✓The authors present a unique case of hyperhidrosis as a side effect of a misplaced deep brain stimulation (DBS) electrode near the ventrointermedius (Vim) nucleus in a patient with essential tremor. Magnetic resonance imaging of the brain showed electrode placement in the left anterior thalamus traversing the hypothalamus. High-frequency electrical stimulation possibly resulted in unilateral activation of the efferent sympathetic pathways in the zona incerta. Although a rare complication, hypothalamic dysfunction may occur as a stimulation-related side effect of Vim-DBS.
Alan Diamond, Christopher Kenney, Michael Almaguer and Joseph Jankovic
Rudolf Fahlbusch, Oliver Ganslandt, Michael Buchfelder, Werner Schott and Christopher Nimsky
Object. The aim of this study was to evaluate whether intraoperative magnetic resonance (MR) imaging can increase the efficacy of transsphenoidal microsurgery, primarily in non—hormone-secreting intra- and suprasellar pituitary macroadenomas.
Methods. Intraoperative imaging was performed using a 0.2-tesla MR imager, which was located in a specially designed operating room. The patient was placed supine on the sliding table of the MR imager, with the head placed near the 5-gauss line. A standard flexible coil was placed around the patient's forehead. Microsurgery was performed using MR-compatible instruments. Image acquisition was started after the sliding table had been moved into the center of the magnet. Coronal and sagittal T1-weighted images each required over 8 minutes to acquire, and T2-weighted images were obtained optionally. To assess the reliability of intraoperative evaluation of tumor resection, the intraoperative findings were compared with those on conventional postoperative 1.5-tesla MR images, which were obtained 2 to 3 months after surgery.
Among 44 patients with large intra- and suprasellar pituitary adenomas that were mainly hormonally inactive, intraoperative MR imaging allowed an ultra-early evaluation of tumor resection in 73% of cases; such an evaluation is normally only possible 2 to 3 months after surgery. A second intraoperative examination of 24 patients for suspected tumor remnants led to additional resection in 15 patients (34%).
Conclusions. Intraoperative MR imaging undoubtedly offers the option of a second look within the same surgical procedure, if incomplete tumor resection is suspected. Thus, the rate of procedures during which complete tumor removal is achieved can be improved. Furthermore, additional treatments for those patients in whom tumor removal was incomplete can be planned at an early stage, namely just after surgery.
Michael G. Muhonen, Scott C. Robertson, Jeffrey S. Gerdes and Christopher M. Loftus
✓ Serotonin (5-HT) produces constriction of peripheral collateral blood vessels. Using an animal model, the authors tested the hypothesis that 5-HT constricts collateral vessels in the cerebrum. A branch of the middle cerebral artery (MCA) was occluded proximally and cannulated distally in anesthetized dogs. Blood flow to the area at risk for infarction was detected by perfusing the cannulated MCA branch with microsphere-free blood during systemic injection of radioactive microspheres (shadow flow technique). Blood flow to collateral-dependent and normal cerebrum was measured during intravenous infusion of 5-HT (10 and 40 mg/kg/minute). Serotonin produced a dose-related reduction of blood flow to collateral-dependent cerebrum, increased collateral vessel resistance in large cerebral arteries and collateral vessels, and decreased cerebral artery perfusion pressure. In contrast, blood flow to normal cerebrum was not altered because a decrease in small vessel resistance effectively compensated for a decrease in MCA perfusion pressure. These findings indicate that 5-HT produces constriction of collateral vessels in the cerebrum. This response is clearly different from normal small cerebral vessels, which dilate during 5-HT infusion.
Arjun S. Chandran, Michael Bynevelt and Christopher R. P. Lind
The subthalamic nucleus (STN) is one of the most important stereotactic targets in neurosurgery, and its accurate imaging is crucial. With improving MRI sequences there is impetus for direct targeting of the STN. High-quality, distortion-free images are paramount. Image reconstruction techniques appear to show the greatest promise in balancing the issue of geometrical distortion and STN edge detection. Existing spin echo- and susceptibility-based MRI sequences are compared with new image reconstruction methods. Quantitative susceptibility mapping is the most promising technique for stereotactic imaging of the STN.
