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Open access

Deep brain stimulation in Latin America in comparison with the US and Europe in a real-world population: indications, demographics, techniques, technology, and adverse events

Adriana Lucia Lopez Rios, Fabián Piedimonte, Gabriel J. Arango, Manoel J. Teixeira, Alfonso Arellano-Reynoso, Griselda Del Carmen César, Hans Carmona, Daniel Ciampi de Andrade, Carlos Aníbal Restrepo-Bravo, Jose Miguel Gloria Escobar, Hui Xiong, Ricardo Martínez, and Todd Weaver

OBJECTIVE

The aim of this study was to provide geographic comparisons of deep brain stimulation (DBS) procedures in Latin America with the US and Europe regarding primary indications, demographic information, clinical and device-related adverse events, technology used, and patient outcomes using the Medtronic Product Surveillance Registry data as of July 31, 2021.

METHODS

Two thousand nine hundred twelve patients were enrolled in the registry (2782 received DBS and 1580 are currently active). Fourteen countries contributed 44,100 years of device experience to the registry. DBS centers in Latin America are located in Colombia (n = 3), Argentina (n = 1), Brazil (n = 1), and Mexico (n = 1). Fisher’s exact test was used to compare the difference in proportions of categorical variables between regions. The Wilcoxon signed-rank test was used for the EQ-5D index score change from baseline to follow-up.

RESULTS

The most common indication for DBS was Parkinson’s disease across all regions. In Latin America, dystonia was the second most common indication, compared to essential tremor in other regions. There was a striking finding with respect to age—patients were an average of 10 years younger at DBS implantation in Latin America. This difference was most likely due to the greater number of patients with dystonia receiving the device implants. The intraoperative techniques were quite similar, showing the same level of quality and covering the main principles of the surgeries with some variations in the brand of frames, planning software, and microrecording systems. Rechargeable batteries were significantly more common in Latin America (72.37%) than in the US (6.44%) and Europe (9.9%). Staging of the DBS procedure differed, with only 11.84% in Latin America staging the procedure compared with 97.58% and 34.86% in the US and Europe, respectively. The EQ-5D score showed significant improvements in all regions during the first 6–12 months (p < 0.0001). However, the 24-month follow-up only showed an improvement in the scale for Latin America (p < 0.0001).

CONCLUSIONS

DBS was performed in Latin America with similar indications, techniques, and technology as in the US and Europe. Important differences were found, with Latin America implementing more regular use of rechargeable devices, including younger patients at the time of surgery, and showing more sustained quality of life improvements at 24 months of follow-up. The authors hypothesize that these disparities stem from differences in resources among regions. However, more studies are needed to standardize DBS practice across the world to improve patients’ quality of life and provide high-quality care.

Open access

Complete encasement of the radial nerve by a giant lipoma: illustrative case

Eugene S Bah, Damiano G Barone, and Robert J Spinner

BACKGROUND

Among the spectrum of adipose lesions associated with peripheral nerves, complete circumferential encasement of the nerve by the lesion is a very rare entity. The authors report the first case of a giant lipoma that completely and circumferentially encased the radial nerve.

OBSERVATIONS

A 57-year-old woman presented with a large left-arm mass that she had noticed over a year following significant weight loss. She had hypersensitivity and dysesthesias in the left posterior arm but no weakness or other symptoms. Magnetic resonance imaging of the left upper limb demonstrated a large lipoma completely encasing the radial nerve, originating at the level of the spiral grove proximally and extending distally to the lateral epicondyle. The lesion was completely resected at surgery with total preservation of radial nerve function.

