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Open access

Impact of subthalamic nucleus stimulation on urinary dysfunction and constipation in Parkinson’s disease

Asra Askari, Brandon J. Zhu, Jordan L. W. Lam, Kara J. Wyant, Kelvin L. Chou, and Parag G. Patil

OBJECTIVE

The effect of subthalamic nucleus (STN) deep brain stimulation (DBS) on urinary dysfunction and constipation in Parkinson’s disease (PD) is variable. This study aimed to identify potential surgical and nonsurgical variables predictive of these outcomes.

METHODS

The authors used the Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) Part I to assess urinary dysfunction (item 10) and constipation (item 11) preoperatively and at 6–12 months postoperatively. A multiple linear regression model was used to investigate the impact of global cerebral atrophy (GCA) and active electrode contact location on the urinary dysfunction and constipation follow-up scores, controlling for age, disease duration, baseline score, motor improvement, and levodopa-equivalent dose changes. An electric field model was applied to localize the maximal-effect sites for constipation and urinary dysfunction compared with those for motor improvement.

RESULTS

Among 74 patients, 23 improved, 28 deteriorated, and 23 remained unchanged for urinary dysfunction; 25 improved, 15 deteriorated, and 34 remained unchanged for constipation. GCA score and age significantly predicted urinary dysfunction follow-up score (R2 = 0.36, p < 0.001). Increased GCA and age were independently associated with worsening urinary symptoms. Disease duration, baseline constipation score, and anterior active electrode contacts in both hemispheres were significant predictors of constipation follow-up score (R2 = 0.31, p < 0.001). Higher baseline constipation score and disease duration were associated with worsening constipation; anterior active contact location was associated with improvement in constipation.

CONCLUSIONS

Anterior active contact location was associated with improvement in constipation in PD patients after STN DBS. PD patients with greater GCA scores before surgery were more likely to experience urinary deterioration after DBS.

In Journal of Neurosurgery Publish Before Print

Open access

Single-cell analysis of 5-aminolevulinic acid intraoperative labeling specificity for glioblastoma

Zhouzerui Liu, Angeliki Mela, Michael G. Argenziano, Matei A. Banu, Julia Furnari, Corina Kotidis, Colin P. Sperring, Nelson Humala, Aayushi Mahajan, Jeffrey N. Bruce, Peter Canoll, and Peter A. Sims

OBJECTIVE

Glioblastoma (GBM) is the most common and aggressive malignant primary brain tumor, and resection is a key part of the standard of care. In fluorescence-guided surgery (FGS), fluorophores differentiate tumor tissue from surrounding normal brain. The heme synthesis pathway converts 5-aminolevulinic acid (5-ALA), a fluorogenic substrate used for FGS, to fluorescent protoporphyrin IX (PpIX). The resulting fluorescence is believed to be specific to neoplastic glioma cells, but this specificity has not been examined at a single-cell level. The objective of this study was to determine the specificity with which 5-ALA labels the diversity of cell types in GBM.

METHODS

The authors performed single-cell optical phenotyping and expression sequencing–version 2 (SCOPE-seq2), a paired single-cell imaging and RNA sequencing method, of individual cells on human GBM surgical specimens with macroscopically visible PpIX fluorescence from patients who received 5-ALA prior to surgery. SCOPE-seq2 allowed the authors to simultaneously image PpIX fluorescence and unambiguously identify neoplastic cells from single-cell RNA sequencing. Experiments were also conducted in cell culture and co-culture models of glioma and in acute slice cultures from a mouse glioma model to investigate cell- and tissue-specific uptake and secretion of 5-ALA and PpIX.

RESULTS

SCOPE-seq2 analysis of human GBM surgical specimens revealed that 5-ALA treatment resulted in labeling that was not specific to neoplastic glioma cells. The cell culture further demonstrated that nonneoplastic cells could be labeled by 5-ALA directly or by PpIX secreted from surrounding neoplastic cells. Acute slice cultures from mouse glioma models showed that 5-ALA preferentially labeled GBM tumor tissue over nonneoplastic brain tissue with significant labeling in the tumor margins, and that this contrast was not due to blood-brain barrier disruption.

CONCLUSIONS

Together, these findings support the use of 5-ALA as an indicator of GBM tissue but question the main advantage of 5-ALA for specific intracellular labeling of neoplastic glioma cells in FGS. Further studies are needed to systematically compare the performance of 5-ALA to that of potential alternatives for FGS.