Ravikant S. Palur, Caglar Berk, Michael Schulzer and Christopher R. Honey
Object. There is an active debate regarding whether pallidotomy should be performed using macroelectrode stimulation or the more sophisticated and expensive method of microelectrode recording. No prospective, randomized trial results have answered this question, although personnel at many centers claim one method is superior. In their metaanalysis the authors reviewed published reports of both methods to determine if there is a significant difference in clinical outcomes or complication rates associated with these methods.
Methods. A metaanalysis was performed with data from reports on the use of unilateral pallidotomy in patients with Parkinson disease (PD) that were published between 1992 and 2000. A Medline search was conducted for the key word “pallidotomy” and additional studies were added following a review of the references. Only those studies dealing with unilateral procedures performed in patients with PD were included. Papers were excluded if they described a cohort smaller than 10 patients or a follow-up period shorter than 3 months or included cases that previously had been reported. The primary end points for outcome were the percentages of improvement in dyskinesias and in motor scores determined by the Unified PD Rating Scale (UPDRS). Complications were categorized as mortality, intracranial hemorrhage, visual deficit, speech deficit, cognitive decline, weakness, and other.
There were no significant differences between the two methods with respect to improvements in dyskinesias (p = 0.66) or UPDRS motor scores (p = 0.62). Microelectrode recording was associated with a significantly higher (p = 0.012) intracranial hemorrhage rate (1.3 ± 0.4%), compared with macroelectrode stimulation (0.25 ± 0.2%).
Conclusions. In reports of patients with PD who underwent unilateral pallidotomy, operations that included microelectrode recording were associated with a small, but significantly higher rate of symptomatic intracranial hemorrhage; however, there was no difference in postoperative reduction of dyskinesia or bradykinesia compared with operations that included macroelectrode stimulation.
Case report and review of the literature
Christopher B. Michael, Andrew G. Lee, James R. Patrinely, Samuel Stal and J. Bob Blacklock
✓ The authors present a case of visual loss associated with fibrous dysplasia of the anterior skull base and the surgical management of this case. Preoperative computerized tomography scanning in this patient demonstrated a patent optic foramen and a rapidly growing cystic mass within the orbit, which was responsible for the patient's visual loss. A literature review revealed that this case is typical, in that cystic mass lesions of various types are frequently responsible for visual loss associated with fibrous dysplasia. The authors did not find significant evidence in the literature to support the notion that visual loss associated with fibrous dysplasia is the result of progressive optic canal stenosis, thus raising questions about the value of prophylactic optic canal decompression. Instead, as demonstrated by this case and those uncovered in the literature review, most instances of visual loss result from the rapid growth of mass lesions of cystic fibrous dysplasia, mucoceles, or hemorrhage. Findings of the literature review and the present case of fibrous dysplasia of the anterior skull base support a role for extensive surgical resection in these cases and indicate a need for additional prospective analysis of a larger number of patients with this disease.
Christopher B. Shields and Michael West
Christopher B. T. Adams, Michael R. Fearnside and Sean A. O'Laoire
✓ Serial postoperative angiograms were performed in 28 patients with intracranial aneurysms, 26 of whom had presented with a subarachnoid hemorrhage. The clinical state and intracranial pressure (ICP) were also measured. Angiograms were performed in the ward using a cannula, which was passed into the proximal external carotid artery via the superficial temporal artery. Measurements of the vessel diameters were made, with the preoperative angiogram as a baseline. Patients could be placed into one of five groups depending on the presence or absence of significant arterial spasm, the clinical state of the patient, and the normality or otherwise of the ICP. No patient's condition deteriorated without an elevated ICP and/or significant arterial spasm. The study shows that this spasm is usually associated with a poor clinical state if it reaches a maximum 8 to 12 hours after the operation, although the clinical deterioration is not apparent for a further 6 to 12 hours. Knowledge of the natural history of postoperative arterial spasm may allow earlier treatment of the spasm, which may be more successful than delaying treatment until clinical deterioration has occurred. The worth of the varied drugs proposed for the treatment of spasm may be assessed using this type of protocol.
Van V. Halbach, Christopher F. Dowd, Randall T. Higashida, Peter A. Balousek, Samuel F. Ciricillo and Michael S. B. Edwards
Object. In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.
Methods. Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.
Conclusions. Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.