LESSONS

Lipomas encasing peripheral nerves can be difficult to manage while preserving function. This case adds to the intriguing spectrum of adipose lesions associated with peripheral nerves.

https://thejns.org/doi/10.3171/CASE24148

Open access

Endoscopic endonasal optic nerve decompression in children younger than 2 years old with congenital optic canal stenosis: illustrative cases

Peter H Yang, John S Schneider, Michael R Chicoine, Albert H Kim, and David D Limbrick Jr

BACKGROUND

Congenital optic canal stenosis causing compressive optic neuropathy is a rare disorder that presents unique diagnostic and treatment challenges. Endoscopic endonasal optic nerve decompression (EOND) has been described for optic nerve compression in adults and adolescents but has never been reported for young children without pneumatized sphenoid sinuses. The authors describe preoperative and intraoperative considerations for three patients younger than 2 years of age with congenital optic canal stenosis due to genetically confirmed osteopetrosis or chondrodysplasia.

OBSERVATIONS

Serial ophthalmological examinations, with a particular focus on object tracking ability, fundoscopic examination, and visual evoked potential trends in preverbal children, are important for detecting progressive optic neuropathy. The lack of pneumatization of the sphenoid sinus presents unique challenges and requires the surgical creation of a sphenoid sinus with the use of neuronavigation to determine the limits of bony exposure given the lack of easily identifiable anatomical landmarks such as the opticocarotid recess. There were no perioperative complications.

LESSONS

EOND for congenital optic canal stenosis is safe and technically feasible even given the lack of pneumatization of the sphenoid sinus in young patients. The key operative step is surgically creating the sphenoid sinus through careful bony removal with the aid of neuronavigation.

https://thejns.org/doi/10.3171/CASE23559

Open access

Enlarging neurenteric cyst at the craniocervical junction with a fluid-fluid level on magnetic resonance imaging: illustrative case

Toshihide Takahashi, Kiyoyuki Yanaka, Hitoshi Aiyama, Minami Saura, Michihide Kajita, Nobuyuki Takahashi, Kuniyuki Onuma, and Eiichi Ishikawa

BACKGROUND

Neurenteric cysts are relatively rare benign congenital intracranial cystic lesions that enlarge rarely and very slowly. The authors present a case of an enlarging neurenteric cyst at the craniocervical junction with a fluid-fluid level on magnetic resonance imaging (MRI).

OBSERVATIONS

A 34-year-old man with no significant medical history underwent head MRI to investigate mild headaches. An incidental cystic lesion, approximately 8 mm in diameter, was revealed at the craniocervical junction. Serial follow-up MRI showed cyst enlargement with a fluid-fluid level. Four years later, the cyst reached a size of 15 mm and was surgically removed. The cyst contained cloudy fluid with a high protein concentration, without any bleeding or tissue fragments. Pathological examination confirmed the diagnosis of a neurenteric cyst. The patient recovered well, was discharged home, and has remained recurrence free for 2 years.

LESSONS

The growth dynamics of the relatively rapidly expanding neurenteric cyst at the craniocervical junction were monitored over time using MRI. This cyst exhibited the distinctive feature of a fluid-fluid level as it enlarged. Investigating the mechanisms underlying fluid-fluid level formation may offer novel insights into the pathogenesis of cyst enlargement.

https://thejns.org/doi/10.3171/CASE24180

Open access

Facilitating complete resection of intrinsic motor cortex glioma with titration of high-frequency cortico-subcortical mapping train count informed by navigated transcranial magnetic stimulation: illustrative case

Ryan P Hamer and Adrian J Praeger

BACKGROUND

The dilemma of neuro-oncological surgery involving suspected eloquent cortex is to maximize the extent of resection while minimizing neurological morbidity, referred to as the “onco-functional balance.” Diffuse lower-grade gliomas are capable of infiltrating or displacing neural function within cortical regions and subcortical white matter tracts, which can render classical anatomic associations of eloquent function misleading.

OBSERVATIONS

This study employed presurgical navigated transcranial magnetic stimulation (nTMS) to determine the motor eloquence of a diffuse lower-grade glioma at the superior frontal gyrus extending and intrinsic to the primary motor cortex in a 45-year-old female. Positive nTMS findings were confirmed intraoperatively with high-frequency direct cortico-subcortical stimulation (HF-DCS). Modification of the HF-DCS train count from train-of-five to train-of-two permitted resection beyond classic anatomical boundaries and conventional HF-DCS safe stopping criteria.

