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Maria Mpakopoulou, Haralambos Gatos, Alexandros Brotis, Konstantinos N. Paterakis and Kostas N. Fountas

Object

Stereotactic amygdalotomy has been utilized as a surgical treatment for severe aggressive behavioral disorders. Several clinical studies have been reported since the first description of the procedure. In the current study, the authors reviewed the literature and evaluated the surgical results, neuropsychological outcome, and complication rate in patients who had undergone stereotactic amygdalotomy for severe aggressive behavioral disorders.

Methods

The PubMed database was searched using the following terms: “amygdalotomy,” “amygdalectomy,” “amygdaloidectomy,” “psychosurgery,” “aggressive disorder,” and “behavioral disorder.” Clinical series with more than 5 patients undergoing stereotactic amygdalotomy for aggressive or other behavioral disorders were included in this review. The surgical technique, anatomical target, improvement in psychiatric symptomatology, postoperative employment and social rehabilitation, postoperative neurocognitive function, procedure-related complications, and long-term follow-up were evaluated.

Results

Thirteen clinical studies met our inclusion criteria. Reported postoperative improvement in aggressive behavior varied between 33 and 100%. Procedure-related complication rates ranged from 0 to 42%, whereas the mortality rate was as high as 3.8%. In the majority of the reviewed clinical series, the performance of stereotactic amygdalotomy did not compromise a patient’s learning, language, and intellectual capabilities. The long-term follow-up, although very limited, revealed that initially observed improvement was maintained in most cases.

Conclusions

Stereotactic amygdalotomy can be considered a valid surgical treatment option for carefully selected patients with medically refractory aggressive behavioral disorders. Recent advances in imaging and stereotactic navigation can further improve outcome and minimize the complication rate associated with this psychosurgical procedure.

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Theofilos G. Machinis, Kostas N. Fountas, John Hudson, Joe Sam Robinson and E. Christopher Troup

Objective

Ventriculoatrial (VA) shunts remain a valid option for the treatment of hydrocephalus, especially in patients in whom ventriculoperitoneal (VP) shunts fail. Correct positioning of the distal end of the catheter in the right atrium is of paramount importance for maintaining shunt patency and reducing the incidence of VA shunt-associated morbidity. The authors present their experience with real-time transesophageal echocardiography (TEE) monitoring for the accurate placement of the distal catheter of a VA shunt.

Methods

Four patients underwent conversion of a VP shunt to a VA shunt under the guidance of intraoperative fluoroscopy and TEE between May 2003 and December 2004. After induction of general anesthesia, the TEE transducer was advanced into the esophagus. A cervical incision was made and the external jugular vein was visualized. An introducer was passed through an opening in the jugular vein and a guidewire was placed through the introducer. Under continuous TEE guidance, the guidewire was carefully advanced into the superior vena cava. A distal shunt catheter overlying a J-wire was then passed to the superior vena cava, again under TEE guidance. The catheter was advanced to the right atrium after removing the guidewire.

Final visualization with TEE and fluoroscopy revealed a good position of the catheter in the right atrium in all four cases. The mean duration of the operation was 91 minutes (range 65–120 minutes) and the mean operative blood loss was 23 ml (range 10–50 ml). No procedure-related complication was noted.

Conclusions

Real-time TEE is a safe and simple technique for the accurate placement of the distal catheter of a VA shunt.

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Aristotelis S. Filippidis and Kostas N. Fountas

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Kostas N. Fountas, Eftychia Kapsalaki and Georgios Hadjigeorgiou

Object

The wide application of deep brain stimulation in the management of movement as well as other degenerative neurological and psychiatric disorders has renewed the interest in using deep brain stimulation in the management of medically intractable epilepsy. Various stimulation targets have been used with significantly varying results in aborting seizure activity. Electrical cerebellar stimulation (CS) has been used for more than 50 years in the management of epilepsy, with conflicting results. In the current study, the authors review the pertinent literature to outline the role of CS in the management of medically refractory epilepsy.

Methods

The PubMed medical database was systematically searched for the following terms: “cerebellar,” “epilepsy,” “stimulation,” and “treatment,” and all their combinations. Case reports were excluded from this study.

Results

The pertinent articles were categorized into 2 large groups: animal experimental and human clinical studies. Particular emphasis on the following aspects was given when reviewing the human clinical studies: their methodological characteristics, the number of participants, their seizure types, the implantation technique and its associated complications, the exact stimulation target, the stimulation technique, the seizure outcome, and the patients' psychological and social poststimulation status. Three clinical double-blind studies were found, with similar implantation surgical technique, stimulation target, and stimulation parameters, but quite contradictory results. Two of these studies failed to demonstrate any significant seizure reduction, whereas the third one showed a significant poststimulation decrease in seizure frequency. All possible factors responsible for these differences in the findings are analyzed in the present study.

Conclusions

Cerebellar stimulation seems to remain a stimulation target worth exploring for defining its potential in the treatment of medically intractable epilepsy, although the data from the double-blind clinical studies that were performed failed to establish a clear benefit in regard to seizure frequency. A large-scale, double-blind clinical study is required for accurately defining the efficacy of CS in epilepsy treatment.