In Journal of Neurosurgery Publish Before Print

Open access

Cervical intradural traumatic neuroma without history of trauma: illustrative case

Elias Elias, Kimmo J Hatanpaa, Matthew MacAllister, Ali Daoud, Charbel Elias, and Zeina Nasser

BACKGROUND

Traumatic neuroma typically refers to a reactive process in the injured peripheral nerve, characterized by an excessive growth of axons, Schwann cells, and fibroblasts at the proximal end of the nerve after its interruption. The authors report a case of a traumatic neuroma in the cervical nerve root in a patient with no history of trauma.

OBSERVATIONS

The patient presented with sensation loss in the right-hand ulnar distribution, right flank around the T4–11 region, and right small toe along with motor power weakness over the right upper and lower extremity. Magnetic resonance imaging revealed an intradural extramedullary mass lesion with extension along the C7 nerve root. Histological examination showed traumatic neuroma. A total resection of the lesion along with the resolution of sensory and motor deficits was achieved directly after surgery.

LESSONS

Traumatic neuroma should always be kept in the armamentarium for diagnosis of an intradural nerve sheath tumor.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Impedance trend from a symptomatic perielectrode cystic cavity following deep brain stimulation: illustrative case

Brooke Elberson, Hayden Scott, Rohit Dhall, and Erika Petersen

BACKGROUND

Deep brain stimulation (DBS) is a well-established neurosurgical intervention for a growing number of neurological and psychiatric diseases. Patients who are affected by Parkinson’s disease may benefit from DBS of either the subthalamic nucleus or the globus pallidus internus. Patients who undergo DBS often notice a significant reduction in their clinical symptoms; however, the procedure is not without risks. Multicenter studies have reported postoperative complications such as hardware infection, intracranial hemorrhage, and perielectrode edema.

OBSERVATIONS

The authors report a case of a perielectrode cyst managed conservatively. Tracking the impedance trend was a novel approach to monitor for changes within the cyst and to herald a clinical change in the patient. Perielectrode cystic formation can be a transient process that resolves spontaneously or with conservative, nonoperative management, and all diagnostic information is valuable in making clinical decisions.

LESSONS

Impedance values have provided an appropriate estimation of this patient’s clinical picture. The authors suggest treatment of edema and a cyst after DBS lead implantation through conservative management and observation, avoiding the removal of hardware if a patient’s clinical picture is either stable or improving and forgoing additional clinical imaging if the impedance values are trending in an appropriate direction.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Intraoperative confocal laser endomicroscopy for interpretation of a sellar hemangioblastoma: illustrative case

Irakliy Abramov, Charuta G Furey, Yuan Xu, Jennifer M Eschbacher, Kris A Smith, and Mark C Preul

BACKGROUND

Intraoperative frozen sections play a critical role in surgical strategy because of their ability to provide rapid histopathological information. In cases in which intraoperative biopsy carries a significant risk of bleeding, intraoperative confocal laser endomicroscopy (CLE) can assist in decision-making.

OBSERVATIONS

The authors present a rare case of a large sellar hemangioblastoma. Preoperative radiographic imaging and normal pituitary function suggested a differential diagnosis that included hemangioblastoma. The patient underwent partial preoperative embolization and a right-sided pterional craniotomy for resection of the lesion. Gross intraoperative examination revealed a highly vascular sellar lesion requiring circumferential dissection to minimize blood loss. The serious vascularity precluded intraoperative frozen section analysis, and CLE imaging was performed. CLE imaging provided excellent visualization of the remarkable vascular structure and characteristic histoarchitecture with microvasculature, intracytoplasmic vacuoles, and atypical cells consistent with hemangioblastoma. Resection and decompression of the chiasm was accomplished, and the patient was discharged with improved vision. The final histopathological diagnosis was hemangioblastoma.

LESSONS

When the benefits of obtaining intraoperative frozen sections greatly outweigh the associated risks, CLE imaging can aid in decision-making. CLE imaging offers real-time, on-the-fly evaluation of intraoperative tissue without the need to biopsy a vascular lesion.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Letter to the Editor. Before surgical sural nerve neurolysis, study neighboring sensory nerves

Josef Finsterer

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Letter to the Editor Response

Kenji Yagi

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Recurrence of a large intracranial fusiform aneurysm treated with overlapping Pipeline embolization devices: illustrative case

Jeyan Sathia Kumar, Nisha Dabhi, Daniel M. S Raper, Stepan Capek, R. Webster Crowley, M. Yashar Kalani, Ryan T Kellogg, and Min S Park

BACKGROUND

Flow diversion, specifically with the Pipeline embolization device (PED), represents a paradigm shift in the treatment of intracranial aneurysms. Several studies have demonstrated its efficacy and at times superiority to conventional treatment modalities for aneurysms with a fusiform morphology, giant size, or wide neck. However, there may be a nonsignificant risk of recurrence after flow diversion of these historically difficult-to-treat aneurysms, relative to aneurysms with a more favorable morphology and size (i.e., saccular, narrow necked). To date, only three papers in the literature have demonstrated the recurrence of a completely occluded aneurysm on follow-up.