LESSONS

Anatomical correlates of function can inaccurately inform the surgical management of diffuse lower-grade glioma, which represents the utmost opportunity for progression-free survival. Integrating an individually tailored nTMS-DCS surgical strategy contributed to complete resection, negating the requirement for adjuvant therapy. Serial nTMS follow-up may assist with the characterization of tumor-induced functional reorganization.

https://thejns.org/doi/10.3171/CASE24197

Open access

Pituitary germinoma after resection of a mature third ventricular teratoma: illustrative case

Tim J Hallenberger, Emma von Seth, Michel Roethlisberger, Raphael Guzman, and Jehuda Soleman

BACKGROUND

Metachronous intracranial germ cell tumors (iGCTs)—unrelated, histologically different iGCTs occurring at different time points—occurring within the same patient remain a rarity. Herein, the authors report such a case and discuss the literature and potential pathophysiological mechanisms leading to this phenomenon.

OBSERVATIONS

A 9-year-old boy presented with new-onset impaired balance, headaches, nausea, visual disturbances, and left facial paresis. Magnetic resonance imaging (MRI) scans revealed a suspected pineal region teratoma originating from the pineal gland with consecutive obstructive hydrocephalus. A mature teratoma was diagnosed and resected. Postoperative recovery was good, and the patient could return to his normal daily activities. However, a new, slowly progressive lesion in the sellar region with an enlarged infundibular stalk was detected on follow-up MRI 3.5 years after initial pineal region teratoma resection. Biopsy revealed a newly developed pure germinoma. The patient was treated with radiotherapy plus chemotherapy and remained relapse free at the last follow-up. Sixteen other cases have reported a surgically resected primary mature teratoma, wherein patients developed metachronous germinomas during follow-up. Different theories try to elaborate this phenomenon, yet none can completely account for it.

LESSONS

Although rare, metachronous iGCT is a phenomenon neurosurgeons should be aware of. In patients treated for iGCT, close long-term clinical, imaging, and laboratory follow-up is recommended.

https://thejns.org/doi/10.3171/CASE2443

Open access

Rare case of tentorial cavernous malformation mimicking a meningioma: illustrative case

Michael Reinert, Danijela Kolenc, Elisabeth Rushing, Arne Fischmann, and Valentina Reinert

BACKGROUND

Cavernous malformations of the dura, especially of the tentorium, are exceedingly rare. In the available literature, only 10 cases have been described to date.

OBSERVATIONS

The authors present the case of a 46-year-old male patient with a 1-cm infratentorial lesion suspicious for meningioma that was found on routine magnetic resonance imaging (MRI) performed for vertigo. The lesion was followed for 1.5 years with no change in signal and size. Nevertheless, the patient was concerned about the lesion and requested removal. The removal was successful and without any neurological sequelae. However, histological evaluation demonstrated a cavernous malformation. Postoperative computed tomography and MRI showed complete removal. Preoperative MRI characteristics, intraoperative images, and a video, as well as histological evaluation, are shown. The case is discussed with respect to the literature.

LESSONS

Cavernous malformations of the tentorium are extremely rare and mimic meningiomas; thus, they need to be taken into account. DOTATOC positron emission tomography may help to differentiate in these cases. Considering the cases reported in the literature, in cases of large tumors, preoperative angiography and possibly embolization may be helpful.

https://thejns.org/doi/10.3171/CASE24168

Open access

Recurrent choroid plexus carcinoma treated with CyberKnife radiosurgery: illustrative case

Lorenzo Yuan, David J Park, Amit R. L Persad, Yusuke S Hori, Armine Tayag, Louisa Ustrzynski, Sara C Emrich, and Steven D Chang

BACKGROUND

Choroid plexus carcinomas (CPCs) are rare malignant brain tumors primarily affecting children younger than 2 years old. These tumors originate from the choroid plexus epithelium and are a subtype of choroid plexus tumors, which account for 1%–4% of pediatric brain tumors. Although CPCs often show a notably high recurrence rate after surgery, the standard treatment approach remains gross-total resection (GTR) of the tumor, given the lack of clinical data supporting the effectiveness of adjunct treatment options such as radiotherapy or chemotherapy.