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Vassilios G. Dimopoulos, Ioannis Z. Kapsalakis and Kostas N. Fountas

✓Differences in skull morphological characteristics among various human populations were first described by Herodotus of Halicarnassus. The Hippocratic treatise On Head Wounds (Περι των εν κεφαλη τρωματων) provided the first detailed description of human skull anatomy. The Hippocratic author presented the first systematic attempt to create a classification system of skull and cranial suture morphology. Detailed descriptions of various human skull types and cranial sutures were provided along with information regarding the macroscopic structure and thickness of different parts of the skull. The significance of skull thickness in patients with head injuries was also presented in the Hippocratic text. The authors discuss the influence of this treatise on the later development of descriptive skull anatomy and on the development of modern neurosurgery.

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Efthimios Dardiotis, Kostas N. Fountas, Maria Dardioti, Georgia Xiromerisiou, Eftychia Kapsalaki, Anastasia Tasiou and Georgios M. Hadjigeorgiou

Traumatic brain injury (TBI) constitutes a major cause of mortality and disability worldwide, especially among young individuals. It is estimated that despite all the recent advances in the management of TBI, approximately half of the patients suffering head injuries still have unfavorable outcomes, which represents a substantial health care, social, and economic burden to societies.

Considerable variability exists in the clinical outcome after TBI, which is only partially explained by known factors. Accumulating evidence has implicated various genetic elements in the pathophysiology of brain trauma. The extent of brain injury after TBI seems to be modulated to some degree by genetic variants.

The authors' current review focuses on the up-to-date state of knowledge regarding genetic association studies in patients sustaining TBI, with particular emphasis on the mechanisms underlying the implication of genes in the pathophysiology of TBI.

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Aristotelis S. Filippidis, Dimitrios C. Papadopoulos, Eftychia Z. Kapsalaki and Kostas N. Fountas

Object

The aim of this study was to provide a systematic update of the current literature regarding the clinical role of the S100B serum biomarker in the initial evaluation of children who have sustained a mild traumatic brain injury (TBI).

Methods

Searches in MEDLINE were defined with the keywords “mild TBI children S100,” “mild TBI pediatric S100,” and “children S100 brain injury.” From the pool of obtained studies, those that had the inclusion criteria of mild TBI only or mixed types of TBI but including detailed information about groups of children with mild TBI were used.

Results

Few studies were identified and fewer included more than 100 cases. The prospective studies showed that the S100B biomarker levels could be influenced by patient age and the time frame between head injury and blood sampling. Moreover, extracranial sources of S100B or additional injuries could influence the measured levels of this biomarker. A normal value of S100B in children with mild TBI could rule out injury-associated abnormalities on CT scans in the majority of reported cases.

Conclusions

The vulnerability of S100B serum levels to the influences of patient age, blood sampling time, and extracranial S100B release limits the biomarker's role in the initial evaluation of children with mild TBI. The application of S100B in pediatric mild TBI cases has an elusive role, although it could help in selected cases to avoid unnecessary head CT scans.

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Kostas N. Fountas, Robert S. Donner, Leonidas G. Nikolakakos, Carlos H. Feltes, Ioannis Karampelas and Joe Sam Robinson Jr.

✓ The authors report a unique case of diffuse spinal metastatic disease due to a pleomorphic rhabdomyosarcoma (RMS) in an adult. In additon to its overall rarity, peculiar characteristics of the particular tumor included its site of origin, demonstrated radiologically as the lumbar paravertebral musculature (psoas muscle) and the transcanalicular spread into the vertebral canal, resulting in thecal compression at multiple levels. The salient clinicopathological characteristics of RMS, as they related particularly to the spine, are subsequently discussed and a short review of the major therapeutic modalities for these tumors is offered.

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Kostas N. Fountas, Joseph R. Smith, Gregory P. Lee, Patrick D. Jenkins, Rebecca R. Cantrell and W. Chris Sheils

Object

Stereotactic radiosurgery (SRS) with the Gamma Knife (GK) is a rapidly emerging surgical modality in the management of medically refractory idiopathic trigeminal neuralgia (TN). The current study examines the long-term outcome in patients with drug-resistant idiopathic TN who underwent GK surgery at the authors‘ institution.

Methods

One hundred and six consecutive patients (38 men and 68 women) with proven medically refractory idiopathic TN were included in this retrospective study. Their ages were 41–82 years (mean 72.3 years). All patients underwent SRS with prescribed maximal radiation doses ranging from 70 to 85 Gy. Isocenters 1–3 were used and plugging was used selectively. The follow-up period was 12–72 months (mean 34.3 months). The patients were divided into 2 groups according to their history of previous surgery.

Results

The initial response rate in patients with no history of previous surgery was 92.9%; in those who had undergone previous surgery, the initial response rate was 85.7%. At the end of the 1st posttreatment year, an excellent outcome was achieved in 82.5% of patients who had not had previous surgery, and in 69.4% of those who had. The respective outcome rates for the 2nd posttreatment year were 78 and 63.5%, respectively. The most common complication was the development of persistent paresthesia, which occurred in 15.8% of patients with no previous surgery and 16.3% of those with previous surgery.

Conclusions

Stereotactic radiosurgery with the GK is a safe and effective treatment option for patients with medically refractory idiopathic TN.