dual language mapping in bilingual neurosurgical candidates. The authors illustrate the feasibility and utility of TMS as a noninvasive functional mapping tool in this child. TMS is safe, effective, and can be used for preoperative mapping of language cortex in bilingual children to aid in surgical planning and discussion with families.

Open access

Laser ablative treatment of musicogenic epilepsy arising from dominant mesial temporal lobe: illustrative case

Christine Park, Saurabh R. Sinha, and Derek G. Southwell

BACKGROUND

Musicogenic epilepsy (ME) is a rare reflex epilepsy in which seizures are triggered by musical stimuli. Prior descriptions of ME have suggested localization to the nondominant temporal lobe, primarily in neocortex. Although resection has been described as a treatment for ME, other surgical modalities, such as laser ablation, may effectively disrupt seizure networks in ME while incurring comparatively lower risks of morbidity. The authors described the use of laser ablation to treat ME arising from the dominant mesial temporal structures.

OBSERVATIONS

A 37-year-old woman with a 15-year history of drug-resistant ME was referred for surgical evaluation. Her seizures were triggered by specific musical content and involved behavioral arrest, repetitive swallowing motions, and word incomprehension. Diagnostic studies, including magnetic resonance imaging, single-photon emission computed tomography, magnetoencephalography, Wada testing, and stereoelectroencephalography, indicated seizure onset in the left (dominant) mesial temporal lobe. Laser interstitial thermal therapy was used to ablate the left mesial seizure onset zone. The patient was discharged on postoperative day two. At 18-month follow-up, she was seizure-free with no posttreatment neurological deficits.

LESSONS

Laser ablation can be an effective treatment option for well-localized forms of ME, particularly when seizures originate from the dominant mesial temporal lobe.

Open access

Delayed hemorrhage following deep brain stimulation device placement in a patient with Parkinson’s disease and lupus anticoagulant syndrome: illustrative case

Robert B. Walker, Audrey A. Grossen, Christen M. O’Neal, and Andrew K. Conner

BACKGROUND

Treatment options for Parkinson’s disease (PD) include both medical and surgical approaches. Deep brain stimulation (DBS) is a surgical procedure that aims to improve motor symptomatology.

OBSERVATIONS

A 66-year-old White male with a 9-year history of PD presented to the neurosurgery clinic for DBS consideration. On the morning of scheduled surgery, preoperative laboratory test results revealed a prolonged prothrombin time of 50 seconds. Surgery was postponed, and further work-up revealed that the patient had a positive test result for lupus anticoagulant (LA). DBS implantation was performed 2 months later. The first stage of surgery was uneventful. The patient returned 1 week later for the second stage. Postoperatively, the patient exhibited a diminished level of consciousness. Computed tomography revealed left frontal intraparenchymal hemorrhage with surrounding edema, trace subarachnoid hemorrhage, intraventricular hemorrhage, and midline shift.

LESSONS

The authors suspect that the hemorrhage occurred secondary to venous infarct, because LA is associated with a paradoxically increased risk of thrombosis. Although there is no documented association between LA and acute or delayed hemorrhage, this case demonstrates a possible relationship in a patient following DBS placement. More research is needed to confirm an association with coexisting LA with PD and an increased hemorrhage risk in neurosurgical interventions.

Open access

Spinal cord stimulator for the treatment of central neuropathic pain secondary to cervical syringomyelia: illustrative case

Bryan A. Schatmeyer, Rakan Dodin, Michael Kinsman, and David Garcia

BACKGROUND

Central neuropathic pain (CNP) of the cervical and/or thoracic spinal cord has many etiologies, both natural and iatrogenic. Frequently, CNP is medically refractory and requires surgical treatment to modulate the perception of pain. Spinal cord stimulation is a modality commonly used in adults to treat this type of refractory pain; however, it is rarely used in the pediatric population.

OBSERVATIONS

The authors reported a case involving a common pediatric condition, Chiari malformation type I with syrinx, that led to a debilitating complex regional pain syndrome. The associated life-altering pain was successfully alleviated following placement of a spinal cord stimulator.

LESSONS

CNP, or the syndromic manifestations of the pain (complex regional pain syndrome), can alter an individual’s life in dramatic ways. Spinal cord stimulator placement in carefully selected pediatric patients should be considered in these difficult pain treatment paradigms.

Open access

Improvement in sagittal alignment and mechanical low-back pain following deep brain stimulation for Parkinson’s disease: illustrative case

Jaime R. Guerrero, Lokeshwar S. Bhenderu, Khaled M. Taghlabi, Jesus G. Cruz-Garza, Comron Saifi, and Amir H. Faraji

BACKGROUND

Parkinson’s disease (PD) is a common neurogenerative disease marked by the characteristic triad of bradykinesia, rigidity, and tremor. A significant percentage of patients with PD also demonstrate postural abnormalities (camptocormia) that limit ambulation and accelerate degenerative pathologies of the spine. Although deep brain stimulation (DBS) is a well-established treatment for the motor fluctuations and tremor seen in PD, the efficacy of DBS on postural abnormalities in these patients is less clear.

OBSERVATIONS

The authors present a patient with a history of PD and prior lumbosacral fusion who underwent bilateral subthalamic nucleus DBS and experienced immediate improvement in sagittal alignment and subjective relief of mechanical low-back pain.

LESSONS

DBS may improve postural abnormalities seen in PD and potentially delay or reduce the need for spinal deformity surgery.

Open access

Tight adhesions after spinal cord stimulation observed during dorsal root entry zone lesioning for pain after spinal root avulsion: illustrative cases

Yuki Kimoto, Koichi Hosomi, Yuichiro Ohnishi, Takuto Emura, Nobuhiko Mori, Asaya Nishi, Takufumi Yanagisawa, Naoki Tani, Satoru Oshino, Youichi Saitoh, and Haruhiko Kishima

BACKGROUND

Patients often experience strong shooting pains after spinal root avulsion. The efficacy of spinal cord stimulation (SCS) for this type of pain is inconsistent; however, dorsal root entry zone (DREZ) lesioning (DREZ-lesion) has often proven to be an effective treatment modality. The authors report two cases in which DREZ-lesion was performed to treat pain after spinal root avulsion after implantation of SCS, but the operations were challenging due to strong adhesions.

OBSERVATIONS

The authors present two cases of patients with pain after spinal root avulsion in whom SCS implantation was only temporarily effective. Patients complained of persistent and paroxysmal shooting pains in the upper extremities. SCS removal and DREZ-lesion were performed, but adhesions in the epidural and subdural space contacting the leads were strong, making it difficult to expose the DREZ.

LESSONS

Although adhesions around the spinal cord can be caused by trauma, the authors believe that in these cases, the adhesions could have been caused by the SCS leads. There are few previous reports confirming the efficacy of SCS in treating pain after spinal root avulsion; therefore, caution is required when considering SCS implantation.