OBSERVATIONS

A 16-year-old female with a history of a recurrent cranial CPC resistant to surgery and radiotherapy was treated with CyberKnife stereotactic radiosurgery (SRS), following resection. The procedures successfully maintained local disease control for 41 months; however, there was a subsequent recurrence, ultimately leading to the death of the patient.

LESSONS

CPC treatment remains challenging. SRS can be used as a viable adjunct to surgery, which remains the gold standard, although it can also be considered for nonsurgical candidates or when GTR cannot be achieved. Nevertheless, it is crucial to conduct additional research to explore diverse approaches for radiosurgery, including its role as the primary treatment modality versus its combination with surgery, radiotherapy, or chemotherapy.

https://thejns.org/doi/10.3171/CASE23748

Open access

Spinal extramedullary hematopoiesis mimicking an epidural tumor in a patient with high-risk polycythemia vera: illustrative case

Ashlee N Hawkins, Jeffrey M Breton, Akrita Bhatnagar, Nitika Paudel, and Jean-Marc Voyadzis

BACKGROUND

Here the authors present the case of a 43-year-old male with a history of T-cell lymphoma, which was treated with azacitidine plus cyclophosphamide, doxorubicin, vincristine, and prednisone and autologous hematopoietic cell transplant, and high-risk polycythemia vera (PCV) presenting with severe lower-back pain radiating to the bilateral legs with associated lower-extremity weakness and splenomegaly.

OBSERVATIONS

T2-weighted magnetic resonance imaging revealed multilevel epidural lesions involving T1–10 and S1–2. Because of severe spinal canal stenosis, the patient underwent surgical decompression of T5–7, with immediate postoperative alleviation of the lower-extremity pain and complete resolution of the lower-leg weakness. Biopsy results revealed extramedullary hematopoiesis (EMH) mimicking a spinal epidural tumor. EMH is radiosensitive and displays a rapid response to low dosages, so the patient was further treated with palliative radiation therapy for residual tumors and symptom alleviation, as well as hydroxyurea and corticosteroids as indicated for cytoreduction.

LESSONS

EMH associated with PCV or myeloproliferative conditions occurring within the spine is a rare phenomenon without a standard treatment approach.

https://thejns.org/doi/10.3171/CASE23659

Open access

Surgical cavity dilatation after resection of IDH-mutated astrocytoma of the mesial temporal lobe: illustrative cases

Yohan Caudron, Juan Martino, Sébastien Froelich, and Emmanuel Mandonnet

BACKGROUND

Space-occupying tumor bed cysts may exceptionally happen after the resection of diffuse low-grade glioma. Their mechanism and management remain debated. The authors report two cases of tumor bed cysts occurring after the resection of a left temporal diffuse low-grade glioma with two different evolutions.

OBSERVATIONS

The first patient showed a spontaneous decrease in the cyst volume and did not report any symptoms. In contrast, the second patient showed a progressive increase in the cyst volume and reported headaches and difficulties in finding words. Endoscopic cyst fenestration was performed and led to symptom relief and normalization of the surgical cavity.

LESSONS

A tumor bed cyst is a rare complication of temporal low-grade glioma resection. Its formation is due to entrapment of the choroid plexus in the temporal horn widely opened into the surgical cavity. Endoscopic cyst fenestration should be offered only in symptomatic cases.

https://thejns.org/doi/10.3171/CASE23674