OBSERVATIONS

The authors describe a patient with a giant middle cerebral artery fusiform aneurysm treated with multiple telescoping PEDs. On the 3-month follow-up angiogram, there was complete occlusion of the aneurysm. The patient was lost to follow-up and presented 4 years later with a recurrence of the aneurysm between PED segments, requiring retreatment. The patient represented 3 years posttreatment with the need for repeat treatment of the fusiform aneurysm due to separation of the existing PEDs along with stent reconstruction. At the 20-month follow-up after the third treatment, the initial aneurysm target was found to be occluded.

LESSONS

This case illustrates the need for long-term follow-up, specifically for patients with giant wide-necked or fusiform aneurysms treated with overlapping PEDs.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 12 (Sep 2023)

Open access

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case

Dominic Chau, Zachary R Barnard, , Thomas J Muelleman, Adam M Olszewski, Anna K D’Agostino, Marcel M Maya, Peyton Nissen, Kevin A Peng, Wouter I Schievink, Gregory P Lekovic, and

BACKGROUND

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory.

OBSERVATIONS

A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula.

LESSONS

Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever “otogenic” pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 11 (Sep 2023)

Open access

Noninvasive assessment of glymphatic dysfunction in idiopathic normal pressure hydrocephalus with diffusion tensor imaging

Charalampos Georgiopoulos, Anders Tisell, Rafael T. Holmgren, Andreas Eleftheriou, Johanna Rydja, Fredrik Lundin, and Lovisa Tobieson

OBJECTIVE

Diffusion tensor imaging (DTI) along the perivascular space (ALPS) (DTI-ALPS)—by calculating the ALPS index, a ratio accentuating water diffusion in the perivascular space—has been proposed as a noninvasive, indirect MRI method for assessing glymphatic function. The main aim of this study was to investigate whether DTI-ALPS would reveal glymphatic dysfunction in idiopathic normal pressure hydrocephalus (iNPH) and whether the ALPS index was associated with disease severity.

METHODS

Thirty iNPH patients (13 men; median age 77 years) and 27 healthy controls (10 men; median age 73 years) underwent MRI and clinical assessment with the Timed Up and Go test (TUG) and Mini-Mental State Examination (MMSE); only the patients were evaluated with the Hellström iNPH scale. MRI data were analyzed with the DTI-ALPS method and Radscale screening tool.

RESULTS

iNPH patients showed significantly lower mean ALPS index scores compared with healthy controls (median [interquartile range] 1.09 [1.00–1.15] vs 1.49 [1.36–1.59], p < 0.001). Female healthy controls showed significantly higher ALPS index scores than males in both hemispheres (e.g., right hemisphere 1.62 [1.47–1.67] vs 1.33 [1.14–1.41], p = 0.001). This sex difference was not seen in iNPH patients. The authors found a moderate exponential correlation between mean ALPS index score and motor function as measured with time required to complete TUG (r = −0.644, p < 0.001), number of steps to complete TUG (r = −0.571, p < 0.001), 10-m walk time (r = −0.637, p < 0.001), and 10-m walk steps (r = −0.588, p < 0.001). The authors also found a positive linear correlation between mean ALPS index score and MMSE score (r = 0.416, p = 0.001). Simple linear regression showed a significant effect of diagnosis (B = −0.39, p < 0.001, R2 = 0.459), female sex (B = 0.232, p = 0.002, R2 = 0.157), and Evans index (B = −4.151, p < 0.001, R2 = 0.559) on ALPS index. Multiple linear regression, including diagnosis, sex, and Evans index score, showed a higher predictive value (R2 = 0.626) than analysis of each of these factors alone.

CONCLUSIONS

The ALPS index, which was significantly decreased in iNPH patients, could serve as a marker of disease severity, both clinically and in terms of neuroimaging. However, it is important to consider the significant influence of biological sex and ventriculomegaly on the ALPS index, which raises the question of whether the ALPS index solely reflects glymphatic function or if it also encompasses other types of injury. Future studies are needed to address potential confounding factors and further validate the ALPS method.

In Journal of Neurosurgery Publish Before Print